Harris, Winokuer. Principles and practice of grief counseling_ау

 

 

 

 

 

 

Contents

Preface                                                                              ix

Acknowledgments                                                           xiii

Share Principles and Practice of Grief

Counseling: Second Edition

Part I: Theoretical Underpinnings

1: Thoughts About Counseling                                       1

2: Unique Aspects of Grief Counseling                         13

3: Theories and Orientation to

Bereavement                                                              25

4: The Social Context of Loss                                        43

Part II: Practice and Process

5: The Practice of Presence                                           57

6: The Basics of Counseling Practice                            71

7: Working With Bereaved Individuals                         91

8: Living Losses: Nonfinite Loss,

Ambiguous Loss, and Chronic Sorrow                   107

9: Working With Emotions – Yours

and Theirs                                                                125

10: When Grief Goes Awry                                           143

11: The Clinician’s Toolbox: Therapeutic

Modalities and Techniques in the

Context of Grief                                                       169

12: Ethical Issues in Grief Counseling

Practice                                                                    197

vii

CONTENTS

Part III: Current Issues and Trends

13: Caregiver Issues for Grief Counselors                                       213

14: Current Issues and Trends for Grief Counselors                       233

Afterword                                                                                           249

Appendix: Case Studies                                                                   253

Index                                                                                                 261

 

 

 

 

 

Preface

This book grew out of our need to have a text for the university-based courses that each of us teaches to students who are interested in furthering their knowledge and skills in grief counseling and support. We found that there are many good texts that explore research and theory in counseling psychology, and many other books that expound upon grief and bereavement theory and research. However, we have been unable to find a book that combined both the practical aspects of counseling with the current research and the theory related to grief and bereavement. After years of piecing together articles, course reading packets, and chapters selected from different texts, we decided to design a book that would explore both the practical knowledge and skills that are available in counseling psychology with some of the current research and theory in the area of loss, grief, and bereavement. Both of us have been practitioners in this area for over 30 years, and we have drawn upon our own clinical work to “flesh out” things that we think would be most helpful to clinicians who wish to work effectively with bereaved individuals.

We are often asked by clinicians who specialize in other areas of counseling, “How can you do this kind of work all the time?” We also smile at our students’ surprised faces when they see that we are not (always) dressed in black, morbid, and void of humor, as those who work around individuals who are dying or bereaved are often stereotyped. We try to convey to our students our passion for this area, and the rewards that we find in our practice with bereaved individuals. We realize that every day is precious. Our clients continually remind us that life is a gift, and that our time is limited – so we make the most of it. We firmly believe that working with individuals who are dying and bereaved makes us live our lives more consciously, fully, and with a greater appreciation. In our work with individuals who have experienced all types of losses, we have had the privilege of sharing very personal time with people who are hurting, vulnerable, and broken. However, we also have the opportunity to see how people are able to draw upon their strengths and innate resilience, and re-enter the world with a stronger sense of themselves and of the gifts that life has to offer.

We view the practice of grief counseling as a unique sphere of practice, which is another reason why we wanted to write this book. Although counseling in general is meant to address issues that occur in everyday life, and loss is certainly a universal experience, we wanted to be able to focus upon grief as a painful but adaptive process, with some unique features that separate it from other types of issues that are addressed in general counseling practice. We further expand upon this idea later, but we want to state at the beginning that we believe a key aspect of grief counseling is that it does not focus upon what is wrong, but rather on what is right about the grieving process, and our emphasis is upon how we can facilitate the healthy unfolding of this adaptive process rather than on its containment.

One other unique feature of this book is the discussion of grief as a response to losses that are death related and nondeath related, tangible and intangible in their description. An individual does not have to lose a loved one to death in order to grieve; grief can occur after placing a loved one with advanced dementia in a long-term care facility, with the ending of an intimate relationship, with the loss of hopes and dreams, and with the loss of self that may accompany life-altering events. Grief is viewed as an adaptive response to experiences that challenge our assumptions about how the world should work, and how we view ourselves and others within that world. Although we devote an entire chapter to this topic, this broader view of grief will be woven through all of the material that is presented in the various chapters.

Because we make no assumptions about the background of the reader, we start with the basics of counseling and the therapeutic relationship. In Chapters 1 and 2, we explore the purposes that counseling may serve, and the unique aspects and challenges that may occur in counseling individuals who have experienced significant losses. We then move into some basic material about current theories of grief and bereavement and how these understandings apply to clinical practice in Chapter 3. New to this edition is a chapter (Chapter 4) that explores the social context of loss, detailing the ways that we are socialized to think about and respond to loss and grief. We then focus on issues that are salient to setting up the therapeutic relationship with clients, and specific counseling practices that we believe are relevant to working with bereaved individuals. We devote an entire chapter (Chapter 5) to the cultivation of presence within the context of the counseling relationship, using this material to form the foundation upon which grief counseling should occur. In no other form of counseling is the value of presence more relevant or timely; counselors who focus on trying to problem solve and “fi x” things with their clients may find working with bereaved clients to be an exercise in frustration and futility. We think it crucial for grief counselors to understand and embrace the gift of presence as the primary therapeutic stance in working with bereaved individuals. We then take the material from the previous chapters and discuss basic concepts of counseling practice in Chapter 6.

In Chapter 7, we begin to integrate counseling theory and practice directly with grief and bereavement theory. In this chapter, we explore some of the “nitty-gritty” expectations of the counseling process with bereaved clients. We then expand upon definitions and understandings of loss and grief in Chapter 8 by exploring grief that may be present, but which may often be unrecognized or invalidated because it is not related to a death per se. We include a chapter (Chapter 9) on working with strong emotions because many clinicians find working with clients who are experiencing such intensity to be intimidating or difficult, and their focus is often upon containment of emotions rather than upon the potential to use strong emotional content to deepen the client’s therapeutic process. In this chapter, we discuss concepts such as emotional intelligence and specific ways that strong emotions can provide valuable grist for the mill in the clients’ process (and the counselor’s self-awareness).

Chapter 10 opens up the discussion of when grief goes “off track,” and how to recognize when additional resources and referrals are indicated in complicated grief scenarios. Chapter 11 provides an overview of some of the therapeutic techniques and tools that we have found to be effective in working with bereaved individuals, adding to the clinicians’ “toolkit” some possible resources that may be helpful with specific types of clients and situations. In Chapter 12, we explore ethical issues that may be particularly relevant to grief counseling, and we make recommendations for how grief counselors can ensure that they are practicing in ways that are competent and ethically sound. In Chapter 13, we identify some of the common pitfalls that can affect grief counselors, and how the unique features of individuals who are drawn to this type of work can actually make the counselor more vulnerable to experiences such as burnout and secondary traumatization. In Chapter 14, we explore some of the current and upcoming issues that we see in our field, so that individuals who wish to specialize in the area of grief counseling can critically reflect and incorporate best practices into their clinical work. We include a section at the end of each chapter to allow the reader an opportunity to better absorb and reflect on the content with directed questions and exercises and a glossary of important terms. In the Appendix section, we have provided sample case studies for the reader to analyze using the book materials. Qualified instructors may obtain access

 

 

 

 

 

 

 

 

 

I THEORETICAL UNDERPINNINGS

 

CHAPTER 1 Thoughts About Counseling

Most of the time, we find our own way through the difficult times in our lives without the need for a professional to assist us. Life is full of ups and downs, and we usually learn to adjust to change, cope with difficulties, and develop our own sense of resilience along the way. There are times, however, when some of our life experiences throw us into a place of great upheaval, severely taxing us and overwhelming our coping abilities. Many of the experiences that challenge us at this level involve painful and significant losses that force us to deeply question ourselves, others, and the world. It is at these times that we may choose to seek the assistance of a counselor. In this chapter, we explore what counseling is and examine some of the more common misconceptions about counseling. We will also look at the therapeutic relationship that develops between the counselor and the client in the counseling setting, consider the different contexts in which counseling may occur, and briefly discuss the goals of grief counseling.

WHAT IS COUNSELING?

In its simplest form, counseling is about two people sitting down in privacy, with one of these individuals listening intently and responding in a helpful manner to the other person who is expressing his or her concerns about problems in living (Feltham, 2010; Yalom, 2009). The field of counseling psychology arose out of a grassroots movements of the 1960s as a response to what were viewed as heavy-handed, elitist therapies that focused on the weaknesses and foibles of the client and that were seen as perpetuating client dependence and disempowerment.

Counseling is seen as a means to address everyday life concerns and issues related to daily living, not as a means to dissect an individual’s deep psychic secrets and family dysfunctions. The philosophy of counseling is basically that human beings possess innate strengths and resilience that can be drawn upon during times of struggle and crisis. Counseling offers the opportunity to help identify these areas of strength within individuals. The counseling process provides an avenue for empowerment of individuals to draw from these resources in order to work through difficult situations. Goals of counseling may include the following:

  • Assisting clients to gain insight and perspective on their situation, behavior, emotions, and relationships
  • Providing a safe place for clients to express feelings and clarify their thoughts
  • Providing a context for the client’s experience within a broader perspective (e.g., within a family context, social and political structures, existential viewpoint).
  • Enhancing the development of clients’ skills in dealing with painful and distressing situations
  • Empowering clients to become their own best advocates
  • Facilitating clients’ process of finding and making meaning in their life experiences

Counseling is an experience, a relationship, and a process. The counseling process is highly dynamic and interactional between the client and the counselor, with the central focus on the client’s needs and experiences. Counseling does not involve having an expert analyze the client with the goal to fix him or her. In the counseling relationship, the counselor and the client work together as a team to help the client to understand his or her experiences, and to develop awareness of what he or she can do to work through the current issue.

It is important at this juncture to delineate between counseling and therapy. Counselors typically assist people with issues and problems that arise in everyday life that are causing angst and difficulty. Counselors typically engage with clients who are basically functional, but who are struggling with an issue that is having an impact on their life in a significant way. Counseling is usually of short term or limited in the time that the client needs this assistance. In contrast, therapy involves in-depth work with clients, aimed at long-standing struggles and unresolved deeper issues that may require longer, ongoing supportive work. In therapy, clients usually work on restructuring their core aspects. In counseling, clients focus on reframing everyday life events and identifying the strengths and resources that they need to draw upon to work through these events.

 

 

MISCONCEPTIONS ABOUT COUNSELING

Popular media and culture perpetuate a negative view of counseling by frequently portraying a client who is loosely identified as “neurotic” sitting in an office with a gloating professional who acts like a condescending parent figure, talking to the client in a way that is belittling and demeaning. In addition, call-in radio and television shows that feature a guest psychologist or “doctor” of some sort who tells people how to solve their problems in 10 minutes or less for the sake of entertainment do not give a very accurate representation of the counseling process. Many people probably have a very unrealistic and stereotypical view of counseling as a result of these types of portrayals. In this section, we try to dispel some of the more common misconceptions about counseling.

Misconception #1: Only Individuals Who Are Weak Seek Counseling

Many people think of going to a counselor as a sign that something is wrong with them, or that seeking professional assistance is an indication of weakness. This commonly held thought is predicated on the belief that people seek professional help because they are somehow inadequate or needy. This misconception is most likely an extension of the value our society places on stoicism and rugged independence, which rewards us for denying and hiding our emotions at times of vulnerability, rather than supporting our healthy need to reach out to our communities and healers when we need to do so. Public expressions of the more vulnerable emotions, such as sadness or anxiety, do not necessarily result in offers of support; rather, their disclosure seems to serve as an invitation for criticism and judgment, along with lowered social status (Harris, 2009 – 2010).

Our society places a great deal of expectation for us to be “above” emotion and to “overcome” our humanness, and counseling is often associated with emotions that are socially stigmatized. Therefore, seeking counseling is seen as something that “weak” people do because they cannot control their feelings or they are too weak to manage them according to social expectations. Seeing a counselor is not about whether one is weak, but rather it is more closely associated with our human need to reach out for support at a time when our ability to accommodate something that has happened is deeply challenged. We are social creatures who live in community with others, and yet there is a strong dichotomy in regard to needing to be close to others while not allowing others to see us when we are not strong and independent. Professional counselors understand the courage it takes for a client to be willing to confront his or her problems head on and to expose such vulnerability in order to work through these difficult times.

Misconception #2: The Counselor Is the Expert

Another misconception about counseling focuses on the role of the counselor as the expert. Certainly, professional counselors have usually completed a great deal of training and they often have graduate-level degrees in their field. The natural assumption is that the counselor is in a position of being the expert, and the client comes to the counselor to find answers to problems by drawing from the counselor’s expertise. We distinguish between the expertise of the counselor in the process of counseling and the expertise of the client in his or her life and choices. The client knows his or her values, beliefs, and life experiences better than anyone else, and the role of the counselor is not to give advice or figure out what the client should do. Instead, the counselor acts as a facilitator to help the client to find his or her own answers, solutions, and choices. We strongly believe that each person has his or her own best answers deep inside, and that the role of the counselor is not to solve the client’s problems, but rather to help that person find what he or she needs to work through the painful times and problematic areas.

Misconception #3: People Who Need Counseling Are Basically Emotionally Unstable

Another misconception about the counseling process is that a person must be crazy or unstable if he or she is seeking help from a counselor. It is true that when someone is going through a difficult time, especially an acute grief reaction, there is a wide range of emotional responses that can be associated with that loss (Worden, 2009). Those emotions are often described by bereaved individuals as similar to riding a “rollercoaster,” with feelings changing rapidly and varying widely, and the sense of being out of control often highly distressing. Such feelings have led many of our clients to ask questions, such as, “Am I normal?”; “Am I going crazy?”

We often reassure these clients that although they are normal, the disequilibrium that they are experiencing can be the stuff of crazy making! It is not because people are going crazy or that something is wrong with them that they seek counseling, but rather it is because they are experiencing a significant challenge (e.g., a death, divorce, grief, a personal trauma, unresolved childhood issues), and they need to have a safe place to sort these things out with someone who can walk alongside them in an empathetic, yet objective, way.

Misconception #4: People Who Have Good Friends Do Not Need a Counselor

Many individuals would say that they could get the same support from having a discussion with close friends or family members as they can by speaking with a counselor, and it is true that most of us have friends and family members who we rely on for support during difficult times. However, sometimes these individuals are also personally involved in the same difficult situations, or they are directly affected by them. As a result, these individuals may have their own opinions or strong feelings that may hinder our ability to openly share our difficulties or to seek their counsel.

In actuality, a counselor can provide a listening ear and trained support that a friend might not be able to provide. Lewis Aron describes the special type of listening in which counselors engage:

That is what we offer: We listen to people in depth, over an extended period of time and with great intensity. We listen to what they say and to what they don’t say; to what they say in words and to what they say through their bodies and enactments. And we listen to them by listening to ourselves, to our minds, our reveries, and our own bodily reactions. We listen to their life stories and to the story that they live with us in the room; their past, their present, and future. We listen to what they already know or can see about themselves, and we listen to what they can’t see in themselves. We listen to ourselves listening. (Safran, 2009, p. 116)

This specific type of listening is unique to counseling and is unlike other types of interaction. Unlike a relationship with a friend, relative, colleague, or another caring human being, counselors do not just listen – they provide a means for clients to hear themselves more clearly, and hopefully, come to some awareness of what is causing them to feel the way that they feel. Although friends might have wonderful listening skills and a desire to help, there is often a problem with friends acting as counselors because it is very difficult to see a friend who is hurting and the desire to “fix” or “rescue” may interfere with the client’s ability to solve the problem or issue for himself or herself. Suffice it to say that most of our clients have good friends and family members available to them, but they usually find that the unique relationship with the counselor offers something important that these other relationships cannot during certain difficulties.

Misconception #5: Focusing on Problems Will Make Them Worse

The last misconception that we would like to address is the belief that we should just forget about our problems and move on in life. Although we readily agree that not everyone will find counseling helpful, especially if they are not prone to talking openly with others about the more personal aspects of their lives, it is concerning that there is so much social pressure for people to ignore their feelings and act as if everything is fine when it is not. Unfortunately, this scenario is what commonly occurs, and in many instances, the problem festers and resides in the background, drawing energy away and resurfacing in unwanted ways throughout one’s life. It is true that in counseling we tend to focus on client’s feelings and their expression rather than supporting their suppression, which is more socially acceptable. However, focusing on feelings and actively working with strong emotions will not cause a client to lose control and have a “mental breakdown.” Delving deeply into the difficult emotions that clients bring to the session does not cause depression or encourage the client to “wallow” in pain and self-pity. The contrary often seems to occur, as many of our clients will tell us that they feel lighter and more connected with themselves and others after they have been able to identify and share their feelings with someone who supported them in this way.

As a counselor, it is important to be aware of these common misconceptions and how they may influence your clients. Many people are very fearful of pursuing counseling mainly because of these misunderstandings about the purpose and process of counseling. However, if they were to understand what the counseling process is really about, they might view the process differently.

THE THERAPEUTIC RELATIONSHIP

Developing a range of skills and techniques is very important and useful in working with clients. However, no intervention is more important than first establishing the relationship on which the therapeutic encounter is founded (Horvath, Del Re, Fluckiger, & Symonds, 2011; Norcross, 2010). The relationship between a counselor and a client is both like and unlike any other kind of relationship. What makes this relationship unique? The following list gives an overview of what is unique about what we call the therapeutic alliance with a client:

  • The relationship exists to meet the needs of the client; the client’s needs and agenda are the primary focus.
  • Although the counselor possesses training and experience that are unique to the process, there is recognition that the client is the true expert, because only the client has had direct experience with his or her life and only the client knows what is best for himself or herself.
  • The relationship is a real relationship; counselors will have real feelings about the process and the client, and the client’s feelings and stories will most likely have an impact on the counselor. Because the relationship is a real relationship, issues of personality and goodness of fit may have an effect on the success of the therapy. It is important for counselors to recognize that they may not work well with everyone, and for clients to realize that finding a counselor who is a “good fit” is as important as finding a counselor with appropriate training and credentials.
  • The relationship has specific, described boundaries that are in place to protect both the client and the counselor.
  • The relationship exists within a framework of defined ethical practices for counseling.
  • The relationship is not a friendship, a parental relationship, or a teacher – student relationship, although certain aspects of each of these types of relationships may, at times, be present within the therapeutic alliance.
  • The relationship is built upon a model of respect and empowerment; the counselor follows the lead of the client and builds upon the inherent strengths that are present in the client.

The basic conditions for counseling were defined in person-centered therapy by Rogers (1995) as accurate empathy, unconditional positive regard, and congruence. Accurate empathy refers to the ability of the counselor to enter the client’s inner world of private personal meanings and feelings “as if” it were that of the counselor, but without ever losing the “as if” quality. Entering the world of the client in this way conveys a deep sense of the message, “I am with you completely.” Unconditional positive regard is the stance of the counselor to the client, indicating an attitude that, despite one’s failings and faults, the counselor relates to the client with deep respect, with value, and without any conditions. It is not that the counselor “sugarcoats” problematic areas in the client’s life and way of being, or that the counselor ignores negative or unskillful tendencies that are apparent, but the counselor chooses to focus on trusting in the innate tendency of human beings to grow and develop when given the right conditions for this to occur.

Finally, congruence is a little more complex in its description within the therapeutic alliance. Basically, when a counselor is congruent, he or she is aware of his or her own thoughts and feelings within the encounter with the client, and shares these real thoughts and feelings with the client. A related term to congruence is genuineness, in which the counselor is not merely just fulfilling a role within the therapeutic relationship, but is actively engaged as a real person in that relationship, and shares thoughts, feelings, and reflections with the client that are based within the counselor’s personal experience with the client and not just drawn from theoretical knowledge and viewed through a diagnostic lens (Geller & Greenberg, 2012; Slife & Wiggins, 2009; Yalom, 2009). In this book, we repeatedly go back to these conditions as the foundation of the counseling relationship, with an understanding that the concept of engaged presence is the prerequisite to the counselor’s being able to offer these necessary conditions to the client.

GRIEF COUNSELING

Now that we have discussed what counseling is and what it is not, it would probably be helpful to discuss the specific subset of counseling practice that focuses on grief and bereavement. In her book, Necessary Losses, Viorst (2010) states that loss is something that we cannot avoid and that loss experiences can be both difficult and transformative. Our lives are often shaped and shattered by the experience of various losses over time. The death of a loved one can certainly be one of the most crippling events that we encounter. Because we live in a society where we expect to live a long, healthy life, and there is little exposure to death on a regular basis, most people do not have the opportunity to develop a repertoire of responses to death before being plunged headfirst into a major loss experience. We also do not have many good role models for how to walk the path of grief in a way that allows for much variation, other than the typical social messages that offer empty platitudes and reward bereaved individuals for being busy and distracted, and for “getting over it” as soon as possible. A counselor who understands the basic tenets of good counseling practice and who also has expertise in the grieving process can provide a highly specialized form of support to an individual who is struggling with a significant loss (Larson, 2014; Worden, 2009).

Individual Counseling

Perhaps the most common venue for grief counseling, individual counseling can provide the support and guidance to help a bereaved individual navigate through significant loss experiences. Clinicians who are trained in the unique aspects of grief counseling can help a person better understand this experience and place it into a sense of perspective in regard to normalcy and expectations. Grief counseling might also help the client to identify and develop effective tools to cope at this very time. In addition, the grief counselor is often the safe person who can hear about things that are difficult for the client to tell others within his or her friendship network and family circle. Grief counseling is directly related to general counseling because loss and grief are universal and everyday experiences, and counseling is aimed at helping individuals to get through times in everyday life that are especially challenging or difficult.

Marriage/Couple Counseling

When two individuals who share an intimate relationship experience a significant loss, there are often challenges to the couple in the form of disparities in grieving style. The most common scenario for couple counseling is after the death of a child (Finkbeiner, 2012; Rosenblatt, 2000). The death of a child is one of the most difficult losses that can be experienced; it is expected that we will inevitably bury our parents, and there is a 50 – 50 chance that we will have to bury a spouse, partner, or significant other. However, it is not the natural order for parents to have to bury a child. It is not unusual, even in healthy marriages, for conflicts to occur. Partners who are already in a great deal of pain after the loss of a child often do not have the energy to resolve conflicts with the other partner. There is also the compounding issue of differences in grieving style that often surfaces during this painful time (Doka & Martin, 2010). As a result, it is common to hear partners grieve the loss not only of their child but also of each other due to the deep, paralyzing grief that each experiences and the disparities in how that grief is manifest. In this scenario, couple counseling can provide the grieving couple with an understanding of their grief and the tools to explore where they are stuck in their grief. As a result, they may be able to learn new behaviors and skills to break out of the destructive cycle of blame and isolation that can cause a great deal of damage to the relationship between them.

Family Counseling

Although there is the expectation that family members will grieve together and provide support to one another, the reality is that dissimilar or incongruent grief often occurs and causes conflicts within the family system (Harris & Rabenstein, 2014; O’Leary, Warland, & Parker, 2011). People who experience a mutual loss within a family may be the least able to support each other, because the relational dynamic with each other and the deceased person may impede the ability to find common grief pathways. Loss of a family member disrupts the family system, and the family must reorganize after the loss. Family members may also be depleted after a long period of caregiving, and there may be a lack of available energy to deal with the underlying family dynamics and stresses that have built up over time, and often come to the surface after a family member dies. Counselors who are trained in family therapy and who also understand the complexities of grief within these family systems may be able to bridge the gaps in the family system that has been torn by caregiving burdens, losses, and dissynchronous or asynchronous grief.

GOALS OF COUNSELING

The purpose of grief counseling is to help individuals work through the feelings, thoughts, and memories associated with the loss of a loved one in a way that is congruent with the bereaved individual’s personality, preferences, values, and goals. Understanding the goals of grief counseling can help clinicians to work more effectively with clients. Although most people associate grief counselors with assisting individuals who are grieving the loss of a loved one, the scope of grief counseling encompasses supporting individuals through all kinds of change, transitions, and losses. As you look through these goals, think of how they may also apply to losses that may not be related to death, such as the ending of a relationship, the loss of employment, or the loss of functionality or health.

Some of the goals of grief counseling are as follows:

  • Providing the bereaved a safe place to share their experiences and feelings
  • Helping the bereaved to live without the person who died and to make decisions alone
  • Helping the bereaved to honor the continuing bond with the deceased person while moving forward into life again at some point in the future
  • Providing support and time to focus on grieving in a safe environment
  • Recognizing the importance of important times, such as birthdays and anniversaries, and supporting the client through these dates and special times
  • Providing education about normal grieving and the normal variations in grieving among individuals
  • Assisting clients to integrate the loss into their assumptive world or to rebuild that world after a significant loss
  • Helping the bereaved to understand his or her methods of coping
  • Engaging clients to recognize their innate strengths in coping and adapting to significant loss experiences
  • Identifying coping problems the bereaved may have and making recommendations for further professionals and resources in the community
  • Empowering the client in approaching life and others after experiencing a life-changing loss

We have written this book in a way to hopefully provide you with a solid foundation in counseling and grief theory, interspersed with practical suggestions for your work with bereaved individuals. At its core, grief counseling is basically good counseling practice that is also embedded with the current research, theory, and clinical wisdom from those who have spent years in research and practice with bereaved individuals. We hope that the contents of this book help you to be a better informed and reflective practitioner with clients who have experienced significant, life-altering losses.

CONCLUSION

Counseling is a unique form of support that occurs within a relationship between the counselor and the client, occurring within specific boundaries with the goal of supporting and empowering the client through difficult times in life. Counseling may occur with an individual client, a family, or a group of individuals who share similar loss experiences. Grief counselors help individuals as they work through the grieving process in a way that is congruent with the grieving individual’s personality, preferences, values, and goals.

Glossary

Accurate empathy – The ability of the counselor to enter the client’s inner world of private personal meanings and feelings “as if” it were that of the counselor, but without ever losing the “as if” quality.

Congruence – When a counselor is congruent, he or she is aware of his or her own thoughts and feelings within the encounter with the client, and shares these real thoughts and feelings with the client.

Core conditions of counseling – Established by Rogers in person-centered counseling; these are the three conditions that must be in place for the therapeutic alliance to occur: accurate empathy, congruence, and unconditional positive regard.

Counseling – Professional support that has defined boundaries with the intent of assisting individuals to effectively work through everyday life issues that cause difficulty or distress.

Therapeutic alliance – The unique relationship with a client that is focused solely on the client’s needs, whereby the client feels safe, supported, and understood by the counselor.

Therapy – In-depth professional work with clients, aimed at long-standing struggles and unresolved deeper issues that may require long-term supportive work. In therapy, clients usually work on restructuring core aspects of themselves.

Unconditional positive regard – The stance of the counselor to the client, indicating an attitude that, despite one’s failings and faults, the counselor relates to the client with deep respect, with value, and without any conditions.

Questions for Reflection

  1. Brainstorm about some of the media personalities and popular depictions of counselors that come to your mind. How are the counselors portrayed in these depictions? How do you think these portrayals influence the profession of counseling and the view of the general public about counselors and those who seek counseling? Based on the information in this chapter, how is the actual counseling process different from these portrayals?
  2. In this chapter we discuss how counseling is different from receiving support from friends or family members. What do you think are the specific differences between support from a counselor and other types of support?
  3. After reading this chapter, has your thinking about what counseling offers changed from what it was previously? If so, in what ways?
  4. If you were to provide grief counseling to bereaved individuals, what do you think would be your biggest challenge personally?

 

 

 

 

CHAPTER 2 Unique Aspects of Grief Counseling

Loss, change, and death are all universal human experiences, and each one of us will become intimately acquainted with the grieving process at many points throughout our lives. Most individuals who are trained in psychology and other counseling-related professions typically have an understanding of the process of therapy after significant life events occur. However, we venture further in this chapter to explore what makes grief counseling a unique form of therapeutic support, and how the practice of grief counseling may differ from counseling for other types of issues.

One of the most important aspects of grief that differentiates it from other issues that clients bring into the counseling relationship is that the grieving process itself is an adaptive response and not a form of pathology. Grief is the normal, natural response to loss. Grief is not something that we strive to “overcome” or to which there is “recovery,” as one might recover from an addiction or an illness. Counselors who work with bereaved individuals understand that although the grieving process may involve a tremendous amount of pain and adjustment, the goal of grief counseling is to facilitate the unfolding of the healthy and adaptive aspects of the process as it is manifest within each client, trusting that this unfolding will eventually help the bereaved individual to reenter life in a way that is meaningful.

GRIEF AND THE ASSUMPTIVE WORLD

At a basic level, our expectations about how the world works begin to be formed from birth, through the development of the attachment relationships of the infant and young child. Bowlby (1969, 1973) posited that early-life attachment experiences lead individuals to form “working models” of the self and of the world. We essentially learn whether the world is a safe or a threatening place from these working models. Bowlby’s theory of attachment also suggested that significant losses can threaten these working models, resulting in a need to rebuild or restructure one’s working models to fit the post-loss world. Building upon Bowlby’s work, Parkes (1975) extended the concept of the “internal working model” to that of the “assumptive world,” which he stated was “… a strongly held set of assumptions about the world and the self, which is confidently maintained and used as a means of recognizing, planning, and acting,” (p. 132) and that it is “… the only world we know, and it includes everything we know or think we know. It includes our interpretation of the past and our expectations of the future, our plans and our prejudices” (Parkes, 1971, p. 103).

Parkes (1971) stated that the assumptions that individuals form about how the world works are based on their previous life experiences and attachments. He also emphasized that experiencing a significant loss can threaten one’s assumptive world. Recent research that links attachment style to the way an individual navigates the grieving process after a significant loss would also support the role of early experiences with attachment figures as a template for how experiences are interpreted and integrated in later life (Burke & Neimeyer, 2013; Mancini & Bonanno, 2012; Mikulincer & Shaver, 2013). In her extensive work that explored the construct of the assumptive world in the context of traumatic experiences, Janoff-Bulman (1992) stated that expectations about how the world should work are established earlier than language in children and that assumptions about the world are a result of the generalization and application of childhood experiences into adulthood. Forming a belief that the world is safe is related to the sense of “basic trust” described by Erikson’s (1968) model of human development.

Although attachment theory was originally founded in the psychoanalytic tradition of psychology and the discussion here draws heavily upon attachment as a means of understanding how assumptions are developed, the broader context of the assumptive world goes far beyond the realm of psychological theory or cognition. Janoff-Bulman (1992) identifies three major categories of assumptions, which have been broadened and extrapolated for our reference here:

  1. Assumptions about how the world should work and basic beliefs about other people. For example, many people probably assume that overall there is more good than bad in the world and that people are generally trustworthy. It is important to keep in mind that this category/ assumption will vary from person to person. The main point is that whatever an individual believes about how the world works, that belief is foundational to many choices, decisions, and expectations about the world and other people who are taken for granted in everyday life.
  2. How people attach meaning to the world and to their lives. An example of this assumption might be that many people assume that the world is meaningful and that good and bad events are distributed in the world in a relatively fair and controllable manner. The category of meaningfulness emphasizes the ideas of justice and control over certain aspects of life. Most individuals tend to believe that misfortune is not haphazard and arbitrary; that there is a personoutcome contingency attached to negative life events. At a basic level, especially in Western-oriented cultures, negative events are often viewed as punishment and positive events are rewards. JanoffBulman (1992) states that this assumption is “that we can directly control what happens to us through our own behavior. If we engage in appropriate behaviors, we will be protected from negative events and if we engage in appropriate behaviors, good things will happen to us” (p. 10).
  3. How individuals view themselves, including their worth and how they fit into their social network and cultural context. Most Westernoriented societies place a great deal of value on the individual’s intrinsic worth and value and on individual accomplishment. Other societies may view the worth of an individual in relation to that person’s place within a family system or a larger social context.

Janoff-Bulman (1992) stated that these three categories of beliefs can be called world assumptions, and together they make up an individual’s assumptive world.

Why are we discussing the development of our assumptive world? Because significant losses often assault those assumptions we have formed about the world from when we were very young. We learn that people can harm, even murder, those who we love. We learn that our view of the world as a safe and predictable place, where good things come to those who work hard and where all human beings have value and worth, may not be what we actually encounter in our experiences later in life. Somehow, we then have to reconcile the world that we now know to exist with the world that we believed to exist, and the grieving process helps us to rebuild our assumptive world so that we can feel safe and functional again in this new awareness and experience of the world that differs greatly from our previously held beliefs about how that world should work. The revised assumptive world allows us to attach meaning to our experiences and provides us, once again, with a sense of safety about the world. Rather than being a symptom of a disorder, grief is a multifaceted adaptive response to the disorder and disorganization that can occur after our lives (and our assumptions about the world) have been upturned by a significant loss. Instead of attempting to inhibit grief, we believe that grief needs to be allowed to unfold without hindrance so that the loss experience can be assimilated into one’s existing assumptive world or the assumptive world can be rebuilt in a way that makes sense of the loss that has occurred.

COMING TO TERMS WITH CHANGE AND LOSS

There are many misconceptions about what is involved in grief counseling and the way that therapeutic support works with bereaved individuals. It is not uncommon for a grief counselor to receive calls from individuals who think that family members need grief counseling because they are not “over” the grief or progressing through the grief as they should. The common misunderstanding is that grief counseling will “fix” people or return them to the prior level of functioning. Some of these kinds of expectations placed upon bereaved individuals are rooted in social norms that reward productivity, stoicism, and materialism, and the role of social pressures on bereaved individuals is discussed in a later chapter. It is impossible to reverse time and to control events that are out of our control and we cannot “fix” what has happened (e.g., we cannot bring back the deceased person to relieve the separation distress of the bereaved individual). We also do not focus on helping bereaved individuals to feel better necessarily, because we understand that the process of rebuilding one’s world after a significant loss is naturally going to involve a painful time when the many layers associated with loss must be addressed, and the resulting readjustment that occurs can be a very difficult process.

We crave predictability and stability in our lives. In fact, most of us operate on the assumption that we have a lot of control over the events in our lives (Heckhausen, Wrosch, & Schulz, 2010). One of the basic assumptions espoused by Janoff-Bulman (1992) indicates that most people in Western society believe that if you work hard, you will be rewarded. In our clinical work, we frequently see individuals who experience profound anxiety because they can no longer live under the illusion that things can remain constant and unchanging; this realization usually occurs as a result of the experience of a significant loss or dramatic change in their lives. Even though we attempt to function as if there is certainty and stability in everyday life, the world around us and even our bodies serve as metaphors for the normalcy of loss, change, and transition. The seasons change. Living things are born, grow, reproduce, and die. Many of the cells that exist in our bodies today were not present a year ago, and may not be present in our bodies in a month from now. This moment is gone and replaced by another moment in time. We cannot stop the changing nature of life, just as we cannot stop time in its place or change the course of events, although this topic has frequently been the subject of fantasy.

Weenolsen (1988) speaks of our innate resistance to change and our belief that things can remain the same as the “fundamental illusion,” functioning to allow us to feel safe and solid in the world. However, our clinging to this image causes us great difficulty when the illusion cannot be maintained, such as when a major loss event does indeed occur or when we come to the realization that we have very little control over ourselves and the people, places, and things that matter very much to us. For many of the bereaved individuals who seek counseling, the realizations that (a) we really have very little control over the events in our lives, (b) there is very little predictability and stability in the world, and (c) we will never be the same again form the foundation of the work that occurs in the counseling process.

UNDERSTANDING BEREAVEMENT THEORY IN COUNSELING PRACTICE

It is very important for counselors who wish to effectively support bereaved individuals to have a working knowledge of current theories of bereavement. The literature in thanatology is relatively new in comparison to other fields of study, and most of the current thinking in grief counseling is grounded in ways of thinking about grief, loss, adjustment, and coping that have been reported and published within the last 20 years. We will spend an entire chapter exploring some of the current research in bereavement, current bereavement theories, and ways of working therapeutically with bereaved individuals, but at this point it is important to recognize that there is a separate and unique body of literature in this area that has direct application to grief counseling.

One important aspect of the study of bereavement that we must keep in mind is that grief is not just a psychological issue that is experienced by the grieving individual in isolation. Grief can be experienced and expressed in many ways, which includes thoughts, feelings, and emotions; however, it can also be experienced physically through bodily symptoms, socially through changes in interpersonal dynamics and expectations for the bereaved individual, spiritually as a quest for meaning or as existential suffering, economically through changes in financial status and expenses incurred after a loss, and practically through the changes that occur in one’s day-to-day routine as a result of a loss. Thus, we look at literature in many fields of study for an understanding of the grief process in all of its many facets and complexities.

Another unique aspect of grief counseling is an understanding of the complexity of the experience and the factors that shape an individual’s response to loss. For example, when there is a loss within a family system, each individual family member will experience grief depending on his or her relationship to the deceased person and other family members, the age and developmental stage of the family members, who provided the caregiving if needed, and the grieving styles of the members (Kissane, 2014). Individuals tend to grieve in ways that are congruent with their age and developmental stage, according to their personalities and attachment styles (Doka & Martin, 2010; Lai et al., 2014; Stroebe, 2002), in the context of social rules and expectations (Doka, 2002; Harris, 2009 – 2010), with the influence of other factors and concurrent stressors at that time (Worden, 2009). Thus, grief counselors need to have a good understanding of how many different areas intersect in this one experience. For example, to explore only the feelings associated with a loss without understanding the social underpinnings and the impact of the concurrent stressors that shape these feelings would provide an inaccurate and overly simplistic account of the client’s full experience.

Understanding current bereavement theory and research allows the counselor to appreciate the normative aspects of grief that may inadvertently be labeled as pathological or abnormal to someone who does not have this awareness. For example, the dominant view of grief until recently was the “grief work” hypothesis (Stroebe, 2002), which stated that individuals must do the “work” of grief by talking about their loss and their feelings, and if a bereaved person did not do this, it was assumed that something was wrong with that individual or he or she was not grieving properly. The grief work model also posited that the goal of grief was to help the bereaved individual to “let go” of their loved one in order to move forward in life. However, in the mid-1990s, research with diverse groups of bereaved individuals demonstrated that although many individuals did, indeed, talk about their loss and their feelings as part of the grief response, many others did not have this same need, and these individuals seemed to cope just as well afterward. In addition, the Continuing Bonds Theory, derived from research by Klass, Silverman, and Nickman (1996), demonstrated the normalcy of bereaved individuals continuing a relationship with the deceased. These researchers found that the ability to find a way to remain connected to the deceased individual often helped bereaved individuals to move forward in their lives after a loss.

WHO BENEFITS FROM GRIEF COUNSELING?

Most grief counselors assume that their work with bereaved individuals is effective. However, recent research into the efficacy of grief counseling provides more detailed information about who would benefit from, and who might actually be harmed by, grief counseling. Studies by Kato and Mann (1999) and Allumbaugh and Hoyt (1999) implied that professional bereavement support did not provide significant benefit to the bereaved participants. It is probably important to take a step back and to ponder the basic premise of many interventions for bereaved individuals. As we have stated earlier in this chapter that grief is a normal and adaptive process, we need to consider why professional intervention may be needed by bereaved individuals to assist an adaptive process that is at work. Indeed, Stroebe, Hansson, Stroebe, and Schut (2001) observed that the general tendency for many bereaved individuals is to improve with or without professional intervention. In addition, Kato and Mann’s (1999) study revealed that many of the bereaved participants would have had a better outcome if they had been assigned to the control (nontreatment) group than to the treatment group. In another study, Jordan (2000) reported that for some bereaved individuals, professional intervention may actually do more harm than good. Neimeyer (2012) provided reflection on grief counseling research, stating that many studies did not capture the 10% to 15% of bereaved individuals who not only would benefit from grief counseling but also should receive intervention to prevent significant negative consequences that may occur as a result of their losses. In a review of research into the efficacy of grief counseling, Schut (2010) similarly concluded that although it is not effective to recruit bereaved individuals into grief counseling if they are not seeking support, professional support may be beneficial for those who do request it and for those who endure a crippling form of complicated grief.

In response to these findings, researchers in the area of bereavement have made some comments and suggested a few guidelines that would be applicable to clinical practice in grief counseling. It is generally agreed that most bereaved individuals are able to adapt to the loss that has occurred with the support of their families and friends and do not require professional intervention. Making the assumption that all bereaved individuals need professional assistance would be inconsistent with the awareness of grief as an adaptive process. It may be the case that although the grieving process is normative and adaptive, if one’s grief does not fit into a socially acceptable or recognized pattern, the bereaved individual may be perceived as abnormal and referred for treatment; when in fact, the social norms that judge the expression of grief in such limited terms may be the issue, and not some dysfunction within the individual. Wolfelt (2005) suggests a model of “companioning” with the bereaved, emphasizing the relational component of therapeutic support, which may be especially helpful if a bereaved individual does not have other supports available to “walk alongside” him or her during the acute grieving process.

In their review of bereavement efficacy studies, Jordan and Neimeyer (2003) state:

[G]eneric interventions, targeted toward the general population of the bereaved, are likely to be unnecessary and largely unproductive. Instead, interventions that are tailored to the problems of mourners in high-risk categories (e.g., bereaved mothers, suicide survivors, etc.), or showing unremitting or increasing levels of distress after a reasonable period of time are likely to be more beneficial. (pp. 778 – 779) Parkes (2002), Schut and Stroebe (2011), and Neimeyer (2012) identified specific at-risk populations that may benefit most from grief counseling. These groups include older men who lose spouses, mothers who lose children, and survivors of sudden or violent losses with traumatic features. Other high-risk individuals may be those with preexisting psychological disturbances, such as depression, substance abuse, posttraumatic stress disorder, and previous history of psychosis. In addition, individuals with high levels of distress early in their bereavement experience are more likely to benefit from professional intervention. Hoyt and Larson (2010) suggest that some of the research about the efficacy of grief counseling (and the lack of positive effects that have been found in many of the studies with bereaved individuals) may be a result of how participants are recruited versus how clients actually seek counseling for assistance when they feel that they need additional help. These researchers state that there is a big difference between individuals who respond to calls for participation in studies and bereaved individuals who contact a counselor for assistance with a grief-related issue.

CONCLUSION

Once you start into a clinical practice specializing in grief counseling, you will no doubt have clients with a diverse range of losses who also have very different ways of grieving, coping, and adapting to loss. Probably the most important aspect of your work will be your ability to “walk alongside” your clients as they share their experiences with you. It is important that you are able to normalize reactions that may be viewed as abnormal by social norms that are unrealistic, and that you are able to recognize when a client is in a high-risk category and in need of additional support. Having knowledge of current bereavement theory and research will help you in this process. Being informed and aware of good counseling practice is also essential to providing a safe place for your clients to journey through their grieving process in a way that allows for the integration of the loss experience into their lives in a way that is healing.

Glossary

Assumptive world – Fundamental beliefs that an individual holds regarding how the world works and how others and one’s self are viewed. The assumptive world is thought to provide individuals with a sense of safety and security in everyday life situations.

Attachment – The formation of signifi cant and stable connections with signifi cant people in an individual’s life. This process begins in early infancy as the child bonds with one or more primary caregivers, and later extends to other signifi cant relationships through the lifespan. Attachment is thought to be an instinctual construct with the purpose of ensuring safety and survival.

Fundamental illusion – The belief that things will always remain the same; maintaining this illusion serves the purpose of allowing people to feel safe and solid in the world.

“Grief work” hypothesis – View of grief that individuals must do the “work” of grief by talking about their loss and their feelings, and if a bereaved person did not do this, it was assumed that something was wrong with that individual. Also indicates that that the goal of grief is to help the bereaved individual to “let go” of their loved one in order to move forward in life.

Questions for Reflection

  1. If grief is an adaptive and healthy process, why do you think we have such a great deal of difficulty acknowledging grief both personally and socially?
  2. Think about the section on the assumptive world. What are some of the assumptions that you can identify personally that guide you in your life? What are some of the ways that your assumptions have been challenged by experiences that you have had in your life?
  3. If, as the chapter states, change and transition are truly constant companions in life, why do most people have difficulty adjusting to change and loss in their lives?
  4. You are a grief counselor and you receive a call from a woman who wants her father to come to see you for counseling after the death of his wife (her mother). She reports that she is concerned that her father does not seem to be grieving at all, and she thinks that he needs to talk with someone. How would you respond to her request?
  5. Perform a search on the Internet with one of the well-known search engines using the key words of “grief counseling,” “grief recovery,” and “helping bereaved individuals.” Read over some of the material that is presented in these links. How many of them still extol the grief work theory of bereavement? What audience do you think each site is trying to target? Based on your reading of this chapter, do you think there is any potentially harmful content on the sites for bereaved individuals?

 

 

 

 

CHAPTER 3 Theories and Orientation to Bereavement

In this chapter, we briefly look at models and theories of bereavement that help us to understand the grieving process a little better. Models and theories serve as descriptors for us and for our clients. They help us to “map out” what may occur after a significant loss in someone’s life. They may also give us a framework for knowledge and insight into the various ways in which people experience grief and adapt to loss, or how bereavement professionals have observed grief responses in their clients. Research-based theories and models may ground our clinical practice in empirical knowledge, and descriptive models may give us practical insights from the anecdotal accounts of other clinicians who do similar work. It is important to keep in mind that no one theory or model can fully encompass all of the manifestations, expressions, and experiences of grief and loss. However, becoming well versed in these descriptions may be of benefit to both the counselor and the client.

Before we embark on our exploration of various theories and models of bereavement, it is important to keep some thoughts in mind. First, although loss and grief are universal experiences, shared by all human beings, the grieving process is highly diverse and variable among individuals. Second, grief is more than an emotional response. Many individuals experience grief in ways that are dominated not by their emotions but by cognitive processes, somatic (bodily) changes, and/or changes in their social circles and patterns. In addition, a person who is grieving a loss exists within a broader social and cultural context, and we do a great disservice to individuals by assuming that they exist as separate entities from these spheres of existence. Finally, we tend to think in terms of adapting to losses and integrating these experiences into our assumptive world rather than focusing on “recovery” from grief or “overcoming” a loss.

DEFINITIONS AND ANALOGIES

For the purposes of this book and our study of bereavement, loss is defined as the real or perceived deprivation of something that is deemed as meaningful. A loss can be death related or nondeath related. A loss experience is one in which a return to some aspect of life that we have cherished or valued is no longer possible. Grief is defined simply as the normal and natural reaction to loss. However, the use of the word “normal” implies that there is a defined expectation of what normal grief should look like, and that is far from true. Although grief is a universal experience that is shared by all human beings, the actual grief response in each individual is very unique, and the expression of grief can vary greatly from one person to another. Many factors, such as personality traits, the presence of concurrent stressors and previous losses, the nature of the loss(es), and the social expectations that are present, have a great deal of influence in shaping the course of grief for an individual, and these are discussed in later chapters.

Sometimes, analogies are helpful to share with bereaved clients to help point out the highly individual and unique nature of grief, especially when these individuals are told by others that somehow their grief response is abnormal.

  • The grief response can be compared to snowflakes, where we can look at the flakes and identify them as “snow,” but when you look closer, the crystalline structure of each individual flake is highly unique and there are an infinite number of patterns that can be found.
  • The grief response is like a fingerprint; all human beings have finger-prints, but each person is identified by a unique fingerprint pattern that is unlike anyone else’s.
  • A significant loss can be seen like a deep wound that will heal with proper care and attention. After a deep wound heals, there is usually a scar in its place. So, although the “wound” is healed, the skin is never the same as it was before. (Another aspect of this analogy is that scar tissue tends to be thicker and stronger than the skin surrounding it.)

ATTACHMENT AND THE GRIEF RESPONSE

As we discussed earlier, a key aspect of bereavement theory is the concept of attachment. In humans, attachment is based on one of our most deeply rooted needs of safety and security (Bowlby, 1969, 1973). Attachment bonds are deeper than relational bonds, and they exist at a level in the human experience that is usually not in a person’s conscious awareness (Parkes & Weiss, 1983). When we speak of attachment in this context, we mean something more than a relational bond. Attachment relationships are linked to our primary, instinctual need to be close to significant others in order to feel safe and to feel a sense of “anchoring” in our world. In infants, the attachment system is formed around the primary caregiver who is present to meet the basic needs of the infant and who responds to the infant’s cries and beginning attempts at social interaction. Later, we form attachments to individuals who tend to be closest to us, or to whom there is significance identified for us. It is important to note that the presence of attachment in a relationship is not necessarily dependent on the quality of the relationship or the personality or temperament of the individuals involved in the attachment bond.

Attachment in humans was first described by John Bowlby, a psychoanalytically trained psychiatrist who worked with young children in postwar England. In his position at the Tavistock Clinic, he observed children who had been separated from their parents (their primary attachment figures), and he made note of some commonalities in the responses of these children, which he termed “separation distress.” Bowlby was also influenced by the work of Hinde (1992), who, like Harlow (1961), studied the effects of infant – mother bonding in rhesus monkeys. Bowlby noted that in the works of both researchers, there were comparable behaviors demonstrated between primates that were separated from their mothers and human infants who were separated from their human mothers. He termed these consistent behaviors “attachment behaviors,” and suggested that these behaviors functioned to ensure that the primary caregiver stayed within close proximity to the needy, helpless infant in both species (Cassidy, 1999).

Bowlby later postulated that attachment between infants and their mothers is an ethologically based[1] construct, which serves to ensure the protection and survival of the infant. Thus, attachment theory was initially born as a merging of the psychoanalytic school of thinking and ethology, the study of animal behavior. Attachment was defined as an instinctually mediated response of an infant to its mother, and this response is delineated in the infant’s developing mind through object representation and maintained through the attachment behaviors (Bretherton, 1992). Bowlby’s later work became an eclectic model that incorporated elements of psychoanalysis, ethology, experimental psychology, learning theory, and family systems to describe the psychological and emotional development of the child.

Colin Murray Parkes, a psychiatrist based in London, U.K., worked at the Tavistock Clinic under John Bowlby. He postulated that the attachment behaviors observed in infants upon separation from their mothers were the same behaviors that grieving individuals display upon the loss of a loved one through death (Parkes & Weiss, 1983). Parkes (1996) conducted extensive longitudinal research with older widows, documenting their behaviors, thoughts, and feelings after the death of their spouses. He found common behaviors between the separated infants in Bowlby’s research and the widows in his own studies. Examples of these common behaviors were searching, pining, and protest upon the disappearance/loss of the attachment figure. Weiss (1975) explored attachment behaviors in the situation of divorce and obtained similar findings.

In addition to comparisons between the separation of infants from their mothers and the separation of adults from attachment figures through death, further studies examined the attachment behaviors of adults in various relationships (Ravitz, Maunder, Hunter, Sthankiya, & Lancee, 2010). The role of attachment in adult relationships has now been explored in longitudinal studies (Fraley, Roisman, Booth-LaForce, Owen, & Holland, 2013). Stable patterns of attachment behavior in children up to the age of 10 were documented by Sroufe, Egeland, and Kreutzer (1990). Clulow (2012) examined the identification of adult attachment styles with specific interactions in married couples. Their data suggest that there are significant correlations between attachment security and marital quality. Simpson and Rholes (2012) explore the role of attachment style to adult intimate relationships. These authors state that adults demonstrate the same types of attachment style in their relationships with other adults that were originally present when these adults were much younger. Thus, their premise is that adult coping strategies and behaviors in intimate relationships are governed by attachment style as determined by childhood attachment experiences.

The “take home” message for this discussion is an understanding that:

  • Grief is part of an instinctually mediated response that is based on our attachment system. Our attachment system typically exists outside of our conscious awareness unless it is threatened.
  • The loss of an attachment figure will be experienced as a threat to most individuals.
  • An attachment relationship is one that is significant, but the attach-ment bond itself is not necessarily dependent on the quality of the relationship. Infants form attachments to mothers who are not attentive; however, the quality of the attachment bond that is formed is certainly affected by the interaction between the two individuals.
  • Attachment relationships are present throughout life and do not only involve parental figures from early life and development.

THE DUAL PROCESS MODEL OF GRIEF

Research by Stroebe (2002) and Stroebe, Schut, and Stroebe (2005) combined the work of all of the researchers in the area of attachment to acknowledge (a) the role of attachment in grief and bereavement, (b) the presence of consistency in adult attachment styles related to childhood attachment style, and (c) the specific coping strategies and appropriate expectations and interventions for grieving adults based on identified attachment patterns. These authors proposed the dual process model of bereavement, which allows for an understanding of diverse responses to separation and loss by examining the underlying attachment issues that are present in grieving individuals. The dual process model (Figure 3.1) posits that bereaved individuals will spend time in acute, active grief over the loss and its implications (loss orientation), and they also will spend time tending to their everyday life and returning to the world of the living that distracts them from their grief (restoration orientation).

According to Stroebe et al. (2005), individuals identified as basically secure in their attachment style will demonstrate a more balanced approach to emotion regulation in grief and will tend to “oscillate” more evenly between loss orientation (overt grief) and restoration orientation (daily functionality and activities of daily living). Individuals who display avoidant attachment patterns will tend to focus more on restoration orientation and will restrict their expressions of distress and avoid seeking support. Individuals whose attachment style is anxious – ambivalent will tend to focus more on loss orientation, and they are more likely to become preoccupied by their grief and will tend to ruminate more about the deceased individual. Individuals who tend to display patterns of disorganized attachment tend to present in ways that are similar to individuals who have suffered from traumatic experiences and have difficulty integrating their experiences into a relational context. The conclusion of these authors is that attachment style influences the course, intensity, and pattern of grieving after the death of an attachment figure.

The use of attachment theory with its terminology, background, and associated predictions offers some interesting possibilities. For instance, when the concept of attachment theory as an ethological construct is applied to the grieving process, there is an implication that the grieving process itself is an adaptive mechanism that also functions to ensure the survival of the individual after the loss of a significant attachment figure. Grief as we know it may thus be a response that is instinctually programmed into us as a result of natural selection. If this statement is true, then the grieving process itself must be allowed to unfold without hindrance for the assistance in adaptation that grief may afford to the bereaved individual. The grieving response would also be seen as separate from the quality of the relationship to the deceased individual, and more of an extension of the attachment pattern of the remaining bereaved survivor, although certainly the quality of the relationship would likely have an impact on the grief process.

TWO-TRACK MODEL AND THE CONTINUING BONDS THEORY

In research and clinical work with bereaved parents in Chicago, and later in Israel, Rubin, Malkinson, and Witztum (2012) propose that the response to loss can be more effectively assessed when both the behavioral – psychological functioning of an individual and the internalized relationship to the deceased are considered. This model addresses grief through a multidimensional lens, exploring both (a) the bereaved individuals’ ability to function and navigate the world after a significant loss (track I) and (b) the tendency of bereaved individuals to continue in an ongoing and meaningful, but intangible, relationship with a deceased individual over long periods of time, and even indefinitely (track II; Rubin, Malkinson, & Witztum, 2011). Rubin and colleagues strongly urge clinicians working with bereaved individuals to identify which “track” appears to be more problematic or prominent for the bereaved person and to focus on that aspect of the grief in the support that is offered. For example, if a widow describes a great deal of stress as a result of the financial matters that were associated with her husband’s estate, the counselor would serve her more readily by focusing on these issues (track I) rather than engaging in therapeutic work that is focused more on the memories and feelings associated with her deceased husband at that time (track II).

When first describing the two-track model of bereavement, Rubin emphasized that the relationship with the deceased person often remains a focal point for the rest of the lifetime of the bereaved individual. In tandem with this model, Klass, Silverman, and Nickman (1996) described what they termed the bereaved’s continuing bond with the deceased individual. It was clear from the data presented in these authors’ research that the bereaved maintains a link with the deceased that leads to the construction of a new relationship with him or her. This relationship continues and changes over time, typically providing the bereaved with comfort and solace. Most mourners struggle with their need to find a place for the deceased in their lives and are often embarrassed to talk about their ongoing relationship with a person who has died, afraid of being perceived as having something wrong with them. The idea of a continuing, ongoing relationship with a deceased individual was a very novel proposition after so much of popular thought (based on Freud’s writings) had been focused on the need to let go of the deceased loved one in order to move forward in life. The work of these researchers actually demonstrated that individuals who were more highly functional and had adapted better after a significant loss were those who were able to maintain a sense of connection (a continuing bond) with their deceased loved ones. Obviously, there will be some complications to this process, as when the relationship with the deceased was difficult or complicated (Field & Wogrin, 2011), or if the bereaved individual displays symptoms of prolonged grief disorder rather than developing an adaptive continuing bond with the deceased individual (Prigerson et al., 2009), which are discussed in Chapter 10.

The Continuing Bonds Theory has very important implications for grief counselors. First is that bereaved individuals may be well served to find ways to reconnect to their deceased loved one in ways that are meaningful. In the course of clinical practice, you will hear a myriad of stories about how bereaved individuals “connect” with their deceased loved ones – through having conversations with them, journaling to them, dreaming about them, feeling a sense of guidance from them or a sense of their presence with them in an abiding way, or finding “signs” that they believe are from the deceased individual to them. We have had clients tell us about hearing significant songs on the radio at opportune times, birds appearing on their porch, seeing patterns in carpeting, electronic devices turning on by themselves, dream encounters and symbols seen in dreams, hearing a voice, feeling a brush of air, finding something that was lost a long time ago now being found in an obvious place, and numerous other ways that are experienced by bereaved individuals as a form of connection with their deceased loved ones. The implication here is clear, as Morrie instructs Mitch in Tuesdays With Morrie: “Death may end a life, but not a relationship” (Albom, 1997, p. 174). It is very important as counselors to normalize this aspect of grief and to recognize its significance for the bereaved individual’s process.

In our clinical practices, we often notice that bereaved individuals seek out support at a time when they have lost the physical and tangible presence of their loved one, and have not yet been able to establish a link to their deceased loved one in an intangible way. There are obviously many other factors that contribute to a decision to seek support after a significant loss, but this is one area where we actively work with clients to assure them of the normalcy of their experiences, and to let them know that in some way, they may need to find a way to “hold on” to their loved one in order to “move on.”

This is a good time to bring up the controversy that surrounds what is known as the “grief work hypothesis.” This belief about grief was that it was necessary for bereaved individuals to talk about their loss and to express emotions in order to work through their grief, and that once painful emotions were worked through, persons could resolve their feelings of grief (Stroebe et al., 2005). We now realize that not everyone grieves through feeling and expressing emotion, and, in fact, insisting that someone grieve in this way when it is not that person’s propensity may induce more harm than good. The grief work hypothesis also posited that the goal of grief work was to eventually let go of the deceased person and relinquish the relationship to that person in order to move forward in life. We now know from the previous discussion that this “letting go” is not supported as necessarily the way many bereaved individuals typically move forward in their lives after losing a loved one.

STAGES, PHASES, AND TASKS

If you were to ask the average person in casual conversation about grief and what it looks like, you would most likely be quoted “The Stages of Grief,” as set out in Ku¨bler-Ross (1969). This book was a seminal piece of work that openly addressed the needs and feelings of dying individuals in a society that had become increasingly death denying. In her book, Ku¨bler-Ross identified five stages in facing death and in being confronted with a significant loss: (a) denial, (b) anger, (c) bargaining, (d) depression, and (e) acceptance. Earlier proponents of this model suggested that the stages occurred in a more stepwise and linear fashion. However, Ku¨bler-Ross later stated that these stages were more like descriptors rather than a prescription to follow, and an individual could fluctuate from one to another readily. Although these stages have been heartily embraced in popular (and academic) thinking, it is important to recognize the fact that the five stages were never actually empirically proven to occur in dying or bereaved individuals (Maciejewski, Zhang, Block, & Prigerson, 2007). The primary usefulness of this theory has been exactly what it did – promote a springboard for beginning discussions about this topic in a society that was generally avoidant and thus relatively uneducated about death and grief.

There are also many theories of bereavement, which suggest that bereaved individuals go through “phases” in the grieving process. Bowlby (1982) described the “processes of mourning,” in which he listed first yearning and searching, then disorganization and despair, followed by reorganization. Parkes (1996) later expanded on these phases by adding an additional phase of numbness at the beginning of grief. Sanders (1999) proposed her five phases of the grief process as (a) shock, (b) awareness of loss, (c) conservation/withdrawal, (d) healing, and (e) renewal. Rando (1993) put forth her description of the process of the “six Rs” of bereavement as (a) recognize the loss, (b) react to what has happened, (c) recollect and review memories associated with the loss, (d) relinquish the world as it once was, (e) readjust to life after the loss, and (f) reinvest and reenter the world. It is apparent that there are many ways of describing the grief process and many different perspectives from which these descriptions are drawn.

Worden (1991, 2009) developed a task-based model of grief, in which the grieving process is compared to the developmental tasks that individuals must master in order to move forward in life. These tasks are as follows:

  1. Acknowledge the reality of the loss. The mourner needs to cease denying that the death has occurred and come to recognize that the loved person is truly dead and that cannot return to life. The mourner needs to examine and assess the true nature of the loss and neither minimize nor exaggerate it.
  2. Process the pain of grief. Sadness, despondency, anger, fatigue, and distress are all normal responses to the death of a loved person; people should be encouraged to experience these feelings in appropriate and supported ways, so that they do not carry them throughout their lives.
  3. Adjust to a world in which the deceased person is missing. A full awareness of the loss of all of the roles performed by the deceased in the life of the mourner may take some time to realize. Challenges to grow are presented to the mourner as he or she assumes new roles and begins to redefine himself or herself, often by learning new coping skills or by refocusing attention on other people and activities.
  4. To find an enduring connection with the deceased in the midst of embarking on a new life. It is important for the bereaved individual to find an appropriate place for the deceased person to occupy in a spiritual or nontangible sense. This task involves creating and sustaining an appropriate relationship with the deceased based on an ongoing emotional connection and memory, so that person will never be wholly lost to them. This task was revised by Worden (2009) over the earlier versions of his model, and it is now very similar to the process that is described in the Continuing Bonds Theory discussed earlier.

Each description of phases, stages, and tasks may point to important aspects of the grieving process and may provide some realistic expectations for bereaved individuals, provided the phases and stages are not seen as necessary scripts for all bereaved individuals, or as a “map” of how grief should be for everyone. However, the downside of these models is that they tend to be seen as placing the grieving process in a linear flow (even if not intended by the model’s originators), and there seems to be an emphasis on the sameness of the grief experience by all bereaved individuals, rather than an appreciation of the diversity that is present within grief. It is very important to remember that no individual’s grief experience will neatly fit into a single model, because there is much variation in how losses are perceived and also in how grief is expressed and worked through.

MEANING RECONSTRUCTION AND GROWTH

The experience of a significant loss will often pose a strong challenge to an individual’s sense of equilibrium. Coping, healing, and accommodation after such experiences are part of a greater process that individuals undertake in an effort to “relearn” their world (Attig, 2011) in light of confrontation with a reality that does not match one’s expectations or assumptions. As we discussed in an earlier section, how we see the world (and our lives) as meaningful is based on the assumptions we have formulated about the world from our earlier life experiences and interactions. A significant loss can shatter the assumptions we have about how the world should be, and we can experience a high degree of distress when we cannot make sense of what has happened, or when we no longer feel a sense of safety or equilibrium in our lives.

Challenges to one’s assumptive world are usually met through the processes of assimilation (where events are interpreted through the lens of the assumptive world satisfactorily), or accommodation (where assumptions are gradually revised somewhat in order to explain a new set of experiences). However, there are times when something may happen that defies belief, or overwhelms one’s ability to integrate the experience with any known way of how the world should work. The phrase “loss of the assumptive world” is used when a negative life event has challenged one’s basic assumptions about the world in a way that these assumptions no longer make sense, and there is no acceptable alternate way of seeing the world that will reconcile previously held assumptions and beliefs with a new reality that does not fit these assumptions (Attig, 2011; Janoff-Bulman, 1992; Parkes, 1971).

Preexisting assumptions that are no longer viable in describing the world and one’s inner working models or schemata must somehow be reworked in order for the person to feel safe in the world again, but this process can be very difficult. Janoff-Bulman (1992) uses the term “shattered assumptions” to describe when a negative life event overwhelms an individual’s core assumptions so completely that reconciliation of reality with one’s existing assumptive world is not possible.

Tedeschi and Calhoun (2004) speak of “seismic life events” that “violate” an individual’s schemas about how the world should work. It is important to note in this discussion that the individual’s subjective appraisal process is very important. How one interprets and perceives an event determines the significance of its impact on the assumptive world. Meaning making is the focus of many authors who explore responses to trauma, loss, and negative life events. Making sense of an event involves a process of attempts to reconcile the occurrence of the event with one’s working models of the assumptive world (Davis & Nolen-Hoeksema, 2001). Frankl (1963), a concentration camp survivor and the developer of logotherapy, asserted that one can survive all forms of harm and harshness by finding meaning and purpose through what one has experienced. By choosing to reflect upon the possibility of something positive occurring after the negative life event, individuals may be able to assign meaning to their experience, which helps to rebuild the foundation for one’s assumptive world that is positive again. Janoff-Bulman (2004) describes the existential issues that must also be addressed and assigned meaning after experiencing a critical event. Survivors are interested not only in why an event happened but also in why an event happened to them in particular. She cites Sartre (1966) in her discussion of existential issues, stating that individuals must create their own meanings through deliberate choice in the face of meaninglessness. She concludes that we may not be able to prevent misfortune, but we have the ability to create lives of value in the wake of misfortune.

Searching for meaning after significant loss appears to be an almost universal phenomenon and an important part of the grieving process (Davis, 2001; Gillies, Neimeyer, & Milman, 2014; Park, 2010). The trauma, shock, and anguish of a major loss assault an individual’s fundamental assumptions about the world. Meaning making can result from reinterpretation of negative events as opportunities to learn new lessons about one’s self or life in general, as a means of helping others, or contributing to society in some way that is related to the experience that occurred (such as the formation of an advocacy group or efforts to help others in similar situations). Perhaps this description offers an explanation as to why many bereaved individuals undertake the founding of trusts, advocacy organizations, and public awareness groups. Mothers Against Drunk Drivers (MADD) is one example of how bereaved parents made meaning by educating the public and advocating for stricter enforcement of laws related to driving under the influence of substances after they experienced the loss of their children from accidents that involved drinking and driving.

Neimeyer (2001) and Neimeyer and colleagues (2002) discuss the social constructivist view of meaning making through the use of narrative reframing in individuals who have experienced significant losses. Neimeyer’s (2001) description of the “master narrative,” which is an “understanding of one’s life and experiences, along with meanings attached to these” (p. 263), is very similar to earlier descriptions of the assumptive world by other writers. He states that significant losses disrupt taken-for-granted narratives and strain the assumptions that once sustained them. Individuals must find ways to make meaning of the life events that have been disruptive by a “reweaving” process that incorporates the new experiences into the existing narrative of one’s life so that it is once again coherent and sustaining.

Searching for meaning in what seems to be a meaningless event is how human beings attempt to reestablish a sense of order and security in the world and to minimize the high degree of vulnerability that occurs after basic assumptions are shattered. Davis, Nolen-Hoeksema, and Larson (1998) focused on two aspects of meaning in their research: meaning as the ability to find a benefit in what had happened and meaning as a way of making sense of the loss. Attig (2001) further delineates the various conceptualizations of the search for meaning by distinguishing between meaning making and meaning finding. Meaning making refers to the conscious and active process of reinterpreting and bringing new meaning to one’s experiences, actions, and suffering, and meaning finding refers to becoming aware of and accepting meaning that arises spontaneously out of grief and suffering. These two processes mix together as one rebuilds the assumptive world after a significant loss.

POSTTRAUMATIC GROWTH AND RESILIENCE

Research published by Tedeschi and Calhoun (2004) suggests that there is potential for more than adjustment after exposure to “seismic” life events. These authors cite numerous instances in their research where individuals encountered tragic bereavement, catastrophic illness, violence, or political oppression, and their exposure to such events led to significant personal accounts of positive growth and development. These authors’ use of the term posttraumatic growth describes the potential that individuals may have for transformation after exposure to trauma, highly stressful events, and crises. Growth in this sense is not a direct result of exposure to these types of events, but rather from the struggle that an individual engages in with the new reality in the aftermath of these events. Posttraumatic growth may also coincide with ongoing distress related to the negative event, because it can be viewed as both a process and an outcome, but not necessarily an acceptance of the event.

Resilience and hardiness, which are two related concepts, speak to a potential for positive outcome after the experience of significant losses. Resilience tends to focus on an ability to go on with life after hardship and adversity (instead of being paralyzed or destroyed by it). Resilience represents more of a “return to baseline” in regard to functioning and views about life. Hardiness is a concept that describes certain individual’s innate tendencies when confronted with challenge (Maddi, 2008; Mathews & Servaty-Seib, 2007). “Hardy” people are those who tend to expect that life will bring challenges and that they can find personal development in meeting these challenges. Individuals who experience posttraumatic growth may or may not have these characteristics, although individuals who score high on hardiness would be very likely to experience posttraumatic growth after a significant loss.

Perhaps most salient to this discussion are the aspects of posttraumatic growth, which reflect upon personal strengths that are developed when some individuals face an assault on their deeply held assumptions about the world. Personal strength may include descriptions of greater self-reliance, fortitude, and self-respect. Janoff-Bulman (2004) gives an account of a client who survived a debilitating accident, who, after months of intense rehabilitation and therapy, stated, “I guess I really am strong … I never knew I had it in me” (p. 30). She also quotes a rape survivor who stated, “I feel stronger now… I came through with my integrity – I got through those months of hell and I know myself as a strong person now” (p. 31). In their descriptions, survivors of traumatic loss events often recognize that they have gone through agony and that they have grown as a result. In the backdrop of suffering, pain, and adversity, individuals may recognize the preciousness of life and be able to identify what is truly “most important” in their lives, which may not have been as easy before the experience.

CONCLUSION

Through the work of bereavement researchers, clinicians, and academics, the present-day thinking of bereavement has been extrapolated. It is generally thought that the grief process has evolved as part of our survival instinct to enable us to integrate the experience of loss into our lives so that we can continue to function and maneuver in a world that is not in our control. We now realize that the grief response helps us to move forward into life, learning how to live again in a world that now does not feel as safe anymore, often without someone who was an integral part of our lives. Grief is seen as healthy and the process as an adaptive albeit painful one. Grief counseling serves to facilitate the natural unfolding of the grief process as it is experienced by an individual. It is important for counselors to remember that the main goal of grief counseling is not to make someone feel better (which is usually not possible anyway), but to provide support and assistance, and to journey alongside the bereaved so that the person will not have to go through this painful process alone.

Glossary

Continuing Bonds Theory – It states that bereaved individuals may be well served to find ways to reconnect to their deceased loved one in ways that are meaningful; often summed up in the statement that death ends a life, but not a relationship.

Dual process model – A model of grief that posits that bereaved individuals will “oscillate” regularly between restoration orientation (e.g., activities of daily living, distractions, and focusing on life) and loss orientation (e.g., remembering the deceased individual, reminiscing about life before the loss, and feeling the pangs of grief).

Grief – The normal and natural reaction to loss.

Hardiness – Refers to a trait in individuals who tend to expect that life will bring challenges and that they can find personal development in meeting these challenges.

Loss – The real or perceived deprivation of something that is deemed as meaningful.

Master narrative – Coherent overarching story and understanding of one’s life and experiences, along with the meanings that are attached to these experiences.

Posttraumatic growth – The potential that individuals may have for transformation after exposure to trauma, highly stressful events, and crises.

Resilience – The ability to go on with life after hardship and adversity (instead of being paralyzed or destroyed by it). Represents more of a “return to baseline” in regard to functioning and views about life.

Two-track model of grief – Explores both the bereaved individual’s ability to function and navigate the world after a significant loss (track I) and the relational aspects of the grief that relate to maintaining a connection with the deceased individual over long periods of time, and even indefinitely (track II).

Questions for Reflection

  1. Before you read this chapter, or before you had any exposure to the current thinking about bereavement, what were your thoughts about grief and the grieving process? Can you think of what may have shaped your thinking before you began reading about grief and bereavement?
  2. A client comes to seek your assistance for grief counseling after the death of her abusive husband, who was an alcoholic and caused her a great deal of harm and terror. Since her husband’s death, she has experienced a great deal of anxiety, and she finds herself ruminating about their relationship. Most of her friends and family tell her that she should be relieved, and she does feel a relief from the exposure to his unpredictability and her feelings of powerlessness to control her family life. She tells you that, mostly, she feels “lost” and paralyzed. Based on the discussion in this chapter regarding attachment and grief, and some of the other theoretical models, can you suggest what is happening to her?
  3. Think of a significant loss experience that you have had or that someone you know has experienced. After reading this chapter and the various explanations of adjusting to loss, which of the theories of bereavement seems to best describe the process you went through after this loss occurred?
  4. Think of examples of disenfranchised grief. What do you think makes some losses more socially acceptable than others? If you have experienced a disenfranchised loss, how was that experience different for you than if the loss was recognized and validated?

 

 

 

 

CHAPTER 4 The Social Context of Loss

While grief is often described as an individual’s unique response to loss, it is shaped and molded to a great extent by the social context in which the grieving individual identifies and resides. These contextual factors have a profound influence on how loss and grief are viewed, including expectations about how grief should be expressed and experienced, and also on the supports and resources that may or may not be available to grieving individuals. As counselors, it is very important to view the client holistically, as a member of many spheres of social interaction, all of which will have an impact on the experience of loss. In this chapter, we look specifically at social influences on the grief experience, including how grief is identified as either normal or abnormal, social norms and rules that affect bereaved individuals’ experiences, and access to potential sources of support and assistance.

SOCIAL SPHERES AND INDIVIDUAL EXPERIENCE

Most of the models of grief that have been proposed originate in the psychological literature, which tends to focus on grief as an intrapsychic, individual experience. Although some of these models may include acknowledgment of the role of family, most tend to describe the experience of the individual, measuring levels of distress, possible problematic coping, and screening for mental disorders, such as depression, posttraumatic stress disorder, and generalized anxiety disorder. Grief is seen as an individual’s personal response to loss, and any treatment or support that is proposed is also directed at the individual level. Thompson (2010) proposes that this current dominant psychological model could be compared to soup that is poured into a bowl, where the soup exists within the bowl but the soup and the bowl remain separate. The bowl simply serves as a container for the soup. Applied in our context, the implication is that the soup (representing an individual’s experience) is held by the bowl (society), but does not interact with it. In contrast, Thompson suggests that instead we look at a different analogy, such as coffee that has cream added to it, where the coffee (society) and the cream (individual) are inseparable and mix together in a way that each is changed and affected by the other. We truly are creatures that are meant to exist in social relationships with others, and the influences of our relationships, social norms, and existing social structures on our lives are impossible to ferret out from our ways of thinking, being, and acting. The experience of grief is a profound example of the interplay between individual and social factors.

Most counselors focus on individual clients who come to them for help in dealing with difficulties that are being encountered in their lives. This form of help is often referred to as micro practice in the social work literature (Kirst-Ashman & Hull, 2009; Wronka, 2008). In micro practice, the focus is on the intrapsychic, individual aspects of the client’s experience and what is happening in his or her life, with interventions focused on the individual’s beliefs, perceptions, and feelings. In this practice setting, the professional helper also has the opportunity to “bear witness” to the client’s story, which can be a very powerful healing experience for the client. Mezzo practice focuses on work with small groups at a local level, such as employees of a specific workplace, members of an extended family system, or a support group that has formed around a specific issue or experience. In mezzo practice, the skills of active listening and reflection that are utilized in micro practice are enhanced by understanding and working with group dynamics as they occur in the interactions and communication among individuals who are present in the group setting. The focus in mezzo practice is on facilitation by the helper. Macro practice looks at larger systems, such as organizations, communities, and even political structures and governments. In macro practice, the focus is on the exploration of social norms and policies, with education and advocacy being the primary ways of addressing organizational, social, and political policies that may have a negative effect on the individuals who are part of these larger groups (Kirst-Ashman & Hull, 2009).

Looking at these levels of intervention is very important, because the strict focus on the individual in isolation (or an atomistic focus; Thompson, 2012) will not address the profound social influences under which an individual must live and function. The emphasis on micro practice can also be problematic because it tends to individualize social problems rather than correctly identify that problematic social norms may actually be at the root of some of the difficulties that individuals experience. As with the image of the cream in the coffee, individual experiences of grief are molded and often profoundly influenced by social messages and norms that have usually been internalized by the grieving individual. This chapter looks at these internalized messages with a “macro lens,” exposing the underlying social norms and rules that may have been adopted into our client’s (and our own) values and self-judgments.

It has often been said that grief is related to our innate tendency to form attachments. This propensity toward attachment identifies human beings as primarily social in nature, needing the acceptance of and affiliation with others in order to feel safe and secure. Thus, the social messages and beliefs held by the dominant group into which an individual belongs will have a powerful influence on how that person perceives himself or herself and also on how the experiences of that individual will be interpreted and either validated or invalidated. If we need to feel socially connected to others in order to feel safe in the world, then experiences that cause us to feel disconnected from our affiliated “group” will be highly disruptive to our sense of safety and security at a very basic level. Feeling isolated or marginalized from our social group increases anxiety, and this anxiety will often motivate us to align ourselves more closely with the values of the group, sometimes even at the expense of our individual feelings and needs (Harris, 2009 – 2010; MacDonald & Leary, 2005).

WHAT IS NORMAL?

Stop and think about what you consider to be normal, everyday food. What is your typical breakfast? What foods do you think of as comforting? What foods would elicit a strong aversion (negative) reaction from you? And yet, people from other cultures may think the foods that you love are detestable and perhaps even disgusting! The point here is that what we think of as “normal” is socially and culturally mediated, and it is also internalized into our personal point of view. It is impossible to separate out what we might view as a tasty dinner from what we were taught was “tasty” as determined by the social and cultural norms of our family, physical location, and cultural views about food. Likewise with grief, what we may consider as a “normal” and acceptable response to loss is largely determined by the social/cultural values and messages that have shaped our thinking. A society that places a high value on productivity and functionality may see emotional expression as a potential threat to these values. After all, people who are emotionally distraught or deeply engaged in their emotions might not be very productive or functional. If loss of productivity is viewed as a challenge to the valued “way of life,” then there would be a great deal of social pressure to minimize or suppress any experience that interferes with one’s ability to be fully functional.

One example of the interplay of individual and social factors in grief is who decides what is normal and abnormal grief? How does the concept of “normal” vary from one society to another? In some societies, the grieving process involves the expectation that mourners will loudly wail and may even physically fling themselves onto the casket or the deceased person at the funeral in a show of profound grief and despair after a death. In other societies, people who remain stoic and hold in their emotions are commended for being “strong” and for “holding up so well” (Despelder & Strickland, 2015). The point here is that definitions of what is normal and abnormal are going to vary and are determined largely by what is valued by the most dominant group in that society. For example, the values in most Western industrialized societies are based on the capitalist focus on productivity, efficiency, and the market economy. These values narrowly shape what is “normal” grief with an emphasis on being strong and functional, returning to work as soon as possible (with limited leave after a loss), and viewing emotional expression as a very private and inconvenient aspect of grief (Harris, 2009 – 2010).

CASE STUDY

I (D.L.H.) began to explore the social influences on grief shortly after I started working with bereaved clients in my clinical therapy practice. I noticed that many of my clients would censor and judge their experiences if they were not aligned with the unspoken social norms and rules related to grief. Most of these norms/rules served to encourage the suppression of grief, which tended to stunt many of my clients’ ability to grieve in the ways they really needed in order to integrate the loss into the fabric of their ongoing lives. I was curious about the role of shame in grief because many of my clients expressed feelings of self-deprecation and loathing because they could not “get over” the grief in a “timely” manner (Harris, 2010). Let us explore a case study to illustrate this discussion:

Jerry was a 57-year-old man whose wife of 35 years (Peggy) had died after a 3-year ordeal with cancer. They were very close, and they did everything together. They loved to travel, planned and cooked gourmet meals together, and were patrons of their local art gallery. They did not have children. Jerry had taken leave from his work in order to be Peggy’s caregiver for the last 6 months of her life. When she died, he was devastated. The house they shared was painfully empty. The friends with whom they had socialized together were kind and attentive, but he felt out of place because they had socialized as a couple. He hated cooking because it was another reminder of Peggy’s absence. Jerry’s boss began to pressure him about returning to work, suggesting that he would be at risk of losing his position if he did not return soon. He told Jerry that “getting back to work will help you to be busy and distracted.” However, Jerry felt unfocused and was concerned about his ability to function in the workplace. He came for counseling 6 months after Peggy’s death, concerned that he was “wallowing” in self-pity and needed help to “just get a grip on life” and go back to work. The pressure from his boss and some of the comments from a few of his friends suggested to him that he just needed to “get on with it” and that perhaps he was not progressing the way he should. In our initial session, I suggested that perhaps his response (“wallowing”) was very appropriate for the significance of the loss of Peggy, and we explored how the loss of his lifelong soul mate affected every area of his life. Much of the work in therapy involved normalizing his feelings and experiences rather than trying to assist him to find ways to “buck up” and be strong.

Interestingly, what seemed to help him the most with his grief was an invitation from Peggy’s friends to join them for coffee one week. When there, they all shared memories about Peggy and how much they missed her. They had set up a foundation in her name with a local art gallery, and they asked Jerry to join them for the first exposition that was sponsored by Peggy’s foundation. Jerry’s sense of isolation and devastation began to lift as he regularly joined these women for coffee and to assist with the work of the foundation. He began to feel more energetic, and he set up a plan to gradually ease back into his workplace.

Was Jerry’s grief “normal?” The current diagnostic criteria would probably indicate that he could readily be diagnosed with complicated grief, a form of disordered grieving that warrants intervention. If Jerry had seen a professional whose model of working with clients was individualistic in nature, he might have been diagnosed with complicated grief (or depression) and begun on a regimen of “treatment” for his disordered grieving response. And yet, what enabled him to begin the journey back into life was the acknowledgment of what was “right” about what he (and many others) had felt was “wrong” with his grief.

What does this mean for individuals who grieve after the experience of profound losses? We are urged to silence our grief or ignore our feelings about our loss experiences. We also feel the pressure to carry on with our lives and our routines as before, being praised for “being strong” in the face of adversity. As a result, individuals who experience profound losses may turn inward, perhaps being able to share their thoughts and feelings with a select few, but still expected to maintain their functionality in the public sphere. We know that raw grief can be temporarily crippling to many individuals, affecting their ability to focus, ability to function, and interest and engagement in the world around them. Thus, it is apparent that the expectations and values of a product-driven society can painfully collide with the individual experience and expression of disabling grief. Social pressures to remain functional, stoic, and strong may not make much sense when your life is decimated by the loss of a loved one or a deeply held part of yourself.

In this instance, what is normal? If we go back to the example of Jerry from our previous section, we can see that Jerry felt a great deal of pressure to function and ignore his pain, and he had also internalized these social norms to the point that he felt shame at not being able to return to work and “get on with it” after Peggy’s death.

In the context of grief counseling, it is important for the counselor to help clients to separate out the social expectations of how they are expected to respond to loss (i.e., how they should respond) from the actual reality of their loss experience (how they actually need to respond) and to normalize grief as a potentially adaptive, but socially uncomfortable and often stigmatized process. Gender socialization and stereotyping are also strong social forces that shape the expectations of how individuals should grieve. For example, men who are sensitive or who express vulnerable emotions publically are often stigmatized as “weak” or effeminate. The fact that Jerry needed to talk about Peggy and that his grief affected his ability to focus would be doubly stigmatizing to him as a man, because men are expected to stay in control and to function proficiently, even in the face of extreme adversity. Women who do not cry or express vulnerable emotions outwardly are often labeled as “frigid” or insensitive (Doka & Martin, 2010). Strong emotions of any type are usually stigmatized, and bereaved individuals may express embarrassment for “losing control” of their emotions in front of others (think about how people will say they are sorry when they cry in public places).

Pressure to view grief in purely individualistic terms, overlaid with the values of strongly capitalistically oriented thinking, twists our fundamentally human experience of loss into pathology, making it into a worse (more disabling, more disempowering) experience than it could have been if adequate support and understanding were available. The problem is not with grief, which can help us to adapt and integrate the losses that occur in our lives. Rather, the problem we often find in our clinical work is that grief causes far more pain and difficulty for our clients when it is rigidly defined and socially controlled in ways that suppress the normal and healthy ways that it can be experienced.

IMPACT OF SOCIAL RULES AND NORMS

In the previous section, we explored how social values can have an impact on the experience of the bereaved individual. Social norms govern appropriate ways of behaving, thinking, and feeling in a particular situation. Norms also may be internalized and thus be considered the “normal” way of behaving, thinking, and feeling by individuals (Brabant, 2002). We continue the discussion to look at the various social “rules” of grief and how they may be applied to bereaved individuals. As grief counselors, we urge you to always bear these issues in mind when you work with clients. In many cases, clients are “stuck” in their grief because they do not have permission to fully enter into their grief in the way that is congruent with their experience of loss. Making these social norms and rules explicit and talking about the ways that grief can be stunted by adherence to expectations that suppress grief rather than supporting it will often create the very space that your grieving clients need in order to address their grief in an open and healing way. Keep in mind that because most people internalize the social norms of the society in which they identify, the “pressure” is often felt within the individual client, even though the issue is rooted in socially mediated values and expectations.

A key component of socially mediated norms in this context is Doka’s (1989, 2002) concept of disenfranchised grief, which states that an individual may have a very significant reaction to a loss, but the loss and the grief are not recognized or validated socially. The implication is that there are norms that provide both social acceptance (and support) or social rejection of a member or group, depending on specific criteria that are identified either overtly (clearly delineated) or covertly (implied). There are several different ways by which the grieving individual is disenfranchised and thus excluded from social support (Doka, 2002):

  • The relationship that was lost was not considered valid, socially acceptable, or important
  • The loss itself is not recognized or viewed as significant
  • The grieving individual is exempted from rituals that might give meaning to the loss or is not seen as capable of grieving for the loss
  • Some aspects of the death or loss are stigmatizing, embarrassing, or unacceptable

Central to this concept are implicit social rules that surround grief. Although these rules are not published in a guidebook or formally dictated to grieving individuals, they pervade most industrialized societies because they reinforce the values of capitalism and the emphasis on productivity and functionality. These rules further delineate:

  • How long grief should last (we now know that grief may never really end)?
  • What are the narrowly accepted expressions of grief for specific members of society, usually delineated along gender lines and social acceptability (men who grieve through their emotions and women who grieve instrumentally through action are often the most socially wounded in their grief)?
  • Who is valued and worth grieving versus who/what is not (think of the loss of pets, loss of friends, miscarriage, significant nondeath losses, as well as intangible losses, such as loss of hope, dreams, and innocence)?
  • Who may have an exemption from socially expected roles and who may not (bereaved parents and widows often have some leeway after their losses, but you can think about typical workplace policies about funeral leave, family pressures around holiday times, and who is included/excluded from funerals and memorials as examples here)?

These social rules can cause a great deal of difficulty for individuals whose grief does not “meet” the socially sanctioned criteria in some way. As we stated earlier in this chapter, we are social creatures and the need to attach and feel a sense of belonging is a core part of what it means to be human. When grief is disenfranchised, or the griever is socially isolated, the process is made much more painful: In order to become more socially acceptable, and to counteract the potential for social isolation or exclusion from lack of conformity to expectations, grieving individuals may try to “mask” their grief in stoicism or find covert ways to grieve that keep their experience out of the public eye. By so doing, bereaved individuals internalize the oppressive forces that are enforced through the social rules of acceptability after a loss occurs. Death and grief signify vulnerability, which is a sign of weakness. In a social system that is based on competition and acquisition, weakness is not tolerable, and so grief goes underground (Harris, 2009 – 2010).

IMPLICATIONS FOR GRIEF COUNSELORS

As counselors, social influences can have an impact on our ability to offer support to grieving individuals. Most counselors are not in a situation in which public funding is readily available to clients to cover the costs of counseling. Thus, our services may be limited by the lack of recognition by insurers and public policies that not only limit how grief should be experienced and expressed but also limit many bereaved individuals’ ability to access supports that may be needed. A cycle of social exclusion, pressure to conform, and difficulty accessing resources occurs because mental health care and counseling tend to be socially stigmatized and devalued as well. Ironically, grief counselors might not be needed if our society were more realistic and inclusive of the healthy role of grief in everyday life!

As grief counselors, you may truly assist your clients by reframing the aspects of the grieving experience that are socially stigmatized as a problem with unrealistic social expectations and not with the client’s experience. A phrase that I (D.L.H.) often use with clients is, “let’s look at what’s right about what’s wrong.” In other words, in many instances clients’ responses make sense when placed in the context of the losses they have experienced, but their responses are often viewed as “wrong” socially because they do not abide by the dominant social model of how grief should be experienced. Going back to the case study, Jerry was disturbed that he could not be more functional and productive after Peggy died. Yet, when the situation of losing his soul mate of 35 years was considered, along with all the secondary losses associated with her illness and death, his grief made sense and was very appropriate in relation to the magnitude of his loss. Given in the following section are some suggestions for how you might support and empower your grieving clients by your awareness of how social rules and political policies can profoundly affect their experiences.

Application of Diagnostic Criteria to the Grieving Process

In Chapter 10, we explore times when grief goes “awry,” that is, when the loss and the grieving process completely overwhelm and consume someone. We caution counselors to keep in mind that jumping in to intervene may be felt very negatively by clients. Do not be afraid to question how your work may be informed by unhealthy and unrealistic social messages and pressure that reinforce an unrealistic idea of “normal” grief. Mary Friedel-Hunt, a social worker whose husband died 4 years after he was diagnosed with Alzheimer’s disease, articulates this point very well in her blog:

Just how long are we allowed to feel stunned? What are the social norms we “must” honor? How long does society allow we who grieve to have a “diminished sense of self”? How sad that this comes along at a time when so many are working so hard (and making headway) in changing the way society looks at and deals with loss and grief. The losers here are the bereaved themselves … I resent it when professionals (or anyone) decide that my (or those of my clients or any bereaved person) normal feelings and responses to such a loss are a medical issue, abnormal (prolonged, complicated, whatever), and that I (or other bereaved people) need treatment versus support (even treatment by meds that are sometimes harmful). I resent it when professionals negate the reality that we grieve a significant loss forever or when they deny that traumatic loss is defined by the traumatized person who needs only (in most instances by far) to be accepted, heard, felt and supported – not judged to be “sick,” “symptomatic” and in need of “treatment.” As a bereaved spouse, I choose not to pretend to “move on” (whatever that means) in order to avoid judgment. Maybe it means I forget the many, many years and sacred moments spent with him. I refuse to tell others I am “fine” to avoid judgment when I am feeling sadness at a given moment or on a given day. I am where I am and I encourage those I support

to do/be the same. (Friedel-Hunt, 2015, paras. 4, 7, 8)

Cultivate Self-Awareness

Lee and Hypolito-Delgado (2007) emphasize the need for clinicians to cultivate personal awareness of how they have been and are influenced by social and political forces, in order to be able to identify and disentangle the potential detrimental impact of these forces on their engagement with their clients. Learn to monitor your internal reactions and self-talk to identify your own biases, opinions, and expectations, and consider their impact on how you interact in your everyday world and with your clients. In order to effectively do this work with clients, you need to be congruent with the values and ideals that you espouse. For example, if you suppress or deny your experiences of grief due to social constraints, how can you truthfully bear witness to and facilitate the full expression and experience of grief with your clients?

Work From an Empowerment Model

Most models of professional training imply that a person with the training, schooling, and credentials is an “expert” and the client seeks treatment from the person with expertise in order to feel better. However, if grief is a common human experience, what is being treated? A colleague once observed that hunger is a normal human experience, and he queried whether we are “treating” hunger when we eat (Neil Thompson, personal communication, February 4, 2015). The idea, of course, sounds ridiculous. But you can apply a similar analogy to grief – if grief is a normal human experience, then what is the role of grief counselors and what are we “treating”? Most of the work of grief counseling is focused on empowering grieving individuals to engage with their grief so that the adaptive aspects of the process can do its necessary work. We do not “treat” grieving individuals; rather, we seek to empower them to honor their grief with the support they need in order to do so.

Monitor Your Use of Language

Anyone who has completed a professional training program knows the language and “jargon” that are used among those who practice in that field. However, using this kind of language with clients can create more of a power differential between the counselor and the client, perpetuating the social hierarchical status of “professional” versus “client.” Although it may be important to know this language and to use it as needed in collegial sharing, think about the words and especially the “jargon” that you use with clients and why you use it. Sometimes, clients appreciate being able to have a name to identify their experience in language. Many of our clients know what disenfranchised grief is and how it applies to their situations. Their understanding of terms such as this can be empowering.

However, commonly used words in psychological descriptions, such as dysfunctional, disordered, impaired, pathological, or identifying a person with a diagnosis may reinforce the social vulnerability that an individual experiences after a life-altering loss event (Dietz, 2000). Given the tendency for diagnoses to be utilized as a dividing line between those who are “healthy” and those who are mentally ill, great care must be taken when associating a client’s distress and pain with a reified set of criteria in a diagnosis code. There is often a conflict created for clinicians in this issue because insurance companies often require a diagnostic code to be assigned in order for reimbursement of services.

Using language that opens possibilities helps to encourage people to identify their ability to adapt and create meaning within change. Individuals feel empowered when the focus is on their strengths and resilience rather than on their perceived dysfunction. Focusing on the innate strengths in a client can provide a powerful catalyst for growth in contrast to the paralyzing effects of oppressive social expectations. For some clients, there may be initial resistance to the identification of their strengths and attempts to cope with adversity due to the presence of internalized negative beliefs and attributions toward themselves. In clinical practice, we can gently explore how these negative beliefs began and are reinforced in clients’ daily lives. We often explicitly identify the social rules and expectations that augment these negative self-perceptions, giving clients the opportunity to differentiate their actual experiences and responses from unrealistic social expectations that are intended to serve the purposes of a materialistic culture. By naming these rules and acknowledging their influence on daily life, clients have the opportunity to see their strengths more clearly and identify where they have actively engaged in coping and surviving in the context of situations that have made them feel powerless and helpless.

Validate and Support Subjective Experiences

It is important to be able to enter the reality that is experienced by the client – as the client feels it, understands it, and participates in it – in order to fully appreciate the client’s world (Larson, 2014). The process of validation occurs through an ongoing dialogue, in which the counselor actively listens to the client’s descriptions and feelings and acknowledges the impact of these experiences on the client’s world. The client’s descriptions and experiences are what matter the most, and are the most important part of the process. This aspect of the therapeutic relationship is of primary importance, as we have already discussed how disenfranchisement robs people of the ability to experience their grief as it needs to unfold, pressuring conformity with social norms and expectations that often deny and stigmatize their experiences.

It is important to name and validate losses for the significance in which clients actually experience them – not because they are expected to do so by the social rules surrounding the loss experiences. In this process, it is important to identify where clients’ experiences have been invalidated, pathologized, or marginalized by social rules and where oppressive factors have robbed the person of his or her subjective expertise and agency.

Cultivate Compassionate Awareness

The phrase “we’re all in this together” may sound trite, but it does speak to the deeper reality that we all experience grief and losses as we go through life, and nobody is immune to pain and suffering at some point. Within the boundary of a professional relationship, clinicians must be able to work from a framework that emphasizes bearing witness to the experience of another human being rather than adopting a role of authority over a client’s experiences. In professional training programs, we are often taught about empowerment and the role of the therapeutic alliance. Rarely do we have discussions about suffering and compassion, and yet it is our ability to acknowledge this pain and suffering, bear witness to it without turning away, and offer ourselves as instruments to relieve this suffering that forms the foundation of healing during these very difficult times. Loss and pain are a part of life, not experiences to be suppressed and hidden away because they highlight our vulnerability. As grief counselors, you will regularly be reminded of the commonality of human frailty, vulnerability, and fragility that we all share. Allowing yourself to be open to these experiences in yourself and others is an act of healing.

CONCLUSION

In grief counseling, it is important to be able to identify how social forces influence the process of adaptation to loss. We are social beings, and as such, we all are interconnected by our shared human experiences, with loss being one of these. We cannot define ourselves in isolation, and we all experience the dynamic interplay between our individual selves and the social and political structures in which we live. Grief counselors need to be able to assist their clients to grieve in ways that are congruent with their needs, free from the dictates of social rules that may deny or invalidate the deeply human experience of grief.

Glossary

Atomistic view – Assumes that each individual in a society stands alone as an independent, self-sufficient unit. The individual is seen as the “atom” of society and therefore the only true object of concern and analysis.

Disenfranchised grief – Refers to situations in which the loss is not recognized as valid, the griever is not recognized as a valid person to mourn a loss, the grief response of the individual falls outside of social norms, or in which the loss itself has a social stigma attached to it.

Macro practice – Focuses on systemic issues at the social/political level. Emphasis is on the role of social norms and policies, with education and advocacy being the primary ways of addressing organizational, social, and political policies.

Mezzo practice – Focuses on work with small groups at a local level; may include group therapy, self-help groups, or neighborhood community associations. Attention is usually placed on the group dynamic, goals, and/or problem solving at the local level.

Micro practice – Focusing on personal interactions with attention to individual beliefs, perceptions, and feelings.

Social norms – Rules and expectations about how members of a certain society should behave, think, and believe, and identification of what is considered acceptable behavior within a social group.

Questions for Reflection

  1. Think of a significant loss (death or nondeath) that either you or someone close to you experienced. Identify the social messages that you (or this other person) received in relation to the loss and the experience of grief afterward. How did these messages affect your/the other person’s response to this loss?
  2. Identify at least three situations in which grief might be disenfranchised. In what ways does the disenfranchisement of grief in these situations reflect the existing social norms about grief?
  3. Many public/social policies reflect the norms of the dominant culture. Identify some of the (social/community/workplace/institutional) policies related to grief and discuss the purpose they serve in relation to social norms and rules (e.g., most large companies allow 3 days of paid funeral leave for direct members of family, most insurance companies will provide limited payment for counseling services provided there is a diagnosis code and the provider has the credentials that are specified).
  4. Many professionals think that a category of complicated grief should be included as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) in order to allow individuals the opportunity to receive support and professional help when needed. Others in the field express concern that providing a diagnosis attached to grief (which is seen as a normal and adaptive process) contributes to the pathologization and medicalization of a normal human experience. What do you think?

 

 

 

II PRACTICE AND PROCESS

CHAPTER 5 The Practice of Presence

When I (D.L.H.) was a nursing student, I was assigned to the care of an elderly patient named Ella who was suffering from metastatic colon cancer. Ella was a feisty and funny woman, and she would readily share her thoughts and opinions with me as I was assisting her with her personal care. We had a good rapport, and I was a primary caregiver to her for several weeks while on this particular rotation in my nursing program. One day, I arrived for my clinical rotation on Ella’s floor and I was told by the nurse in charge that Ella had taken a turn for the worse. I prepared myself emotionally before going into Ella’s room, not sure of what I would find there and how I would feel when I saw the changes that were described to me by the charge nurse.

I walked into Ella’s room; she was asleep on her side, facing away from the door. Her breakfast tray was untouched. When I went up to her and said her name, she smiled a little weakly and then nodded back off again. Not knowing what else to do, I completed Ella’s bath and changed her sheets as usual. That took a very short amount of time because Ella kept her eyes closed and did not answer me when I spoke to her. When I finished with her personal care, I had a lot of time to spare, because in the past our conversation usually filled in the time that I was allotted to spend with her. Not knowing what else to do, I proceeded to water the plants at the window. I then straightened and organized her personal items in the bathroom, which had not been used in a good while. I cleaned off her bedside table, and filled her water pitcher with fresh ice water, knowing very well that she would never drink it. I began monitoring the doorway, concerned that my clinical instructor would walk by and see that I was not busy and think that I was not doing what I was supposed to do. I added a blanket to Ella’s bed, and I was in the midst of adding another pillow when Ella reached out and grabbed my arm, opened her eyes, and said simply, “SIT.” So I sat on the edge of a chair next to her while she rested, her hand gripping my arm … and I watched the doorway, concerned that I would be reprimanded for sitting down while “on the job.” When I directed my focus to Ella, she seemed to be sleeping and unaware of my presence. However, whenever I tried to move away, her grip would tighten on my arm. Ella could not engage with me verbally, and she did not want me to be scurrying around her in a lot of busyness, but she obviously wanted my presence with her.

Many years later, when I entered my graduate training program in counseling psychology, I recalled this experience. It was my first lesson in the gift of presence. I now will sometimes do a parody with my students about the lesson I learned from Ella that day: Do not just do something; sit there! In my readings about this topic, I came across the concept of presence. Being present is described as something that is multilayered – that in addition to offering our physical presence, there are deeper forms of “being with” someone. For example, being psychologically and emotionally present and attentive with someone involves good listening, empathy, being nonjudgmental, and fully accepting of that person and his or her experience. A further expansion of this concept, described as therapeutic presence by McDonough-Means, Kreitzer, and Bell (2004), described this kind of presence with another as a “spirit-to-spirit connection,” requiring “that the caregiver have skills of centering, intentionality, intuitive knowing, at-one-ment, imagery, and connecting” (p. 25). Geller and Greenberg (2014) describe therapeutic presence as:

The state of having one’s whole self in the encounter with a client by being completely in the moment on a multiplicity of levels – physically, emotionally, cognitively, and spiritually. Therapeutic presence involves being in contact with one’s integrated and healthy self, while being open and receptive to what is poignant in the moment and immersed in it, with a larger sense of spaciousness and expansion of awareness and perception. This grounded, immersed, and expanded awareness occurs with the intention of being with and for the client, in the service of his or her healing process. (p. 7)

We live in a world that values individuals for their productivity and their efficiency. People tend to lead very busy lives, and if you are not busy, there is an implicit assumption that something must be wrong with you. When at a social gathering, one of the first things people will ask is, “What do you do?” Our lives and mentality are built around doing, producing, and consuming. However, one of the most important skills required of a counselor is the ability to “be with” someone and not what to “do to” someone. Learning theory and acquiring skills for interventions with clients are both important for being a good counselor. However, interventions and book knowledge are not going to be enough when you have a client sitting in front of you who is experiencing intense emotional pain.

Most training for counselors focuses on the content of the therapeutic encounter, emphasizing the development of communication skills and possible approaches and interventions to specific client issues (Hick & Bien, 2008). Very little training explores the counselor’s quality of “being with” the client, and yet there is a good amount of research indicating that what fosters the most growth and change in therapy springs from the relationship that clients form with their counselor and the awareness of their counselor’s ability to journey alongside them, rather than the specific techniques that were utilized and the theoretical orientation of the counselor (Geller & Greenberg, 2002; Wampold, 2001; Yalom, 2009). In short, the relationship with the counselor and the sense of the counselor’s attentive, engaged presence provides the foundation from which much of the work of the therapeutic encounter extends.

“BEING WITH”

When you are starting out in the work of grief counseling, you might find that you get “stuck” in the process because you might not know what to say to a client or you may not know what to “do” when a client shares something that is deeply painful. You may be afraid of saying the wrong thing and making the client feel worse or of not saying enough and thus falling short of the desire to assist your client. Often, it happens that a great deal of time in the session is spent with the budding counselor nervously trying to decide what to say and how to respond to a client, and experiencing a great deal of anxiety about what should be said and done, when it might be much more productive and meaningful to learn how to simply be with a client before uttering a single word. We would like to use this chapter as an opportunity to address some of these concerns from the standpoint that sometimes less is really not just more – but best.

Beginning counselors often find themselves unsure about what to say to clients, and they often feel pressured to say and/or do something that will make a difference to their client. However, if you really stop and think about it, there is nothing that you can say that will make a bereaved individual feel better, because you cannot bring back the lost person and you cannot return someone’s world back to the way it was before the loss occurred. The main issue, which is the significant loss of a loved one or of an aspect of the self that has been profoundly altered, is not something that can be fixed, changed, or reversed. There are no “a-ha” moments that will make a bereaved person all of a sudden look up and tell you that he or she is now “better.” Nothing you can say or do will change the amount of pain that person is experiencing from the loss he or she has experienced.

In their everyday lives, most bereaved individuals are aware of a fair degree of social distancing by others who are afraid of saying the wrong thing or who do not want to make them feel worse by what they say – so the tendency is to avoid the person and the discomfort that is aroused by the uncertainty (Harris, 2009 – 2010). It is very important that grief counselors do not perpetuate this scenario. A helpful stance in working with bereaved individuals might be an understanding that you may not be able to help the bereaved individual to feel better; however, you can still make a tremendous difference by remaining fully present to that person and his or her experience as it is shared. With the advent of modern medicine’s focus on cure and fixing what is broken as the goal of professional helping, the emphasis on outcome and recovery has permeated our thinking about other aspects of life that may not fit very well into such a model. Healing, in this context, is more about care and process than about cure and outcome. Thinking “I cannot take this pain away from this person, but I can ensure that he or she will not have to go through this pain alone” may help to reframe some of the expectations around the role of the grief counselor.

As we discussed earlier, grief is not a pathological state but an adaptive process that allows us to adjust and accommodate to significant loss events in our lives. In light of this understanding, one of the main goals of grief counseling would be to allow the adaptive aspects of grief to unfold without hindrance so that the bereaved individual can integrate the loss experience into his or her life. Thus, as a grief counselor, it is important to learn to “sit with” grief, even though it can be a very difficult and intense process at times. This “sitting with” someone involves cultivating a sense of presence that is open, engaged, and compassionate. We now attempt to describe what is meant by the term “therapeutic presence,” and how to cultivate the practice of presence with oneself and with clients.

CULTIVATING PRESENCE

Perhaps the best way to establish a strong therapeutic relationship with a client is to begin with your relationship to yourself. It has been said by many wise individuals that we cannot offer to others what we are not offering to ourselves. Indeed, the concept of the “wounded healer” (Nouwen, 1972) implies that we allow the painful life experiences that we have endured to sensitize us to the pain of others when they are in similar dark places. Much has been written in the counseling literature about the counselor’s use of self as a source of healing in the therapeutic relationship (Baldwin, 2000; Geller, Greenberg, & Watson, 2010; Wosket, 1999; Yalom, 2009). In this section, we look at important ways of thinking and being that will be of benefit when supporting others who are experiencing difficult and painful losses.

Safety Inside/Safety Outside

This phrase does not have to do with locking windows and doors, but of taking stock of what it is like to feel emotionally comfortable and safe with ourselves and others. If you think about those who are closest to you and whom you trust, consider what allows you to trust them, and to feel safe sharing some of your deepest thoughts and feelings with them. When you know that someone will be honest with you, but will also show respect and regard for you, there is a sense of feeling safe with that person. Rogers (1995) stated that human beings crave unconditional love and regard, and this is not a narcissistic tendency, but a real need to feel safe and deeply appreciated.

When we speak of “safety inside,” we are referring to your inner world – your thoughts, feelings, and reactions to yourself. For example, an individual who is continually driven to perfectionism and strives constantly to achieve may have an inner world filled with negative thoughts about himself or herself about not “measuring up,” or needing to prove his or her worth, or that he or she is lacking in some way. It is not unusual to hear someone say out loud, “I am so stupid!” These reactions can be comedic and they are often not taken seriously – but it is important to listen deeply to the thoughts you tell yourself on a regular basis about how you perceive yourself and how you respond to life situations. Cultivating a feeling of being safe with yourself means that you are careful with yourself just as you would be careful with the words you share with someone whom you love – and you are no different from someone else who deserves your love and respect.

Shame, the sense that something is deeply wrong with us, is a very painful experience, and the debilitating effects of feeling shamed by someone else can have a profound effect on that person. Shame differs from guilt in that when there is guilt, it is usually over something that we have done, which can hopefully be corrected or amends can be made; on the other hand, shame implies that there is something wrong with who we are, and we are paralyzed in our attempts to address it because there is no specific source or action – just a deep-seated sense of being inferior, feeling worthless, or being like damaged goods (Harris, 2010). Shame in this sense leaves us unable to connect with others in a meaningful way because we cannot move beyond the need to avoid the pain of it, while we are inescapably drawn to try to alleviate the ineffable source of the shame at the same time (Harris, 2010).

Checking in with the dialogue that occurs inside your mind is often referred to as listening to your “self-talk,” and it can be a very important place to start when you want to be a counselor. If you are in the habit of respecting yourself and being kind with yourself, while you are also honest in your selfappraisals, you can “sit” with yourself in calm and patient awareness. If not, “sitting with” yourself or with someone else will be much harder because you really are not safe in the silence, because these times of quiet can become the moments when your mind can be permeated by negativity, self-loathing, and insecurity, and nobody would want to remain in that place very long.

Self-Awareness and Reflection

Presence begins with the therapist’s self-reflective abilities and personal work as preparation for being with another person who is seeking the therapeutic encounter. Being able to understand yourself and what makes you “tick” may be very important when you are with clients whose experiences may be similar to yours or with individuals who may “trigger” some of your painful past experiences and associations. In our classes, we often give students an assignment that requires them to complete an inventory of the loss experiences of their lives, from birth to the present (see the loss line exercise later in this chapter). These loss experiences may or may not involve the death of someone close; rather, they are experiences where life took a turn that was unplanned, unexpected, and required a period of adjustment and grief. Often, students will identify moving from one place to another, the loss of friends through changes in life situations, the ending of romantic relationships, and lost hopes and dreams alongside losses that have occurred after the death of someone significant. The purpose in assigning this exercise is to allow for an opportunity to reflect upon how these losses have shaped their lives and to see places where there may be some lingering vulnerability, enabling an ability to separate feelings and experiences from those of a client who may share a similar experience and feelings.

In the development of greater self-awareness and open reflection on one’s life and experiences, there is an invitation to self-correct when necessary. The ability to respond to a situation by choice after reflection rather than to react quickly without much thought is certainly much more conducive to living in a way that is in line with your true intentions and values. This way of being will certainly give you a greater capacity to listen with openness to others who need to know that you will listen to and reflect on what they share with you rather than jumping in with quick advice and conclusions. Geller and Greenberg (2014) offer several suggestions for counselors to prepare for their time with a client. They suggest the following practice before the start of a session with a client:

  • Before meeting your next client, take a moment just to be still. Whether seated or standing, feel your feet firmly placed on the ground.
  • Begin to pay attention to your breath. Place your hand on your abdomen and feel your belly expand with a full inhalation and contract with a full exhalation. Pay attention to the rise and fall of your belly breath.
  • Start to visualize your next client. Be open to the energy of this person, connecting to his or her human-ness.
  • Open your eyes and walk to the door to greet this person, while connecting to the ground, to your breath, and to the intention for presence. (p. 236)

In a qualitative study with expert therapists, Geller and Greenberg (2014) explored what is involved in the experience of presence in the therapeutic relationship. They concluded that being fully present to clients in the therapeutic encounter involved the following:

  • Preparation for presence, which entailed the therapist making a philosophical commitment to practicing presence in his or her personal life and developing an attitude of openness, acceptance, and nonjudgment before working with clients.
  • The process of presence, which involved being authentic in the session with the client, being open and receptive during sessions, and listening with the “third ear.”
  • Experiencing the presence, which allowed for deep absorption in the client’s world without becoming attached to outcomes, and being fully aware, alert, and focused on the client during that time.

Geller and Greenberg (2002) state:

Therapists’ presence is understood as the ultimate state of moment-by-moment receptivity and deep relational contact. It involves a being with the client rather than a doing to the client. It is a state of being open and receiving the client’s experience in a gentle, nonjudgmental and compassionate way … being willing to be impacted and moved by the client’s experience, while still being grounded and responsive to the client’s needs and experience. (p. 85)

Presence is one of the most difficult concepts for individuals in Western society to grasp, as the opening scenario of this chapter with Ella describes, because the main focus in helping professions is typically on “doing something” rather than “being with” someone. Our ability to offer our full attention and empathetic presence to another human being is one of the greatest gifts that we have. Learning how to be fully present to others begins with learning how to be fully present to ourselves and our experiences.

A relatively new area of exploration is the intersection of Eastern philosophy with Western psychology, more specifically in the application of mindfulness to the therapeutic venue. Several authors describe the value of regular contemplative practice or the development of mindfulness practice for the therapist as a means to learn how to be fully present on a daily basis in one’s life and to apply this same practice of presence to being fully present to clients as they seek counseling (Epstein, 2007; Geller & Greenberg, 2014; Hick & Bien, 2008). Some therapeutic modalities draw directly or indirectly from these same practices to assist clients in developing ways of being and thinking in their lives that will facilitate deeper engagement with life while providing an opportunity to let go of their expectations and ways of thinking that interfere with living more fully (Kabat-Zinn, 2005; Kumar, 2009; Welwood, 2000). Although many of these authors emphasize the value of a formal meditative practice, the key aspect of any type of contemplative practice involves the development of a philosophy that allows for letting go of expectations and outcomes, learning to live from moment to moment in the present, and the ability to cultivate greater awareness and presence with one’s self and with others.

Cultivation of Compassion

Compassion is defined as the ability to demonstrate kindness, understanding, and nonjudgmental awareness toward human responses, especially those that involve suffering, inadequacy, or perceived failure of some sort (Neff, Kirkpatrick, & Rude, 2007). Halifax (2011) defines compassion as a capacity that allows us to be attentive to the experience of others, to be able to wish the best for others, and to sense what will deeply serve others. These authors state that compassion serves as a buffer against anxiety and leads to enhanced psychological well-being. Berlant (2004) sees compassion as a way of responding to others out of the recognition of shared human experience. She discusses the withholding of compassion as a form of cruelty that can be manifested in individual and social responses. Compassionate responses take into account the awareness that we all share common human experiences and traits. Nobody is perfect; nobody is immune from painful life experiences and nobody is spared from some kind of suffering at some point in time.

Individuals who gravitate toward the helping professions typically have a great deal of empathy for others, but they often have difficulty feeling compassion toward themselves. To deny compassion for ourselves can be highly detrimental, because to separate ourselves out from the compassion we may extend to others means that we constantly need others in our lives to prove that we are valuable and worthy because we are unable to do this for ourselves. It can be dangerous to have this kind of mentality and to be working with vulnerable individuals, because without a strong sense of self-compassion, the helper will need clients to bolster his or her weak sense of self and in the process may inadvertently use clients for his or her own needs, thus violating the objective of the therapeutic relationship to place the client’s needs as primary.

Stop and think for a minute about how you define compassion. If you were to describe someone who is compassionate, what would their attributes be? People who are identified as compassionate are those who see the suffering of others and are moved to address this suffering in some way. Cultivating compassion involves a willingness to see the pain of others, to allow yourself to be exposed to others’ suffering, and to choose to be an instrument of relief to that suffering in ways that are possible. Because we cannot remove many of the causes of suffering, such as death and significant losses, we resonate with those who suffer by bearing witness to their pain, journeying alongside those who are grieving, and being present and nonjudgmental to those who suffer. Far from being a passive process, demonstrating compassion requires us to actively and decisively “be with” another individual when others may leave quickly or get frustrated because they cannot “fix” what has happened. Being compassionate requires a great deal of inner strength and awareness, and it takes time and practice to cultivate the ability to remain grounded, focused, and fully present in such an engaged and open way (Vachon & Harris, in press).

The Being with Dying Program, developed by Roshi Joan Halifax and offered through the Upaya Zen Center in Santa Fe, New Mexico, is based on the development of mindfulness, receptive attention, and cultivation of presence through contemplative practice. The premise of the training is that cultivating stability of mind and affect (emotions) enables clinicians to respond to others and themselves with full presence and compassion (Halifax, 2012, 2013). The program provides skills, reflection on attitudes and behaviors, and tools that change how caregivers work with the dying and bereaved. Halifax’s and her colleagues developed the G.R.A.C.E. model to help clinicians to focus on compassionate responses in their interactions. The acronym G.R.A.C.E. stands for:

G – Gather your attention

R – Recall your intention

A – Attune by checking in with yourself, then the patient/client

C – Consider what will really serve by being truly present in the moment

E – Engage, enact ethically, and then end the interaction

The practice offers a simple and effective way to open to the experience of the suffering of others, while remaining centered and connected to your own deepest intentions, and to develop the capacity to respond with compassion in all types of situations (Halifax, 2013). We discuss this model further when we address caregiver issues in Chapter 13.

Many forms of therapeutic training require student counselors to be in counseling themselves as part of their training. There is certainly merit to this approach, because one of the best ways to develop empathy for clients in the therapeutic setting is by being a client yourself. Being a client is also an excellent way to see the process modeled through your encounter with a trained counselor and also a good start to developing skills for self-awareness and reflection. There is perhaps no better way to learn than by doing!

PRACTICE OF AWARENESS AND PRESENCE

The following exercises are suggestions to assist you in the process of self-awareness, self-reflection, and the cultivation of a sense of presence. We suggest that you spend time exploring each of these exercises and find someone who will honor your process and with whom you can share your experiences and responses.

Loss Line Exercise

A personal loss is any loss that results in a significant change to our lives. Personal losses include the death of a significant person, relationship loss, job loss, pet loss, loss of dreams, divorce, immigration, loss of health, or loss of self.

  • . Create a list in chronological order of all of your personal losses. Include only the year and who or what was lost. For visual impact, it is helpful to diagram these losses on a timeline on a sheet of paper.
  • Look over this “loss line” that you have made. Think about each loss that you have indicated on the sheet of paper and its impact on your life. Make note of developmental or maturational differences at each stage of life that is highlighted in the loss history. How have your losses shaped you as a person now? What losses still feel “raw” or continue to overshadow your life at this point in time? How would the way you have handled your losses affect how you will work with a client who has encountered similar losses to yours?

Presence Exercise (You Will Need a Partner for This Exercise)[2]

Ideally, partners should not be too familiar with one another, although this might be unavoidable. It might be helpful to have a third person read this exercise aloud for the two partners who are participating in it.

PART ONE:

Please sit facing your partner, a comfortable distance apart but close enough that you could lean forward and whisper to one another.

Begin by closing your eyes and settling into your body. Try to recall a time when you opened your eyes on the world in innocence and wonder. If you cannot recall such a time, simply visualize that you now have those eyes that are about to open on the world, as if for the first time. Take a few moments to try to discover this inner sense of wonder and innocence.

Now, open your eyes, keep your gaze lowered, and try to maintain a soft, slightly unfocused seeing, as opposed to staring or glaring… You will be looking in the area of your partner’s knees or lap. Please open your eyes softly now.

You become aware of the presence of another. In your visual field there is something that all of your senses tell you is not simply an inanimate object. Even just looking into this area of the person before you, your innate knowing tells you that this is a living being, just like you. Even at this stage you may sense the movement of breath in the other.

And now very slightly and gently raise your field of vision to include the lower abdomen of your partner – focusing on the area below the rib cage. Now you clearly become aware of the breathing of another. It may happen that the rhythms of your in – and-out breaths begin to harmonize. Do not strive to consciously make this happen – just gently observe whether this synchronicity arises naturally. Calmly and silently stay with this awareness for a few moments.

This time, raise your vision very slightly, keeping this field soft and unfocused, from the shoulders down to the lap, so that you are gently taking in the whole upper torso of the person before you. You become aware in looking at this other and feeling your own breath that breathing involves the entire upper body – not just the nostrils, not just the lungs. Now you can more fully sense the presence of this person in front of you.

Now, slowly, gently, and with compassion for both yourself and the other, please look into the face of your partner… You behold a face completely unique in the world and, yet, fundamentally not so different from yours… You can see in this face, as if looking in a mirror … this face that has known countless moments of loss and grief of all degrees … this face that has yearned for the same joys as you … this face that has been thrilled with love and acceptance … and torn by rejection and shame … this face that expresses the whole history of the heart … this person who longs for the same peace and happiness you do … this universal longing for the end of suffering…

Just gently allow yourself to look into the eyes and face before you for a few more moments… At this point, sometimes some giddiness or reluctance arises because doing this part of the exercise can be uncomfortable, and you may feel self-conscious. If this occurs, try to raise your sight one last time and simply look innocently and deeply into the face of your partner. When you follow this instruction please do not avert your gaze. If it feels too intense for an instant, just close your eyes and locate that innocent, nonjudgmental vision again.

PART TWO:

At this point, you will need to think of a true story of personal loss. How current and how profound the loss is completely up to you. But obviously, the more profoundly you share, the more powerful this experience will be. Just take a second to decide who is going to share first… The listener who is bearing witness to the story of loss just listens. It is vitally important that there be no cross-talking. Please hold back your impulse to reach out and touch or comfort the person for now. You do not have to sit poker faced – your body language and facial expressions are going to naturally respond to the story, but please do not speak.

Allow about 3 to 5 minutes for the telling of the story. When the first partner has completed telling his or her story, then signal that the second partner can begin to share his or her story.

When the second partner has completed telling his or her story, allow a few moments to close your eyes and be with your partner. Then, share with each other what it was like to do this exercise. What was it like to listen without being able to “do” or say something? How did it feel to share in this context?

This exercise is often a poignant demonstration of how difficult it is to simply be fully present to someone else without “doing” something. It gives an idea of how to engage with someone by offering presence without interfering with the other person’s flow or process.

Simple Presence Practice

This is a practice that you can do at any time, in many different situations. Do this for just a minute or two at a time. When you are in a situation in which there is sharing of some sort, whether it be a social setting or a more clinical setting, begin to focus on one person near you. Notice that person’s body language. Close your eyes and listen to the tone of that person’s voice and the quality of his or her speech. Then, listen to the words that the person is using and how these words are conveying feelings, thoughts, and ideas. If the person is not talking or stops talking and is silent, allow your breathing patterns to match his or hers briefly. Reflect upon what you learned about that person (or yourself) from your focused attention for this brief period of time.

CONCLUSION

Learning how to be fully present with your client is foundational to the ability to be effective in working with grieving clients; however, it may also be one of the biggest challenges to beginning clinicians. Counselors need to find ways to cultivate their ability to be aware, focused, and engaged with themselves and their clients in a moment-to-moment awareness. This type of awareness and therapeutic presence can be cultivated through reflective and contemplative practices. Ultimately, fully attentive, engaged presence can be a healing practice for both counselors and clients alike.

Glossary

Compassion – Sensitivity to the suffering of one’s self and others with the desire to relive that suffering; the ability to demonstrate kindness, understanding, and nonjudgmental awareness toward human responses, especially those that involve suffering, inadequacy, or perceived failure of some sort.

Presence – The act and intention of “being with” another individual, with full attention and engagement.

Therapeutic presence – Involves the counselor engaging the skills of centering, intentionality, intuitive knowing, at-one-ment, imagery, and connecting with the client.

Wounded healer – Implies that we allow the painful life experiences that we have endured to sensitize us to the pain of others when they are in similar dark places.

Questions for Reflection

  1. In your own experience, what might hinder your ability to be fully present to another person as described in this chapter? How does presence in this chapter concur with or diverge from how you have viewed being a helper to those who are in painful circumstances?
  2. Complete the two exercises described in the chapter with someone who you trust. What was the experience like for you? How about for the person who completed the exercises with you?
  3. We are often conditioned to think of healing to be the same as cure or being relieved of a painful situation. Based on the concepts in this chapter, how can healing include times when it is not possible to change someone’s circumstances or relieve their pain?
  4. Think of times when you have been uncomfortable because you did not know what to say or do. Can you think of other ways to remain in these situations, using the concepts about presence that were presented in this chapter?

 

 

CHAPTER 6 The Basics of Counseling Practice

Although we firmly believe that counseling practice is rooted in the personhood of the counselor and the relationship that is formed between the counselor and the client, there are some therapeutic techniques and responses that you might find helpful to “give words” to your intentions with clients. Counselors who are newer to the field will often say that they are concerned that they will say something that will make the bereaved person feel worse, will say something that is inappropriate, or will not say anything and will feel foolish because they are tongue-tied. Hopefully, this chapter provides some ideas for responding sensitively to bereaved individuals, and perhaps provides more. We start with some basic skills to incorporate into your regular, everyday practice, and then discuss how to get started with a client. We then go to some “trickier” areas that you might want to consider as you begin working with clients.

SETTING UP THE GROUNDWORK

As we have discussed earlier, establishing the therapeutic alliance is the most important step in beginning the counseling process. Learning how to be fully present to yourself and your client in a way that is open and receptive sets the stage for building up the work of the sessions. Because we have discussed presence and the conditions of the therapeutic alliance already in great detail, let us move forward from how to “be” with clients to what to say and “do” with clients that will best express your intentions and desire to journey alongside them. We start with a description of basic attending skills and what these are. Next, we explore the role of empathy in the therapeutic relationship. Then we discuss some practical ideas about how to help clients to tell their stories and what might provide the best support to them as they walk through their grief journey.

ATTENDING SKILLS

Attending skills are very basic things to which you need to “attend,” both in yourself and in your client. When you are attending to your client, you are focused on what your client is sharing, on your client’s body language, and on your own inner responses and body language. It is important to keep in mind that much of our communication with others is nonverbal, even when someone is talking. So, we listen to someone’s words, but we also perceive their body language to identify what may be “underneath” the words – and clients do the same with you as well. So, it is important that your body language and your focus be congruent with your intentions and the words, thoughts, and feelings that you share with the client. Here are some basic thoughts about attending:

  1. Eye contact – Involves looking at clients in a culturally appropriate way. This does not mean maintaining an unrelenting gaze, but rather looking into their eyes from time to time, especially when they are speaking, so that they are connected with you and they know you are focused on them. It is very important to remember that not all cultures interpret eye contact as comfortable or appropriate. If you notice that your client seems uncomfortable with maintaining eye contact with you, you may want to modify your gaze to looking just to their side or occasionally looking down from their eyes for brief periods of time. If the eye contact discomfort seems obvious, it is a good opportunity to check in with your client about comfort and expectations around this issue. Another reason that clients may feel uncomfortable with eye contact is that some people are unaccustomed to being the intense focus of another person’s attention in the way that a counselor may focus on a client in a session. These feelings and issues provide a chance to deepen the trust and respect in the encounter if they are approached in a sensitive and respectful way.
  2. Vocal qualities – You need to think about your rate of speech, the volume of your speech, and your tone when speaking with clients. We tend to speak very quickly because we are accustomed to quick responses and sharing a lot of information in short snippets of time either through technological means or in short encounters with others. It is important in the counseling session to consciously slow things down, to take the time to focus not only on what is being said but also on how it is being said. You should think about how you speak so that you are easy to hear – not too high, too low, or monotonous. Ask a trusted friend for feedback on your verbal quality, or listen to yourself on a recording device – the voice is an instrument that can be finetuned, if need be.
  3. Verbal tracking – Involves active listening on your part, where you follow the client’s story, asking relevant questions that permit deeper understanding. Do not interject your own ideas, unless they would be helpful to the client, and conduct the session such that the client does most of the talking. You cannot follow every detail of the client’s narrative, and some clients are confused and scrambled in their account, but search for the main threads and themes that make a complete whole. Another related aspect of verbal tracking is sometimes referred to as “intuitive tracking,” which focuses not as much on the details as on the implicit feelings and meanings that a client shares with you. This may take some time to develop, and it may be a skill that is easier for some more than others to practice.
  4. Attentive body language – Your positioning and physical presence can send a powerful signal to clients that you are tuned in to them. The same can be said for when your body language might demonstrate disinterest, impatience, tiredness, or distraction. Think about the bodily clues that indicate to you that someone is listening to you and engaged with you. We usually suggest that you should be sitting about 4 feet from the client, and often not directly facing the client, but turned to the side a little. When listening, you may wish to lean slightly in the direction of your client, and not be afraid to use hand gestures and facial expressions that help to convey your thoughts. When watching videotaped sessions of clients and counselors, it is common to see that the counselor begins to mimic the client’s body language, facial expressions, and gestures. This synergy between the counselor and the client is common, and it often indicates that there is a comfort and sense that the counselor and client are “in tune” together.

Clients tend to feel uncomfortable if you are too close or your body language is too intense, or if your body language appears closed or distracted, such as looking at a watch, crossing your arms across your chest, or if you tend to be someone whose foot tends to move rapidly when you are talking. Remember, clients often feel that the process can be intimidating and there is vulnerability in sharing things that are so intimate about oneself, so it is important to consciously think about how your body language will be perceived by a client.

A related issue is whether or not to take notes during a session. We feel this is a personal decision that each counselor will need to make. If you find that you need to take notes to keep track of details and to monitor the process during the session, then you might wish to share with your client at the beginning of the first session how you use your notes and why you are taking notes. Keep in mind that clients will be very aware of your writing during a session, and they may be influenced if you tend to write a lot when they share about one aspect of their experience or if you do not seem to note something that they think is important. Always ensure that taking notes does not prevent you from fully engaging with your client, and that the notepad is not “in the way” of your ability to maintain your presence and focus on the client at all times. Remember, the client is in front of you, and the story is the client.

  1. One of the easiest algorithms to remember about attending skills with clients was the SOLER model, described by Egan (2013) in his work titled The Skilled Helper. In the SOLER model, we keep in mind the following:

S – Squarely face the client, or be at a 45-degree angle. Do not have a desk or table between you.

O – Open posture, avoid crossing arms; leg crossing is okay in our culture, but not with the ankle across the knee.

L – Lean forward slightly, bend slightly toward the client to invite conversation.

E – Eye contact, appropriately, means looking directly at the client at times, but also breaking contact to give the person a break.

R – Relaxed posture and body language, not holding tension or anxiety; a natural and comfortable position.

OBSERVATION AND TRACKING SKILLS

Observation skills help us to ascertain information about the client through careful observation on the part of the counselor. Most of us already use our observational skills to “read” others’ nonverbal cues – sometimes you might remember the “gist” of a conversation or how someone was feeling, but not be able to remember everything that was said to you in that conversation. As a counselor, learning how to focus simultaneously on both nonverbal and verbal cues that the client gives is an important skill to develop. Many clients do not have words to express their thoughts or feelings accurately, but you may be able to help them to do so by observing their expressions, body language, and behaviors during a session. In noticing these things with a client, you might be able to incorporate your observations into the material of the session to help a client articulate deeper thoughts and feelings. For example, you might say something like, “I noticed some hesitation when you said that everything is going well. Can you tell me a little bit more about that hesitation?” Another example may be to note nonverbal cues in the absence of words, such as, “I noticed a sad expression on your face just now … can you tell me about that?” As stated earlier, it is common for counselors to automatically mirror a client’s posture or gestures without even thinking about it. This alignment with the client’s body language can be called “movement synchrony,” and you will usually see it occur when the client and counselor are deeply engaged in the session.

Verbal tracking is used by the counselor to more closely follow the client’s story or how a client tends to share an experience. In verbal tracking, the counselor tends to “pick out” things that point to a deeper level of a client’s experience or awareness. Clients tend to illustrate their life themes by underlining words with significant meanings. When clients use words that indicate strong feeling states, or have an intense association or connotation, it is important for the counselor to take note and not miss these cues. Examples of these types of words might be hopeless, helpless, at a dead end, overwhelmed, paralyzed, and lost. These words often carry a great deal of significance for how the client perceives what has happened or where the client’s “crux” issue may reside. One important point to make when discussing this aspect of verbal tracking is to be aware that counselors may have their own selective attention – meaning that we might tend to focus on what we think is important and, in so doing, we could miss what the client feels is important. Awareness about our own biases and areas in which we are more comfortable in a dialogue may help to prevent us from tracking clients in a way that is more suitable to our needs than to what a client may need.

Another form of tracking is to follow the use of language that the client uses. For example, some clients tend to be very concrete in their thinking, and literal in how they share their experiences. These clients may be uncomfortable if the counselor uses metaphors and abstract interpretations in their discussions together, and they may be more comfortable discussing things in a more concrete and behaviorally oriented way. Other clients may readily want to discuss patterns in their lives and seek to understand their underlying feelings and motivations. Matching a client’s style may help the client to be more comfortable, especially in the beginning of the counseling relationship. With time, clients may experience more growth and expand their awareness of themselves and others if they are challenged to think in ways that might, at first, seem a little “out of the box,” but this type of challenge is usually not helpful until the therapeutic alliance is well established.

When clients make statements such as “I think…,” or “I feel…,” or “I believe…,” they are making “I” statements. These statements are important indicators of the inner world of the client, and need to be attended by the counselor. Many clients have a great deal of difficulty making these kinds of statements because they are not accustomed to being heard or valued; if this is the situation, the counselor might have to encourage the client to make these statements in the sessions in order to try out their use in conversation.

One final aspect of verbal tracking is paying attention to the client’s verbal style. Most people demonstrate a clear preference in verbal styles, and if you listen carefully to the words that a client chooses in his or her descriptions, you can “match” your client’s style more readily, and the client may feel more comfortable sharing. In addition, matching a client’s verbal style invites rich descriptions and explorations of the client’s world and feelings, which can be very helpful in the counseling process. When a counselor attends to this aspect of the client’s sharing, the client often feels deeply understood and quite comfortable in the exchange. Examples of verbal styles might be as follows:

  • Visual – the client uses words that speak about seeing, imagining, visualizing, providing details
  • Auditory – the client uses words that focus on what is heard and may say things that incorporate words and phrases like hearing, sounds like, harmony, noisy, dissonant
  • Kinesthetic – the client focuses on movement, action, doing, feeling, touching, warmth, sharpness

APPROPRIATE USE OF QUESTIONS

Questions are typically the way we elicit information from others. Certainly, in some of the humorous skits that are done of a counseling scenario, the counselor asks the client a question, and then writes something down on a notepad, sometimes with a scratch of the chin and a comment like, “Hmmm … that’s very interesting… .” There are some important things to remember about asking questions of clients. First, asking a question puts the counselor in charge of the session, and if you recall from our earlier discussion, we want to empower the client to take the lead in the counseling session; by asking a question, you are requesting a response with a specific answer and taking the session in a direction that may be different from where the client may have initially wanted to go. Asking too many questions in a row can cause a client to feel more like he or she is being interrogated rather than being heard. In addition, it is important to be careful not to use asking questions as a means to “fill” silence in a session because you are uncomfortable with it. Silence and pauses in the session may be important times for the client to be able to sort through some of his or her thoughts and feelings without interruption. Beginning counselors often report that they experience pauses, silence, and breaks in the conversation as awkward and uncomfortable. If there is a pause in the session, stop and take a breath before you speak. Allow yourself to wait for a minute or two – follow your client’s lead – and see if this poignant time gives your client a chance to gather his or her thoughts a little and to go deeper with the material rather than being immediately sidetracked by having to answer a question that you have interjected.

There are basically two types of questions, and each can serve a good purpose. Closed questions are those that can be answered with a “yes” or a “no,” or often with a single word. Closed questions often provide the facts, such as address, age, and length of time since an event, and often begin with “where,” “is,” “are,” and “do.” Closed questions are helpful for asking for specific information, such as demographics, and questions that are pertinent to counseling but are not necessarily part of the process. Examples might be, “Have you seen a counselor before?” or “Do you have a regular medical doctor?” Of course, many clients will often answer a closed question as if it were an open one because of their need to talk. Sometimes, an entire session will open with a simple question that is asked of the client, and the client chooses to elaborate on the answer because he or she feels it is something that is important.

Open questions begin with “what,“ “how,” “why,” and “could,” and allow clients to respond according to their needs. These types of questions invite clients to elaborate on their story and add the details as they wish. Open questions usually cannot be answered briefly, and they often require some thought or expression of feeling. Open questions are used for the following purposes at specific times:

  • To begin the session, or to move the client forward in a story, indicating that you are listening and wanting more detail:

“Can you share with me a little about what brought you to counseling?”

“What are your thoughts about what is happening in your life right now?”

“After the death, what were things like among the other family members?”

  • Used to move the client more deeply into his or her world or experience:

“Could you tell me more about that?”

“What has this experience been like for you?”

  • Used for specific information about what the client has shared:

“Can you give me an example of what you mean?” “How have you managed to get through this time?”

  • Used to make assessment of the client’s situation:

“Who has been there to support you the most?”

“What is your typical day like right now?”

Questions that start with “who,“ “what,” “how,” “when,” “why,” and “where” might be open or closed, but in beginning a sentence with one of these words, you are asking for an answer. The word you use to open a sentence determines the focus of the answer:

  • Who – people
  • What – facts
  • How – feelings and reactions
  • When – temporal aspects
  • Why – reasons (use sparingly)
  • Where – environment and setting
  • Could – might be the most open and productive of all questions

Here are some guidelines to keep in mind in regard to the use of questions:

  1. Use questions consciously and selectively when you need the information and can “go for it” when needed.
  2. Think of how you can incorporate awareness-expanding questions into your sessions:

“Can you describe your ideal…?”

“How might your life look like if this was changed?”

“What is the hardest part of your daily life right now?”

  1. All questions and probes need to be grounded in empathy – understanding that there are valid reasons why a client has made choices and an appreciation of what that person has gone through before getting here.
  2. Build in an internal alarm that goes off if you ask two or more questions in a row and look at why you are asking these questions. Asking too many questions stops the flow, tends to keep the client in his or her head, and leads the client too much.
  3. Base questions on the context of the session and what the client is bringing up.
  4. You must ask questions if a person seems suicidal.
  5. Avoid using questions when you want to show empathy – use a statement instead. For example, you can say, “This is a very hard time right now,” instead of asking, “How difficult is this for you right now?”
  6. Avoid closed questions as much as possible when you are in the midst of a session.
  7. Try to avoid using the word “why” when asking a question, because it may tend to appear judgmental or accusatory to a client, and doing so can place the client in a defensive posture with you, which is counter to your intention of establishing a safe place in the counseling venue.

EMPATHY

Empathy is perhaps one of the most essential components of counseling practice. The ability to join empathetically with a client involves your ability to essentially “get into the client’s shoes” and see and experience things as if you were the client. Carl Rogers (1959), the founder of person-centered therapy, described empathy as the counselor’s ability to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the “as if” condition. Thus, it means to sense the hurt or the pleasure of another as he [or she] senses it and to perceive the causes thereof as he [or she] perceives them, but without ever losing the recognition that it is as if I were hurt or pleased and so forth. (p. 185)

Responding to a client with empathy means you intentionally move into your client’s frame of reference – how things seem and feel to your client, trying to experience the world as your client does, while maintaining your awareness that this frame of reference and experience is not yours. All good counseling practices aim to increase our empathetic understanding of our clients with the understanding that joining with clients in this way helps them to feel deeply understood and accepted. You have probably heard the phrase “walk a mile in my shoes.” Empathetic joining is your attempt to do just that – to walk in your client’s shoes, see through his or her eyes, and think about how the world is experienced by him or her. When we are empathetic in our stance with our clients, we share a valued sense of resonance with them, and this experience can be very powerful for our clients.

Sometimes, in the process of trying to experience the world as your client does in empathetic joining, you may get an intuition about something that the client may not have stated openly but seems to be apparent once you begin to join more with that client. This occurrence is sometimes referred to as advanced empathy. It is important to note that you might actually be aware of something that the client is experiencing, which may not necessarily be in the client’s conscious awareness, but is there – the client is generating it and you perceive it. When you listen empathetically to clients, you are often not just listening to their words and using the attending skills described previously, but rather may be engaging in a deeper form of listening that involves your intuition and your own responses to the client’s material. Yalom (2009) spoke of using the “rabbit ears” of the therapist – picking up on often understated but very significant aspects of the client’s story and experiences. Paul Wong (2004), the president of the International Network on Personal Meaning, describes what is meant by advanced empathy:

Advanced empathy requires the listener to go beyond verbal and nonverbal expressions, to develop an insightful awareness and understanding of another person’s intentions, desires and unspoken concerns. It requires the skill to listen with the sixth sense, to feel the pulse of the innermost being, and to make explicit what is hidden beneath consciousness. It involves the insightful construing of meaning and significance from a variety of seemingly trivial clues. It tests hypothesis about the missing pieces of the puzzle and anticipates solutions. (para. 25)

Whenever you think you are “tuning in” to your client in this deeper way, and you believe that you have an insight for the client as a result, it is important to check your perceptions with your client. You can let the client know that you have a “hunch” about something and want to know his or her thoughts about it. Using advanced empathy in this way is not an interpretation or even a “brilliant figuring out” of the client’s material, but an opportunity to share in your client’s world in a deeper way. When you experience advanced empathy, you may sense a pattern emerging and you really “get it” – the connections become apparent between the client’s story, experiences, feelings, and thoughts, and there is a certain clarity that you then reflect back to the client. Remember to offer your hunch as a possibility – invite the client to look at it, and if the client pulls away or does not agree, immediately move on to something else and do not dwell on it.

Empathy is more than a set of skills, and for many counselors it is an innate quality. Learning what empathy is and how to enhance your ability to enter your client’s world in this way is of paramount importance to the development of the therapeutic alliance, where clients feel safe to share their thoughts and feelings and engage with you in a meaningful way. For empathy to be effective, the therapist needs to develop the attitude or mindset of empathy. In other words, empathy works only when it comes from a person who really cares about people and who truly has a compassionate heart. Knowing that the counselor truly cares about the client and values the client is far more important in this process than intellectual understanding and knowledge of details. This type of caring about your clients will “cover” a lot of counselor errors in timing, misunderstandings, and inadvertent miscommunication. A counselor can come across to a client as patronizing, judging, or condescending in the absence of an empathetic connection.

ENCOURAGING, PARAPHRASING, AND SUMMARIZING

These skills involve verbal responses (not questions) that demonstrate to clients that you have listened to their story and understood their thoughts and feelings. These skills also provide clients with an opportunity to reflect upon their stories, clarify what they have shared, and go deeper into their thoughts and feelings.

  • Encouragers – Are head nods, hand gestures, and positive facial expressions that invite the client to continue talking. They include minimal verbal expressions, such as “uh huh,” that go along with the nonverbal engagement and interest that are displayed by the counselor.
  • Paraphrasing – Feeds back to the client the essence of what he or she has said, using some of the client’s words plus some of your own. Paraphrasing can be helpful when you want the client to know that you have “taken in” what he or she has shared, or if you want to try to focus on one aspect of the interaction or story. A good way to paraphrase what a client has shared with you is to start with a sentence stem, based on what you think the client’s verbal style is, and then condense the material in your own words to check with the client for accuracy:

Sight – ”As I see things…”

Sound – ”As I hear you speak…”

Movement – ”You appear moved by this…”

For example, “Let me see if I have heard you correctly. What I think you are saying is that this is all just too much to absorb – it is just too many losses and too many adjustments without a chance to catch your breath in between. Does that sound about right?”

  • Summarizing – Similar to paraphrasing, but a summary will cover a longer time frame and more information. Summarizing can be used to begin the session, for example, “Last time we were together, we talked about… What has happened since?” In the middle of the session, summarization may help to wrap up one part of the session, before going on to something else: “Up until now, we have talked about how it was at the funeral. You have mentioned what happened that day, some of the issues with your family that arose, and how you felt just before the funeral … so, I wonder now what took place in the weeks following his death?” A good summary is often very useful at the end of the session to review what has taken place during the session. Use the sentence stem, a summary of important events and the feelings and key descriptors connected with them, and end with a check for accuracy.

For example, “As I see the situation, you have been distraught over the death of your sister, partly because it was accidental and you had no time to prepare. You have had to be the strong one in the family and support your parents and siblings in their grief. It is possible that you have not taken the time to feel your own grief in the face of all that you have had to do, and now you are overwhelmed and seem ready to collapse. It sounds like there is a lot on your plate, and perhaps we can start with these issues at our next session.”

IMMEDIACY

The client – counselor interaction often closely mirrors the way that clients interact with others. If you find a client to be difficult, nonemotional, scattered in thinking, or irritating in some way, most likely other individuals in the client’s world experience the client in a similar way. Using immediacy involves looking at the here and now – at what is happening in the counseling sessions as grist for the mill in the client’s process. We can move through past, future, and present tenses when clients share their stories, but staying in the present is probably what is most powerful (and helpful) for the client. In his guidebook for therapists, Yalom (2009) discusses the use of immediacy and staying in the “here and now” with clients as vital in assisting clients toward growth and healing.

It is important to remember that timing is crucial when you decide to draw attention to something that you experience with the client in the session. Immediacy is a bit of a “dance” between self-disclosure and feedback, because you choose to share something that you experience with the client in the here and now. Because this type of feedback is uncommon in most people’s lives, clients may not know exactly how to handle you sharing your experience of them during sessions so forthrightly and some clients may feel that you are challenging them or that you are criticizing them. Using immediacy requires skillful communication and perception of both the self and the client by the counselor. We are taught socially not to address issues in this way, so it involves a relearning process. Using immediacy means we are naming what is going on and bringing it up into the conscious awareness in the room. You are noticing what you are seeing and talking about it openly. Yalom (2009) gives an example of how he might use immediacy with a client who casually makes a statement before repeating an oft-told story to him during a session:

“I know you’ve heard this story before but…” (and the patient proceeded to tell a long story).

“I’m struck by how often you say that I’ve heard the story before and then proceed to tell it. What’s your hunch about how I feel listening to the same story over again?”

“Must be tedious. You probably want the hour to end – you’re probably checking the clock.”

“Is there a question in there for me?”

“Well, do you?”

“I am impatient hearing the same story again. I feel it gets interposed between the two of us, as though you’re really not talking to me. You were right about my checking the clock. I did – but it was with the hope that when your story ended, we would still have time to make contact before the end of the session.” (pp. 24 – 25)

Keep in mind that clients may not be used to this type of interaction, and they may interpret it as judgment, shaming, or “calling them on the carpet” when that is not your intention. Therefore, it is very important that you ground any feedback like this in empathy and that you are careful and considerate when you first begin to incorporate its use in your work with a client. Some other examples of immediacy might be like the following:

“I noticed you sighed just now. I wonder what that’s about…”

“Your face grimaced as you talked about that…”

“I am feeling this right now … how about you?”

“I find it difficult that you are smiling right now, but your story is very troubling. Can you tell me a little about that?”

SELF-DISCLOSURE

This skill involves the counselor sharing his or her own story and own personhood at appropriate times in the process. Yalom (2009) describes three kinds of counselor self-disclosure: (a) the mechanism of therapy, (b) feelings that are present in the here and now, and (c) sharing from the therapist’s personal life and experiences. Probably the most difficult form of self-disclosure to gauge is that of your own personal experiences. There are some potential positive effects for clients when counselors disclose aspects of themselves in a session. Some of these positive results with counselor self-disclosure may be that it:

  • Helps to normalize the client’s experiences
  • Helps to give realistic expectations
  • Models self-disclosure for the client, especially if the client has difficulty disclosing information about self
  • Communicates to clients that they are not alone
  • Can be helpful if you are sensing/feeling that you need to be more visible as a real person or that there is a need to try to equalize the power in the therapeutic relationship

Self-disclosure has a lot to do with boundaries, and it is not a good idea to disclose material from your personal experiences if the boundaries of the client are shaky or not intact. Times when you should hold back from selfdisclosure with a client might be in the following scenarios:

  • Boundaries are not set or are problematic (e.g., the client may use the personal material you have disclosed in order to gain access to your personal life; the client has difficulty with maintaining close relationships because of dependency needs or inappropriate behaviors).
  • You are triggered and want to share something for your own release during the session.
  • You sense that disclosing something personal with a client might change the relationship dynamic in an unhealthy or unproductive way.
  • Your self-disclosure leads the client to try to focus on you instead of them; the client may want to talk about you and your experience more as a defense or the client has a habit of wanting to take care of others incessantly or to “rescue” others repeatedly.
  • The client does not tolerate intimacy well. Your sharing something personal could backfire with a client who has difficulty being close to others, because he or she may not be able to handle having personal knowledge of you, or may feel overwhelmed by the information.

So, if you have established a good working therapeutic alliance with a client, and you feel that sharing something from your personal world may afford some benefit to your client, there are a few suggestions to consider beforehand. These might be as follows:

  • Be conscious – know why you are doing it.
  • Be brief – one or two sentences maximum; keep the focus of the session on the client and not on you.
  • Consider whose need it is serving – if you are feeling a lot of emotional energy around sharing something with a client, stop and reflect upon your purpose in sharing this information with your client.
  • Limit the frequency – if you are doing this a lot, explore why. Are you being set up as avoidance? Are you frustrated because the client is not sharing deeply in the sessions?
  • Use your intuition whether or not this is right for this client. If you have any uneasiness about it, wait to disclose until you can give it more time and thought.
  • Use your common sense.
  • Be aware of timing; in the beginning of counseling, the focus should be more on hearing the client and “getting” the story. As you go on in time, and the focus of the sessions begins to move toward growth and the future, self-disclosure may be a very valuable tool.
  • If you have any hesitation about whether to self-disclose or not, err on the side of not disclosing. Remember, once you have disclosed something to a client, you cannot take it back!
  • Keep in mind that clients are not bound by the same adherence to confidentiality as a counselor is. Whatever you may share with a client can potentially be shared with many other individuals in the client’s interactions with others outside of the session.

Clients vary enormously with the appropriateness of this technique, so be very aware and follow the client’s response as a guide. There is no one “right” way to approach this issue with all of your clients, so you would need to gauge your disclosure on a case by case basis.

Self-disclosure certainly has its place in the therapeutic alliance. Counselors tend to vary widely in how they choose to disclose or not to disclose details of their personal lives with clients. Many counselors feel that the benefits of disclosure in regard to their transparency and shared humanity with clients are profound. What is most important to this discussion is that you are able to think about this topic and your comfort with self-disclosure so that you feel reconciled with whatever choices you make about this issue.

HONORING RESISTANCE

Even though a client freely chooses to begin counseling sessions, there may be times when you get the feeling that a client is holding back in the session with you or that a client demonstrates behaviors that indicate to you that something may be awry in the therapeutic alliance. If you have this experience, you may be facing resistance from the client, and it is important to reflect upon what is happening. Keep in mind that for many individuals, the counseling process may be associated with stigma or with identification by others of being “weak.” Counseling can also be expensive for clients, especially if they have very little or no insurance coverage to assist with the costs of sessions. In addition, the venue itself might seem pretty daunting – unsure of what to expect, clients are asked to enter into a relationship with a virtual stranger and share about personal experiences and feelings that they might not have shared previously with even their closest friends and family. For some clients, the choice to seek counseling help might not have been their own. They may have been coerced into counseling by a well-meaning family member, friend, minister, or health care professional, and as a result, they are not willing to fully commit themselves to the process. Given the unique dimensions of the process, it is only natural that some clients will feel a sense of resistance toward counseling.

It is important for a counselor to know how to recognize resistance and how to best respond to its presence within a client. Keep in mind that when someone is feeling resistant, he or she is often feeling highly vulnerable and wanting to protect that vulnerability by putting up a barrier. Often, resistance stems from the client feeling coerced, outmaneuvered, or intimidated, even though these are the last things that a counselor would want to convey. In fact, the resistance may not have anything to do with the counselor at all, but could be more of a reflection upon the client’s anxiety, difficulty trusting, feeling shame, finding the interactions too intense, or the need to stay in the familiar and to be identified with what is known. Resistance is a normal response and it needs to be honored as such. It is imperative that you give the client space when this is happening and not push. In being resistant, the client is able to say “no,” which can be a good thing. It is a natural response to get frustrated with a resistant client – however, it is a normal process and it is important to see it as an opportunity to learn more about the client’s feelings and world view.

Resistance may be manifested in many different ways. Clients may talk “around” an issue and change the subject when things are getting too close for their comfort. Some clients may attempt to use humor, try to focus the session on extraneous things like the weather or details that are not really important, or onto the therapist. When you sense there is resistance, back up and think about what is happening. If your goal is to honor the client’s process, you will most likely pick up on the resistance and handle it with compassion, which is probably what the client needs at this time. Here are common reasons for why resistance may occur:

  • The counselor is leading too much.
  • The client does not feel that the counselor understands him or her.
  • The session or process may be too intense.
  • The counselor is not listening well enough or engaged enough with the client.
  • The counselor is too challenging for the client.
  • The counselor’s body language may be misinterpreted by the client.
  • The client feels that the counselor is judgmental or advice-giving.
  • There is transference on the part of the client that is interfering with his or her relationship with the therapist (e.g., the therapist reminds the client of someone who has been abusive, negative, or highly critical to him or her in the past).

So, once you are aware that there is some resistance being manifested by your client, what is the best way to handle it? Here are some ideas:

  • Remember that it is normal and normalize it – ”It’s okay.”
  • Accept where the client is and be respectful; remember that resistance has a purpose.
  • Understand that resistance and reluctance are fear based and are often related to feeling a loss of control, fear of the unknown, fear of change, and so on.
  • Examine your own fear/resistance – what is your part? (As a counselor, are you afraid of failing, afraid of not working well with the client, or the client not doing well after seeing you?)
  • Examine your interventions – especially any hidden agendas or current “hot issues” for you – are you pushing too hard? Could the client be feeling any subtle coercion or expectations?
  • Go with the resistance and allow it to produce change. You can befriend the resistance – ”I can sense you don’t want to talk about that and it’s okay.”
  • Be realistic, fair, and flexible. Do not be afraid to stretch. Maybe you are expecting too much. Allow the client to have control.
  • Resistance is often felt as a challenge to you, but it may not be about you. Be willing to be open, be honest, look for solutions, and be as honest with yourself as you can be in your work with clients.

GETTING STARTED – THE FIRST SESSION

As we have stated earlier, many people come to counseling without having a clear idea of what it is really about. Clients come to counseling for a variety of reasons, but most initiate counseling in order to feel better, to learn how to cope more effectively with the experiences they have had, or to feel that they are not alone in their situation. So, with these thoughts in mind, let us think about our objectives for the first session that we see a client:

  1. Begin to build a trusting relationship. We have discussed much of the groundwork involved in setting up the therapeutic alliance in previous chapters and in this one as well. This is now the time when you begin to orient the client to your way of being with him or her, and the client begins to have a good idea of your values and way of working therapeutically. Safety in the therapeutic relationship is built upon trust, and you need to be able to share with the client how you will keep his or her disclosures safe and private and how you will begin the work. So, in addition to the intentional offering of your full presence, you will use the skills that we described in this chapter to lay the foundation for your future interactions. In addition, you will need to share with your client about the confidential nature of counseling, and any limits on that confidentiality that may be present.
  2. Teach the client about the gradual, unfolding nature of the counseling process. Ask the client for his or her expectations, and to share ideas about how the counseling process works from his or her perspective. You can also share a little bit about your philosophy of counseling and how you like to work with clients. However, it is also a very good idea to ask your client to identify what he or she might find most helpful as a starting point for this work together. You want to use this first session as a time to let the client know that you wish to follow his or her lead, not the other way around.
  3. Ask the client about his or her concerns and desired outcome from counseling. Do not be afraid to ask the client to indicate to you what he or she hopes will happen as a result of coming to a counselor. It is also important at this time to engage in a dialogue about what the counseling process is and what it is not. For example, some clients will indicate that they want you to tell them what to do. You may then have to explain that you do not tell people what to do, but rather you try to help them to figure out what they feel is best to do after exploring all of the possibilities that are available.
  4. Discuss the collaborative nature of counseling. Ask the client about how you can best support him or her in this journey. Do not be afraid to ask if he or she has seen a counselor in the past, and to describe what that experience was like – and if you need to adjust your way of working with the client to better accommodate his or her needs and expectations. Remind clients that you will frequently “check in” with them during the sessions for their feedback, and that you will also provide honest feedback to them, if they wish.

Some counselors may choose to have a written contract in place with their clients, delineating the roles and expectations of each party in the counseling process. This contract may strengthen the therapeutic alliance by providing a clear understanding regarding what each party is expected to do when entering the contract.

CONCLUSION

Being a counselor can be a very challenging vocation. Being a skilled counselor requires a great deal of discipline, focus, commitment to self-awareness and understanding, and compassionate engagement with clients. Reading about these skills and the counseling process is interesting, but actually having the opportunity to “practice the process” and to spend time immersed in therapeutic encounters will help to refine the counselor’s abilities and skills considerably.

Glossary

Advanced empathy – Moments when the counselor is deeply attuned to the client and has an intuitive knowing about something that the client may not have stated openly, but seems to be apparent in the session.

Attending skills – Include things to which the counselor needs to “attend,” both in himself or herself and in the client. Include body language, eye contact, tone and volume of voice, use of language, and nonverbal cues.

Closed questionsQuestions that can be answered with a “yes” or “no,” or often with a single word. Closed questions often provide the facts, such as address, age, and length of time since an event, and often begin with “where,” “is,” “are,” and “do.”

Empathy – Involves the counselor intentionally moving into the client’s frame of reference – attempting to experience how things seem and feel to the client, trying to experience the world as the client does, while at the same time maintaining the awareness that this frame of reference and experience is of the client and not of the counselor.

Immediacy – The ability of the counselor to use the immediate situation within the session to invite the client to look at what is going on between them in the relationship.

Observation skills – The ability to ascertain information about the client through careful observation on the part of the counselor. Observational skills assist in reading nonverbal cues and fi lling in details about the client’s story and situation.

Open questions – Cannot be answered briefl y, and they often require some thought or expression of feeling. Open questions often begin with “what,” “how,” “why,” and “could,” and allow clients to respond according to their needs. These types of questions invite clients to elaborate on their story and add the details as they wish.

Resistance – The situation in which a client withholds disclosure or engagement in the therapeutic relationship or session, often due to the client feeling threatened or uncomfortable for some reason. Resistance may or may not be conscious on the part of the client.

Self-disclosure – Involves the counselor sharing his or her own story and own personhood at appropriate times in the process. Three kinds of counselor self-disclosure are (a) the mechanism of therapy, (b) feelings that are present in the here and now, and (c) sharing from the therapist’s personal life and experiences.

Verbal trackingUsed by the counselor to more closely follow the client’s story or how a client tends to share about an experience. In verbal tracking the counselor tends to “pick out” things that point to a deeper level of a client’s experience or awareness.

Questions for Reflection

  1. Practice your own skills of empathy and listening to others in social settings. For instance, when you are listening to someone, describe an experience or his or her feelings about something, try to “tune in” by listening to what he or she is saying, and his or her feelings about the experience without asking questions, and without interjecting your opinions. What happens when you do this?
  2. Ask someone you know to describe an event or an experience he or she have had. As he or she is speaking, you can engage with that person, as long as you do not ask any questions. You may use statements, but not questions. What is it like to do this exercise? What can this exercise tell you about how you would interact with different kinds of clients?
  3. Think of a “script” that you might use for your initial sessions with clients. Write out what you would say in the beginning of the first session to set the tone for the counseling, and how you would describe your way of working with clients to a new client. You can practice your “script” with a friend or colleague to fine tune it before you use it with clients.
  4. What are some reasons why a bereaved client might feel some resistance to sharing something with a counselor? How might you address resistance with bereaved individuals in the counseling process?
  5. Practice listening to people as they share their stories and experiences with you. Do you find that you tend to remember details of the story more easily, or that you tend to “tune in” to the tone of the person who is speaking, noticing his or her feelings and reactions more than the details of his or her story? What might this tell you about the way that you will work with clients?

 

 

CHAPTER 7 Working With Bereaved Individuals

Many people are afraid to approach newly bereaved individuals, feeling concerned that they may say the wrong thing, or that they may actually make the bereaved person feel worse by saying something that is inadvertently insensitive or that provokes pain. In this chapter, we explain some practical ideas about how to sensitively approach someone who is bereaved and to offer the best form of support that might be possible to that person.

We have already mentioned in a previous chapter that most bereaved individuals do not require professional support or therapy to cope with their losses and their grief. In this chapter, we are not going to focus so much on what professionals do or do not do, but on what might be helpful to a bereaved person whether you are a friend, colleague, or counselor. Some people seek grief counseling not because their grief is complicated or because deeper unresolved issues in their lives have been triggered by the loss, but because they need a safe place to explore their grief in a healthy way with someone who can offer them unconditional support. We first explore some of the common expressions of the grief experience, and then we discuss some practical suggestions for how to be most helpful to a bereaved individual.

WHAT IS NORMAL?

Although we addressed this issue from a more theoretical and sociological point of view in Chapter 4, this question is perhaps one of the most common queries we receive from clients and students alike. Because there is so much variation in grief from one person to another, how would you know what is normal? One of our clients answered this question very well when she said simply, “Normal is a cycle on the washing machine. If you want normal right now, go to your laundry room and look for it to be written on the dial. That’s where you will find normal when you are grieving.” We laughed at the time when she made this statement, but we have shared it with many other clients, who nod in agreement. When we encounter a significant loss – the “seismic life event” that we mentioned earlier, our entire world gets turned upside down. There is often a sense of being off balance and unable to be the way we have known ourselves to be in the past, and sometimes there is an accompanying sense of paralysis and numbness or a dizzying need to remain very busy that is not normally part of who we are. So, let us start with how grief can be experienced, and then take a look at some of the more unique aspects of the grieving process as a way of exploring the various ways in which grief may be encountered.

How Grief Is Experienced

Although grief is often considered primarily an emotional response, it can be expressed in many different ways with a great deal of variation among individuals. It is important to note that bereaved individuals will most likely experience grief in a way that is congruent with their personality and previous ways of coping with stressful situations. For example, a person who is not typically emotionally demonstrative with others will most likely not all of a sudden become highly emotional or seek out places to share his or her feelings after experiencing a significant loss. Grief can be manifest in many ways:

  • Emotionally – Although we expect to see sadness, this is not always the primary emotion that bereaved individuals may feel. It is very common to feel angry due to what has happened, to feel robbed of the presence of someone we loved who is now gone, or to feel like we have lost a part of ourselves that we valued. Sometimes, the anger is expressed toward medical care providers, clergy, family members, or oneself. The anger can also be more covert, being expressed through sarcastic remarks or cynicism about life and people. Many bereaved individuals report feeling numb – a sense that they are unable to access their feelings – or that they are flooded – that their feelings are very intense and overwhelming. Guilt and remorse are commonly expressed, either for lost opportunities or for things said or done that they now wish had not been, or for issues they feel they will never have the opportunity to clear up. These feelings are often expressed as “if onlys.” It is important to remember that emotions do serve a valuable purpose when they are present, and the listener’s role is not to talk the bereaved person out of these emotions or to try to make him

or her feel better, but to listen and support the sharing of these emotions so that the bereaved individual can benefit from the purpose the emotions are serving. We talk more about working with strong emotions in a Chapter 9.

  • Cognitively – It is common for bereaved individuals to complain that they just cannot focus well, or that their minds seem to wander a lot. Many people describe difficulties remembering, organizing, and keeping track of things. Time may seem to warp as well; a day may seem like forever, or it may seem like a brief period of time. Days and nights can get switched around as well. Many of our bereaved clients describe their minds as “constantly busy,” but not productively so. One client reported that she accidentally forgot to pick up her 2-year-old son from daycare. She stated that she had a nagging feeling that something was amiss, and when she got home, she realized that she had not picked up her son at the usual time of 4 p.m. (and it was now almost 6 p.m.)! This aspect of grief may be very hard if you work, as most people have limited time off work after the death of a loved one, and when they return to work, concentration and focus can be very difficult.
  • Physically – Our bodies often “carry” the weight of our grief through physical symptoms. Many bereaved individuals will share that they often have symptoms that mimic those of their loved ones before they died. One client shared that she had gone to the emergency department three times with chest pain and shortness of breath that had never been present before her husband died suddenly of a heart attack. One very common description from clients is something that we term “restless exhaustion,” in which bereaved individuals may feel continually busy or agitated in their minds, but exhausted physically. When they try to lie down or rest, their minds become even busier; however, when they try to get something done or try to complete a task, they are overwhelmed by feelings of exhaustion and lethargy. Headaches, bodily aches and pains, difficulty sleeping, weight loss and weight gain, digestive problems, and accidents like falling, tripping, and knocking over things are also commonly described (Hensley & Clayton, 2008; Luekin, 2008; Stroebe, Schut, & Stroebe, 2007). It is interesting to note that there is research linking certain types of bereavement to lowered immune function and to higher rates of morbidity and mortality in survivors (Buckley, McKinley, Tofler, & Bartrop, 2010; Goodkin et al., 2001; Hall & Irwin, 2001; Jones, Bartrop, Forcier, & Penny, 2010; Schleifer, Keller, Camerino, Thornton, & Stein, 1983).
  • Spiritually – We have already discussed how a significant loss event can shake up an individual’s assumptive world, and the spiritual effects of a major loss often leave people questioning their beliefs about God or wondering if there is indeed any higher order or purpose in life. Over time, many bereaved individuals will often say that their loss experience deepened their faith or caused them to reexamine beliefs that they had taken for granted before. On a more practical level, clients will often share how their faith communities are sources of support and also, at times, sources of discomfort or disappointment. Although there are studies that examine the effects of spiritual beliefs on bereavement outcome, most do not conclusively demonstrate that either religion or systems of faith have a direct impact on the course of bereavement (Wortmann & Park, 2008). However, it is often thought that many individuals benefit from the sense of structure and ritual that a faith tradition may provide for them after a significant loss, such as the funeral liturgy, mourning rituals, and a sense of belonging to a community at a time when they may otherwise be isolated (Park & Halifax, 2011).

Balk (1999) states that three things must be present for a life crisis to initiate spiritual change in a person: (a) the situation must create a feeling of destabilization that resists restabilization readily, (b) there must be time to reflect upon what has occurred, and (c) the crisis must be something that will be indelibly etched into the life story of the person who experiences it. Balk further states:

Bereavement contains all the necessary ingredients needed to trigger spiritual change. It is a dangerous opportunity, producing extreme psychological imbalance, and possessing sufficient intensity and duration to allow for serious reflection. Its effects color a person’s life forever. (p. 488)

Fowler (1981) mentions that the times in our lives when we end up questioning our beliefs and searching for meaning can produce what he calls a transformed faith consciousness, which allows for greater meaning and understanding in our lives. Thus, a significant loss event carries the possibility of spiritual destabilization, but it may also hold the potential for increased depth and personal meaning in life later on.

  • Socially – There are many effects that grief has on how bereaved individuals interact with others socially. If the bereaved individual has been a long-term caregiver, there is a good likelihood that the social network that was in place before so much time was spent taking care of a dying loved one is no longer in place. Others’ lives have continued in very different ways from the life of the person who became a longterm caregiver, and with increasing demands due to the illness of the loved one, there was likely little time left to socialize and stay in touch with the caregiver’s usual support network (Burton et al., 2008). Our bereaved clients often describe feeling socially isolated and aware that they do not “fit” into any identifiable social group, often feeling acutely aware that they are different in the way they react to things and to their needs in their close relationships than before they were bereaved.

Many bereaved individuals isolate themselves because they have a great deal of difficulty handling social situations where they may be triggered into their grief or where the effort to engage in small talk seems like a great deal of work because their lives have been filled with such deep grief and profound questioning of life and themselves. Many of these individuals have a difficult time fitting neatly in a social context – they may no longer be able to identify with the role that was associated with the deceased person – for example, a widow is no longer a wife; a parent to a deceased child is still a parent, but the child is missing. In addition, many bereaved individuals sense the discomfort of others around them, as people struggle finding the “right” words to speak, or avoid them to prevent the discomfort of an awkward social exchange.

  • Economically – We often do not ask our clients about this particular issue in bereavement, but it is an area that can be of immense concern to bereaved individuals. Two of the younger widows that I (D.L.H.) have seen in my practice had to declare bankruptcy after their husbands died because there was not enough life insurance to cover the debts in their husbands’ businesses and they could not deal with bill collectors and harassing phone calls and letters on top of their paralyzing grief.

If the bereaved individual takes time off work to be the caregiver to a terminally ill loved one, he or she may not only face lost income, but his or her job may have been given to someone else in his or her absence. In addition, those individuals who take a leave from their work after the death of a loved one may do so out of necessity to take care of the estate issues and to take care of themselves emotionally and physically, but this time may be unpaid leave from work, with the result being increased financial strain layered on top of the grief. If the bereaved individual is the executor of the deceased person’s estate, there are often time-consuming responsibilities associated with this role, and there may be conflict with surviving relatives about the distribution of the estate, all of which will land in the lap of the grief-laden executor. Some clients have difficulties accepting insurance monies and proceeds from an estate, citing feelings of guilt that the death of the person they loved has now somehow benefited them financially.

  • Behaviorally – Some of the behaviors in which bereaved individuals may engage can be quite subtle, but they may be very common. For instance, many bereaved individuals will describe feeling like they are searching for their lost loved one in a crowd, or they will automatically scan situations for familiar things that are associated with their loved ones – a car that is similar to the one that your son drove before he died pulls up next to you and you realize that you are staring at the driver, looking for your son in the seat. Or you find yourself going to places that your loved one would go, even if it is not a place that you went together beforehand. Some individuals find engaging in an activity that their loved ones used to enjoy to be comforting – gardening, playing certain music that their loved ones enjoyed, feeding birds, collecting stamps, shopping, watching certain sports events and teams, eating at certain restaurants or certain types of food that their loveds one liked are all frequently described by bereaved individuals, and the common thread is often an identification with the deceased person and an attempt to reconnect with that person in these activities. Clayton (1990) and Pilling, Thege, Demetrovics, and Kopp (2012) describe attempts to cope by the increased use of alcohol, tranquilizers, hypnotics, and cigarettes often reported in bereaved individuals. Many bereaved individuals describe a sense of “going through the motions,” or of being on “autopilot” for a long period of time after they experience a significant loss. One client described this experience as “showing up for work, but leaving my brain at home asleep.”

Extraordinary Experiences

Bereaved individuals commonly describe feeling that their loved ones have connected with them through a sign, a dream, a vision, or a hallucination. We have had clients give descriptions of radios getting tuned in to the favorite station of their loved ones without them recalling changing the tuner themselves, a bird landing on a windowsill that they believe represents a visit from the deceased person, a “sense” of something brushing against their skin, finding a book open to a page where there is a message for them, flickering of lights, butterflies appearing from nowhere, or hearing the voice of their loved ones speaking to them either silently or audibly. The “visitation dreams” that clients describe are often very vivid and totally engaging, often with the deceased person telling them that they are okay, and sometimes the feeling that there was physical contact with the deceased in the dream. Some of the dreams are not comforting and may involve looking frantically for their loved ones, getting lost and unable to find their way out of a place, or of a sense of unease associated with their loved ones or the circumstances around their death.

Many clients share that they have regular “conversations” with their deceased loved ones, most commonly described as silent discussions that occur in their thoughts, but sometimes in audible dialogue as well. These conversations most often happen at the graveside or in a place that was most frequented by the deceased person, such as his or her office, the car, a favorite recreation spot, or a special place that they shared together. Most bereaved individuals describe these experiences as comforting and helpful, which is also supported by Parker’s (2005) research on the topic. What is important to note about these experiences is that they are common among bereaved individuals and they also tend to have a functional role in the grieving process rather than a pathological or unhealthy influence. These experiences are not breaks in reality that would occur in someone with a psychotic or delusional disorder, as the bereaved are aware that the experience is extraordinary when it occurs, and their interpretation of the event is often kept very private to avoid social stigma surrounding the experience or their mental state.

Resurgences

It is now known that grief may never be fully “resolved.” It is more common (and more accurate) to use words such as “integration,” “accommodation,” and “adaptation” to loss rather than to refer to “recovery from grief,” “resolution of a loss,” or “acceptance.” In fact, it is now recognized that grief after significant losses may never really end. Although the intensity of the grieving experience usually diminishes over time, the grief itself may be present in various ways throughout a person’s lifetime. For example, a girl whose father dies when she is 8 years old may experience a resurgence of grief later in her life as she experiences significant life passages and realizes that her father is not there to participate in these times with her. There are times when grief that has abated in its intensity over time can be reactivated in a very real and intense way. Most commonly, these resurgences occur at significant times, such as anniversary dates, the date the loved one died, or at special family times or rites of passage, such as graduations, weddings, the birth of a baby, or some time or event that carries a reminder of a shared time with the deceased (Sofka, 2004). Some people call these “grief triggers,” or “grief surges.” Parkes and Prigerson (2013) use the term grief “pangs” to describe these resurgences of grief. Rosenblatt (1996) addresses the issue of the ongoing nature of grief, stating that grief may never really go away completely, and noting that it is probably unrealistic to think that a bereaved individual will just stop grieving at some point. Rather, he states that grief resulting from major losses will probably recur at many points over a person’s lifetime. Grief can essentially “sneak up” on someone when there is a new pang of grief that surfaces in response to a triggering situation or reminder. Rando (1993) – described STUG reactions – subsequent temporary upsurges of grief that occur in situations in which the realization of the loss and its magnitude are brought into the active awareness of the bereaved individual, sometimes many years later. It is very important to recognize that there is no specific timeline for grief to end, and the resurgence of grief at various points in time after a significant loss is very common and normal.

Grieving Styles

Doka and Martin (2010) extrapolate on different patterns of the expression of grief in their descriptions of adaptive grieving styles. These authors describe three main grieving styles on a continuum, with intuitive grievers at one end and instrumental grievers at the other, and a more blended grieving style between them. Intuitive grievers tend to express feelings and wish to talk about their experience with others. Instrumental grievers tend to grieve more cognitively and behaviorally and tend to express their grief in terms of thoughts, analysis, and actions. Individuals who have a blended grieving style may combine elements of both intuitive and instrumental grieving styles, but they usually have a predominant tendency toward one of the other styles. This exploration of grief emphasizes that there is no “right” way to grieve; however, bereaved individuals are often expected to grieve in certain ways based on gender socialization, and if they do not express grief in a way that is expected by others, their experience may be labeled as problematic or even pathological.

There have been times when a client or a family member of a bereaved individual will assume that a person has not “grieved well” unless he or she has expressed emotions about the loss. As we stated earlier, not all bereaved individuals will grieve through their emotions or will need to share their feelings and talk about their loss. Expressions of grief typically are congruent with an individual’s existing personality, temperament, and preferences. For example, one of our colleagues recently lost his wife. They were extremely close, and her illness and subsequent death occurred over a few short months. He was back to work within a few weeks after the funeral. Many individuals in our work place assumed that he was avoiding his grief and attempting to bury himself in his work, and they expressed concern that he was “hiding” from his grief. However, during speaking briefly with him, it was very apparent that he needed the structure of work to help him through his daily life, and he is by nature, a more cognitively oriented individual, who tends to process his experiences through his intellect and analytical thinking. His grief was very real to him, as is his profound loss, and his choice in going back to work and focusing on everyday tasks was very congruent with his personality and previous ways of coping during times of stress.

For a long time, the goal of grief counseling seemed to be to get the client to emote and to “clear” the grief by having emotional catharsis. However, it seems much more appropriate (and humane) to think of grief counseling not with this type of goal in mind, but to support the bereaved individual in working out the process of grief in ways that are aligned with that person’s values, view of himself or herself, personality, and temperament.

Although emotional expression is now not seen as an imperative in the way it once was, social support to bereaved individuals can be very important in assisting the bereaved individual. What is very important to remember about social support is that individuals will vary widely in what is seen as supportive and what is not. For instance, if we go back to the example of my widowed colleague, I doubt he would find it helpful if one of us showed up to his office, sat down, and asked him to talk about his feelings. Support to him has come in the form of snippets, which allow him to know that his colleagues are thinking of him and care about him, but not placing an expectation upon him to talk about his feelings at length. He also seems to greatly appreciate the ability to talk about his teenage children as they cope with the loss of their mother, and he has often requested information about specific aspects of teen grief and the loss of a parent.

Mediators of Mourning

The most important aspect of grief counseling is attending to the story and needs of the bereaved individual as he or she describes them. In this form of active listening, you might also “tune in” to the aspects of the grief experience that are unique to that person and his or her experience, and how these unique modifiers shape the landscape of grief for this person. Worden (2009) refers to these unique factors as the mediators of mourning, which include (a) identifying the relationship of the deceased person to the bereaved individual, (b) the nature of the attachment to the deceased person, (c) how the person died, (d) the bereaved individual’s history of previous losses and stresses, (e) personality style and how the person has coped in the past with stressful situations, (f) perceived social support that is available, and (g) the presence of concurrent changes and crises that may be occurring at the same time. Worden cautions that in identifying these variables, the focus is on the multidimensional aspects of grief and the many variables that may have an impact on the bereaved individual, and not an attempt to oversimplify grief and its antecedents.

WHAT MAY HELP – PRACTICAL SUGGESTIONS Do Less, Be More

Many bereaved individuals have experienced others trying to “rescue” them because it is so difficult for others to see them struggling or because their own grief issues become triggered in the bereaved person’s presence. We can certainly say that we agree with the dictum of the Hippocratic Oath that states “above all, do no harm” (Vaughn & Gentry, 2006, p. 165). The first rule of thumb is that you cannot “fix it” or even make it better. There is no “a-ha” phrase or intervention that “works.” You cannot bring back the deceased person. You cannot replace what is irreplaceable. A person cannot go back in time and “unknow” what is now known through a significant loss experience. Grief counseling at its heart is very person centered in its approach, and sensitive counselors know how to “lead from two steps behind their client” (Robert Neimeyer, personal communication, June 5, 2014). So, the real goal of helping in this context is to journey alongside the individual so that he or she will not have to go through it all alone. In our “being with” bereaved clients, we bear witness to their experiences, pain, and process. If you are not comfortable with strong emotions (yours or others) or with silence, you will have difficulty working effectively with grieving clients. As we discussed in the section on therapeutic presence, we are fully present and attentive to our clients, following their stories, listening with our ears and our intuition, and, in so doing, we value and validate their experiences. You cannot take away the pain. You can, however, make a difference in how your clients journey through this painful experience.

Know Yourself

If you have any unresolved or “raw” grief issues, be aware that you are very likely to be triggered by working with grieving clients. If you have not worked through some of your own loss experiences, chances are that you will inadvertently shut your client down emotionally to protect yourself or you will “need” your client in order to complete your own grief work. Selfawareness is one of the most important responsibilities of being a grief counselor. Loss issues, as we all know, do not always pertain just to death. We address counselor issues in more depth in Chapter 13, but suffice it to say that grief is a universal experience, and we all experience losses throughout our lives. It is important that counselors be aware of how their loss experiences have shaped and influenced their lives and often their responses to clients. If we remain open to our own experiences, and address them with compassionate awareness, we can more readily maintain our focus on our clients’ processes and needs.

Re-Membering

Although not everyone needs to talk and to share feelings about their loss, those who seek grief counseling are more likely to self-select toward this desire. Much of grief counseling involves “bearing witness” to your client’s story of loss – who he or she was before the loss, the relationship to the person who died if the loss was a death, or the nature of the loss and its meaning, and what life has been since the loss occurred. If the loss is the death of a loved one, we often suggest that the client brings pictures of the person at different times in his or her life, with and without the client in these pictures. You can ask the client to “introduce” you to the deceased person, and in that process you will learn much about the story of the deceased person, and also about the relationship between the client and the deceased person. You can also invite the client to bring “linking objects” to the sessions. These may be special items that serve as reminders of the loved one – pieces of clothing, jewelry, books, samples of the person’s handwriting, cookbooks and recipe cards, and many other things – that invite memories and rich descriptions of the deceased person and the relationship that they shared together. We call this process “remembering,” as you are putting the shattered parts (members) back together as the story of the person and the relationship come together through the sharing.

Many clients welcome the opportunity to speak freely and to share openly about their loss, their feelings, and their process since the loss. This type of sharing may also serve to remind the client of the times that were good or happy, especially if there has been a period of lengthy caregiving, difficulties, or pain before the loss. It is often helpful to use the name of the deceased person in the conversation, and to try to use language that is similar in tone, words, and style to the client in responding to the sharing of the story. Bearing witness to a client’s grief occurs when you listen intently and when you are fully present to the client as the story unfolds. In your listening and responding, you are also acknowledging the significance of the relationship as well as the painful loss and deprivation that are now part of the client’s daily existence, and you are journeying alongside your client as he or she experiences the aftereffects of this loss.

Tuning In – And Then Changing the Channel

As described in the chapter on bereavement theories, recent thinking in bereavement research is that individuals who are grieving need to oscillate between their grief process and their everyday functioning (Stroebe & Schut, 2010). Distraction and “changing the channel” may be helpful at times and are not necessarily indicative of unhealthy denial or avoidance. If clients find that they have been mired down in their grieving process very heavily for a prolonged period of time and they are not “clearing” the grief, it might be helpful to suggest a way to “change the channel” for a while because the process is repeating itself and may be causing more harm by the repetition of the intense feelings without any movement or relief. This is especially important if traumatic material keeps coming up. Teaching containment in these instances might be very helpful. We discuss the interaction of grief and trauma in more depth in Chapter 10. However, it is important to keep in mind that sometimes being able to “zone out” with a funny movie or a good piece of music, or, at times, becoming immersed in life’s everyday details may be more therapeutic to a bereaved individual than hashing out the blow-by-blow details of a loss event with a counselor over and over. For this purpose, I (D.L.H.) have several guided relaxation and visualization CDs that I loan out to clients who find they need a way to disengage from distressing and repetitive thoughts that may interfere with their ability to sleep or function at times when they are feeling depleted and exhausted.

Rituals and Legacies

As we discussed earlier, much of the “work” of grief is the need to find meaning after a significant loss event. The initiation of rituals associated with the loss, or of establishing legacies to commemorate a loss, may be helpful in attaching meaning to what has occurred and to the life of the bereaved individual in the wake of a significant loss event. Although there are very few prescribed mourning rituals in current Western society, clients may find their own personal rituals that give meaning to their experience. Some people may wear the deceased’s clothing in efforts to remain close in some tangible way. Some may write in a journal to their loved ones or to themselves, light a candle, play a specific piece of music or a certain type of music. Queen Victoria, upon the death of her beloved husband Albert, continued to have his clothing laid out every day for ensuing years (Lewis & Hoy, 2011). We explore this aspect of working with bereaved individuals in more detail in Chapter 11. Suffice it here to say that there is no limit to the creativity and ingenuity of ritualized acts as a response to human need born from loss and grief.

When to Refer for Additional Help and Assessment

Although normal grief usually abates in intensity over time, and most bereaved individuals do not require professional help in order to adapt to their loss, there are some instances where additional help from individuals with specialized training is indicated. This type of difficult, complicated grief is explored in greater detail in Chapter 10.

CONCLUSION

Although grief is a healthy and adaptive process, bereaved individuals may wish to share their process with someone who can be fully present and “bear witness” to their experience. Understanding how grief often unfolds and learning about ways to offer support that are congruent with the bereaved individual’s preferences and needs will help grief counselors to work with these clients in ways that can be meaningful and that might help to promote healing and growth.

Glossary

Extraordinary experiences – Events in which a person believes he or she has been spontaneously contacted by a deceased loved one.

Instrumental grievers – Individuals who tend to grieve more cognitively and behaviorally, and who generally express their grief in terms of thoughts, analysis, and actions.

Intuitive grievers – Individuals who tend to express feelings, and wish to talk about their experience with others.

Linking objects – Special items that serve as reminders to clients of a deceased loved one. These items often invite memories and rich descriptions of the deceased person and the relationship that they shared together.

Mediators of mourning – Unique modifiers that help to shape the grieving process for a given individual.

STUG reactionsAcronym for subsequent temporary upsurges of grief; these occur in situations in which the realization of the loss and its magnitude are brought into the active awareness of the bereaved individual, sometimes many years later.

Transformed faith consciousnessDifficult times in people’s lives that lead to greater questioning of beliefs and searching for meaning, with the result being a deeper appreciation of life and one’s beliefs.

Questions for Reflection

  1. Much of the experience of grief involves feeling out of control. Bereaved individuals have no control over the loss of their loved ones or over the changes in their lives that have occurred as a result of a major loss. One exercise to explore loss of control involves having

a blindfold placed over your eyes. Have a partner choose different foods – tastes, textures, spices, and temperatures – and your partner chooses which foods to feed to you without your knowing what you will be fed. After you complete this exercise, talk with your partner about what it was like to not be able to make your own choices about what you were going to eat, or to know what was going to be fed to you. (Be sure to disclose any food allergies or major food aversions in advance!)

  1. Think of a significant loss that either you or someone close to you has experienced. Look at the mediators of mourning written by Worden (2009), as discussed in this chapter, and describe how each mediator played a role in how you or the other person dealt with the loss experience.
  2. In this chapter, we briefly discussed the possibility of assisting a bereaved individual to “change the channel” at times as a way to assist in the grieving process. What do you think makes this suggestion different from unhealthy avoidance of grief?
  3. Think of some of the popular movies that you have seen where grief and loss have played a major role in the plot. How has the grief in these movies been portrayed? What were some of the responses from other members of the cast to the person in the movie who is bereaved? What messages do these movies convey about grief to the public?

 

 

 

 

 

CHAPTER 8 Living Losses: Nonfinite

Loss, Ambiguous Loss, and Chronic Sorrow

In the process of living our lives, we encounter losses on a regular basis, but we often do not recognize their significance because we tend to think of loss in finite terms, mainly associated with death and dying, and not more generally in terms of adaptation to life-altering events and changes. We know that grief is the normal, unique response to loss. However, the assumption is often made that grief is only associated with losses that occur after the death of a loved one. We think that this view of grief is quite narrow. Of course, grief will normally follow the death of someone who we cared about deeply. But does a person have to die for grief to occur? We think that grief is a process that enables us to rebuild our assumptive world after it has been broken, even shattered, by a significant loss event, and losses that are both death and nondeath related can assault our assumptions about how the world should work. In this chapter, we explore different types of losses that are not death related, their unique features, and their impact on us.

Most of the current bereavement literature focuses on death-related losses, and many of the measures used in bereavement research are rooted in the identification of “separation distress” from another individual as the primary feature distinguishing grief from other responses and states, such as posttraumatic stress, depression, and anxiety (Boelen & van den Bout, 2005; Prigerson et al., 2009). Separation distress is characterized by yearning, longing, preoccupation, and searching for the deceased individual (Jacobs, Mazure, & Prigerson, 2000). However, the emphasis on grief in terminology that relates only to the death of a person does not consider the possibility that the same grieving process also allows individuals to integrate significant losses that are perhaps not as tangible or overt. In reflecting upon this aspect of bereavement theory and research, we need to consider the possibility that the emphasis on separation distress after the death of a loved one may be limited in scope. Grief can be more broadly defined as the distress that occurs when an individual’s existing assumptive world is lost because of a significant life-changing event, or what Tedeschi and Calhoun (2004) would refer to as a “seismic” life event. Indeed, Bowlby’s (1988) descriptions of yearning, pining, longing, and searching (which are all considered hallmarks of separation distress over the loss of a significant attachment figure) can be identified in various ways in the experiences of nondeath losses as well.

THE ASSUMPTIVE WORLD AND LOSS

Significant life-changing events can cause us to feel deeply vulnerable and unsafe, because the world that we once knew, the people that we relied on, and the images and perceptions of ourselves may prove to be no longer relevant in light of our experiences. Grief is both adaptive and necessary in order to rebuild the assumptive world after its destruction. It would certainly follow that the process of making meaning, which is a part of the grief response, is applicable to both death-related and nondeath-related losses. Papa and Maitoza (2013) explored grief in the presence of involuntary job loss. Their findings showed support that grief is contingent upon loss of a self-defining role as opposed to loss of others exclusively. Papa, Lancaster, and Kahler (2014) also found similar results suggesting that grief is not a unique response to loss of loved one, but instead it may be a common phenomenology across many types of loss. In addition, Cooley, Toray, and Roscoe (2010) developed an instrument to measure grief after all types of death and nondeath loss events. These researchers found that moving away from the strict definition of grief only occurring after loss through death could be potentially helpful to the clinical process with clients who grieve all types of losses. We hope to see more research in the future that addresses the process of grief after the experience of nondeath losses, allowing recognition of grief that occurs in a much broader context than only after a death occurs.

As we have already discussed, attachment is often identified as a key element in grief, and the attachment model provides an ethological[3] element to the grieving process. Bowlby’s (1988) research demonstrated that the searching and pining behaviors seen in young children who were separated from their mothers resembles the behavior seen in young primates that were subjected to similar conditions. Parkes (1996) expanded this work into the area of adult bereavement and suggested that the attachment system, and the resulting grief when that system is threatened by separation, is an extension of a process that has evolved over time to optimize feelings of safety and to enhance the chances for survival of the individual. From the perspective of evolutionary biology, attachment and the resulting grief that comes with separation appear to confer a survival advantage to the individual.

If grief and attachment are thus interrelated, then to what are we attached when we grieve a nondeath loss, such as loss of a sense of safety, loss of our homeland, or loss of employment? It could be that these defining, overarching losses involve either the loss of an aspect of ourselves to which we are attached or to our place in the world, which makes us feel safe and secure. For example, it is common for immigrants to yearn for their family and friends who are still present in their homeland, to search for what is familiar in their new environment, and to look for commonalities with their known culture in the new country of their arrival. The well-known term “comfort food” implies that identification with foods that are associated with our family and cultural roots provides a sense of comfort when we are stressed or are in unfamiliar territory. Individuals who have lost their jobs may pine for their old lives or selves to return to them, reminiscing about what they used to do, or who they used to be. The natural process of aging often catches us by surprise and we wonder, “Where did that woman in the mirror come from, and where did I go?”

The disequilibrium that results from these types of losses can activate the attachment system, motivating us to draw closer to what is familiar and safe, and the grieving process enables us to adapt to some part of ourselves or our life that is markedly different from what it was before. As discussed earlier, Janoff-Bulman (1992) draws a connection between one’s assumptive world and one’s attachment system, stating that how one relates to and views the world, others, and oneself is an extension of the attachment system that is formed at a very young age. Thus, it would make sense that threats to the assumptive world resonate back to the attachment system upon which that world was built.

NONFINITE LOSS AND CHRONIC SORROW

Patricia met James the week after her mother died from a prolonged fight with cancer. James was sitting at a table in a coffee shop, and the only empty chair in the entire place was next to him at the same table. He looked like he was content to read his paper while sipping his drink, and Patricia needed a place to set her laptop down to work while she drank her morning coffee. James was more than happy to offer the chair and table top to Patricia, and once they started talking, they hit it off very well. Patricia was 40 years old at the time, and James was 53. Over the next year, they dated, traveled together, and met each others’ extended families and close friends. They were such a good fit – even their dogs liked each other! They were married the next year, and they settled into a comfortable routine of sharing meals, walking the dogs, traveling, and reading snippets of the paper to each other on Sunday mornings. They also began trying to have children, and they had discussed the possibility of either adoption or fostering a child to share their loving home with them.

One Sunday morning, James woke up and did not feel well. He was dizzy and felt weak. He called out to Patricia as he was getting out of the shower, and then collapsed in a heap on the floor. Patricia called 911 and an ambulance came and took James to the emergency department of the nearest hospital. Patricia was told that James had suffered a stroke and that he would survive, but it was unlikely that he would be able to speak and he would not be able to use one side of his body. He would have a great deal of difficulty walking because of this weakness, and it was recommended that he spend a few months in a rehabilitation center to help him to gain as much function back as possible.

Patricia was now 44 years old. They did not have children. Both sets of their parents were older and had significant health problems. James was able to come home after Patricia made modifications to the house to accommodate a wheelchair and the special needs he had for personal care. She resigned from her position at work so that she could care for James, taking early retirement, which paid her less than half of her usual income. As time went on, fewer and fewer friends came over to visit; most of the time when the doorbell rang, it was someone from the home health agency arriving to provide care of some sort or to bring medical supplies that were needed. James could understand what Patricia said to him, but he would become very frustrated when she could not understand what he wanted or needed. After several months of caregiving, Patricia slumped herself down in a chair in the corner of the bedroom while James slept. Tears flooded as she assessed her life – or what was left of it – in this room. She would never have children. She could not just run to the store to pick something up without making arrangements for someone to be with James. James could stay like this for years, or he could get worse, and she often worried that she would somehow neglect something important and cause a complication to occur. She was completely exhausted and alone.

This scenario has many losses in it. However, none of the losses are because someone died; rather, the losses are ongoing, and they exist and mingle with the everyday life of Patricia and James as time goes on. We would call these losses living losses, and most of them would fit into the category of nonfinite loss. Nonfinite losses are those loss experiences that are enduring in nature, usually precipitated by a negative life event or episode that retains a physical and/or psychological presence in an ongoing manner (Bruce & Schultz, 2002). Some forms of nonfinite loss may be less clearly defined in onset, but they tend to be identified by a sense of ongoing uncertainty and repeated adjustment or accommodation. There are three main factors that separate this experience from the experience of a loss because of a death event:

  • The loss (and grief) is continuous and ongoing, although it may follow a specific event, such as an accident or diagnosis.
  • The loss prevents normal developmental expectations from being met in some aspect of life, and the inability to meet these expectations may be because of physical, cognitive, social, emotional, or spiritual losses.
  • The inclusion of intangible losses, such as the loss of one’s hopes or ideals related to what a person believes should have been, could have been, or might have been (Bruce & Schultz, 2001).

In their writings, Bruce and Schultz (2001) go on to describe several cardinal features of the experience of nonfinite losses:

  • There is ongoing uncertainty regarding what will happen next.
  • There is often a sense of disconnection from the mainstream and what is generally viewed as “normal” in human experience.
  • The magnitude of the loss is frequently unrecognized or not acknowledged by others.
  • There is an ongoing sense of helplessness and powerlessness associated with the loss.

Jones and Beck (2007) further add to this list a sense of chronic despair and a sense of ongoing dread, because individuals try to reconcile themselves between the world that is now known through this experience and the world in the future that is now anticipated.

In short, the person who experiences nonfinite loss is repeatedly asked to adjust and accommodate to the loss. At the same time, because nonfinite loss is often not well understood, the experience may go unrecognized or acknowledged by others. Support systems may tire of attempting to provide a shoulder to lean on.

A related concept to nonfinite loss is that of chronic sorrow, a term that was first proposed by Olshansky (1962) after his observations of parents whose children were born with disabilities. He noticed that these parents experienced a unique form of grieving that never ended as their children continued to live and the hopes that they had for these children were repeatedly dashed as time went on. Shortly after the introduction of the concept by Olshansky, there were a few articles written about the adjustment and coping in parents of children with various developmental disabilities. Since then, most of the research associated with the concept of chronic sorrow has been reported in the nursing literature. The concept of chronic sorrow has been described in multiple sclerosis, parenting a child with a mental health problem, Alzheimer’s disease, autism, infertility and involuntary childlessness, mental illness, and caring for a child with disabilities. Chronic sorrow has also been linked to Parkinson’s disease, mental retardation, neural tube defects, spinal cord injury, schizophrenia, and chronic major depression (Roos, 2002). Chronic sorrow is often found in situations involving long-term caregiving. Chronic sorrow is defined by Roos (2002) as:

a set of pervasive, profound, continuing, and recurring grief responses resulting from a significant loss or absence of crucial aspects of oneself (self-loss) or another living person (other-loss) to whom there is a deep attachment. The way in which the loss is perceived determines the existence of chronic sorrow. The essence of chronic sorrow is a painful discrepancy between what is perceived as reality and what continues to be dreamed of. The loss is ongoing since the source of the loss continues to be present. The loss is experienced as a living loss. (p. 26)

Chronic sorrow remains largely disenfranchised, and often escalates in intensity or is progressive in nature (Roos & Neimeyer, 2007). Although chronic sorrow is often linked to a defining moment, a critical event, or a seismic occurrence, it can just as easily be the hallmark of the slow insidious realization of what a diagnosis means over time and how it has caused change for the lives in its wake. In our discussions, the term nonfinite loss will refer to the loss or event itself, and chronic sorrow will refer to the response to ongoing, nonfinite losses.

Burke, Eakes, and Hainsworth (1999) describe chronic sorrow as akin to grief-related feelings that emerge in response to an ongoing disparity resulting from the loss of the anticipated and expected normal lifestyle of an individual. Teel (1991) states that in addition to the disparity that exists between what is expected or hoped for and what actually is in reality, the chronicity of the feelings and the ongoing nature of the loss separate chronic sorrow from other forms of grief. According to this author, chronic sorrow can be precipitated by the permanent loss of a significant relationship, functionality, or self-identity.

Lindgren, Burke, Hainsworth, and Eakes (1992) define the characteristics of chronic sorrow to include (a) a perception of sadness or sorrow over time in a situation with no predictable end, (b) sadness or sorrow that is cyclic or recurrent, (c) sadness or sorrow that is triggered internally or externally, and (d) sadness or sorrow that is progressive and can intensify. Chronic sorrow is differentiated from the grief response after a death in that the loss itself is ongoing, and thus the grief is also ongoing and does not end. These authors stress the peaks and valleys, resurgence of feelings, or periods of high and low intensity that distinguish chronic sorrow from other types of grief responses. An individual’s emotions might swing between the flooding of emotion and paralyzing numbness at the two extremes of an emotional pendulum. Most people who experience chronic sorrow generally reside somewhere between these two end points, but fluctuations are common.

Roos (2002) also states that the loss involved in chronic sorrow is a lifetime loss and remains largely unrecognized for its significance. One’s assumptive world is shattered and there is no foreseeable end, with constant reminders of the loss. She states that there is also an undercurrent of anxiety and trauma that separates this type of response from grief that is experienced after the death of a loved one, and the fact that the person usually continues to function separates it from primary clinical depression. Chronic sorrow differs from posttraumatic stress disorder (PTSD) because of the ongoing nature of the loss and the fact that it is not a reaction to an event that has occurred, even though there may be an event that defines when the loss began. The traumatic material in nonfinite loss is related to the degree of helplessness and powerlessness that is felt in light of a situation that has profound, ongoing, and life-altering implications for the individual.

Roos (2002) makes the point that chronic sorrow may apply more to those who are caregivers, because the affected individual may not be able to internalize the world in such a way as to be able to have dreams or life goals, and the intensity of the experience of chronic sorrow is related to the potency and magnitude of the disparity between the reality of the situation and the dream to which a person may cling. The outcome is really unknown, or the progression of what will unfold is unknown, so unpredictability complicates the process. The ongoing presence of the person or the loss inhibits reinvestment into other aspects of life and there are “surges” of loss that are often triggered by various events, as might occur in individuals whose loss was related to the death of another individual (Teel, 1991).

AMBIGUOUS LOSS

Janice pulls her car into the garage and begins to unload the groceries into the kitchen. She knows that her husband, Richard, is home because his car is in the garage, but she does not expect a greeting from him when she gets in the door, and she also does not seek him out to say hello when she gets home. Their two teenage children, Cynthia and Rachel, come from school and immediately go upstairs to their rooms and close the doors. Janice finishes unloading the groceries and prepares dinner. She calls them all when dinner is ready, and they sit at the table to eat together. However, Richard turns the TV on as they are about to sit down at the table, and he watches the news while eating, not saying much to Janice or the girls. Cynthia has begun hanging out with friends from the volleyball team, and she spends a good portion of the dinner time texting back and forth to them on her cell phone. Rachel has her headphones on when she comes to the table, not bothering to remove them when she begins to eat dinner. Janice looks around at the table. She tries to make conversation and ask each one of them about their day. Richard mutters something quick while still watching the TV program, like “Just fine … busy,” whereas Cynthia tries to talk and text at the same time without success, and Rachel acts perturbed at having to remove her headphones to answer her mother’s query. Finally, Janice too eats in silence and watches the TV. Later that night, Janice feels overwhelmed with sadness, but she does not know why. She goes downstairs to get a glass of milk, sits at the kitchen table, and begins to cry.

Many of the nondeath losses that are experienced by individuals are very difficult to name, describe, or validate. As stated previously, many losses are not clearly defined because there is no identifiable “death.” For many individuals, it may be unclear exactly what has been lost. The loss may or may not involve a person and there may not be a defining experience to denote where the loss actually originates. In her development and exploration of loss experiences where there was significant ambiguity, Boss (1999) first used the term ambiguous loss. She described two situations in which ambiguous loss occurs. In the first scenario, the person is perceived as physically absent but psychologically present. Examples may be when a person is missing, such as in divorced families when the noncustodial parent is absent but very much present in the minds of the children. Prisoners, kidnapping victims, relatives serving their country overseas, adoptive families, and situations when a person is absent or missing but very much present in the minds or awareness of their loved ones may also fit this description. Another frequent example would be grandparents who lose contact with their grandchildren after the parents of these children divorce, so they are physically not able to spend time with them, yet thoughts of these children frequently occupy their minds and cause a feeling of grief.

In the second scenario described by Boss, ambiguous loss may be identified when the person is physically present, but perceived as psychologically absent. Examples of this type of loss may be when a family member has Alzheimer’s disease, acquired brain injury, autism, a chronic mental illness, or if there is a family member who is psychologically unavailable because of addictions or some type of ongoing distraction or obsession, as is the case for Janice with her family. Each of these scenarios leaves individuals feeling as if they are “in limbo” (Boss & Couden, 2002) as they struggle to learn to live with ambiguity (Boss, 1999, 2006, 2009).

Boss’s first observations of this phenomenon occurred when she engaged with families in a therapeutic setting, where the family system was outwardly intact, but one of the members was absent psychologically from the family through obsessive workaholism or addiction.

Key aspects of ambiguous loss include the following (Boss, 2009):

  • The loss is confusing and it is very difficult to make sense of the loss experience (as when a person is physically present, but emotionally unavailable).
  • Because the situation is indeterminate, the experience may feel like a loss, but not be readily identified as one. Hope can be raised and destroyed many times over that individuals may become psychically numb and unable to react.
  • Because of ongoing confusion about the loss, there are frequent conflicting thoughts and emotions, such as dread and then relief, hope and hopelessness, wanting to take action and then profound paralysis. People are often “frozen” in place in their reactions and unable to move forward in their lives.
  • Difficulty problem solving because the loss may be temporary (as in a missing person) or it may be permanent (as in an acquired head injury).
  • There are no associated rituals and very little validation of the loss (as opposed to a death where there is official certification of the death and prescribed rituals for funeral and disposition of a body).
  • There is still hope that things may return to the way they used to be, but there is no indication of how long that may take or whether it will ever happen (e.g., if a family member enters treatment for an addiction or if a couple enters marital therapy).
  • Because of the ambiguity, people tend to withdraw instead of offer support because they do not know how to respond, or there is some social stigma attached to the experience.
  • Because the loss is ongoing in nature, the relentless uncertainty causes exhaustion in the family members and burnout of supports.

Boss (1999, 2009) and Weiner (1999) describe the experience of ambiguous loss like a “never-ending rollercoaster” that affects family members physically, cognitively, behaviorally, and emotionally. Physical symptoms may include fatigue, sleep disturbances, and somatic complaints that may affect various body systems. Cognitive symptoms may include preoccupation, rumination, forgetfulness, and difficulties concentrating. Behavioral manifestations may be expressed through agitation, withdrawal, avoidance, dependence, or a pressing need to talk at times. Emotionally, individuals may feel anxious, depressed, irritable, numb, and/or angry. It is not uncommon to be misdiagnosed with an anxiety disorder or a major depressive disorder (Weiner, 1999).

LIVING LOSSES

There is a great deal of overlap between losses that are nonfinite and losses that are ambiguous (Figure 8.1). Perhaps much of the distinctions have to do with their origin in different fields of study, and thus the lens that is used to describe these experiences reflects different ways of viewing loss experiences that may have many similar features. In the literature, nonfinite loss is described more from an intrapersonal perspective, with the loss experience focusing on the individual’s perception and coping (e.g., what did I have that I am now losing), whereas ambiguous loss is a concept that was formulated within a family stress model, and the loss is described in terms of how the family members perceive and define the loss according to the boundaries of the family system (e.g., who is absent from the family system that should be present). In the descriptions of nonfinite loss and ambiguous loss, the common features include (a) dealing with ongoing uncertainty that causes emotional exhaustion, (b) shattering of assumptions about how the world should be, and (c) a lack of rituals and validation of the significance of these losses. Nonfinite loss, ambiguous loss, and chronic sorrow may be linked not only to real losses but also to perceived, symbolic, or secondary losses. They may all be accompanied by shame and self-loathing that further complicates individual authenticity and truthfulness in other relationships, thereby adding to the struggle with coping. For example, Janice may blame herself by thinking that she has been a poor partner to Richard or an inadequate mother to Rachel and Cynthia for her family to be so disconnected; this self-perception could undermine her sense of self as worthy or valuable to others, which is a core aspect of the assumptive world.

 

Although ambiguous losses, nonfinite losses, and chronic sorrow are often disenfranchised (Boss, 2009; Casale, 2009; Doka, 2002; Roos, 2002), the ongoing grief is normal and understandable. Recognition that life as it has been or was expected to be is lost and has been replaced by an initially unknown, unwanted, and often terrifying and inevitable new reality is extremely difficult, forcing a new appraisal of one’s assumptive world. The belief that life is predictable and fair and the notion of justice and compensation cannot survive in the new reality. The self and the world must be relearned. This process is often a disturbing and ongoing focus of concern. There exists a significant body of research on ambiguous loss that indicates a relationship to depressive symptoms and family conflict (Boss, 2009; Carroll, Olson, & Buckmiller, 2007).

IMPLICATIONS FOR COUNSELING

The practice considerations related to both ambiguous loss and chronic sorrow underscore the importance of normalizing the ongoing grief that is present. Because these losses may have no real resolution, and they may unfold as living losses, the grief persists for a prolonged or undetermined time. It is important to recognize that in these scenarios, the ongoing grief is a normal reaction, whether the loss is related to a person or a thing that is greatly valued, or something less tangible, such as a hope or expectation. Flexibility in providing counseling to an individual, couple, family, and group in various constellations at different times can assist in supporting those who are taking on most of the responsibilities. Finding ways to adjust and redefine roles in the family can help to minimize chaos, reduce stress, and improve relationships. One other important point to note is that nonfinite and ambiguous losses may comingle with losses that occur from death. For example, one client who sought counseling for support after her husband died came initially to share her grief over the loss of her husband. Later on, the grief was more about the loss of herself when she married her husband, who had been a very controlling and abusive person at times in the marriage. The initial consultation was for a death-related loss, followed by another layer of her grief that was both nonfinite and ambiguous in nature.

Name and Validate the Loss

Many nonfinite and ambiguous losses and losses that involve an ongoing, chronic process are disenfranchised in nature. Recognizing and naming these losses is cited by Doka (2002) and Boss (2006, 2009) as the first step in offering support to individuals who have experienced disenfranchised grief from loss experiences that are not recognized. The ability to name the experience and its unique effects that are often unacknowledged by others can provide a powerful source of strength to those who experience ambiguous loss and chronic sorrow. Clients who begin to understand the nature of these losses and receive validation for them often experience relief and improved self-concept almost immediately (Roos, 2002). In a study of infertile women, Harris (2009) reported that recognition of the ongoing intense grief response to their infertility allowed participants to spend less time attempting to seek validation for their experiences and more time focusing on active problem solving within the confines of their situation. You may wish to talk about the assumptions that have been broken or shattered from the client’s assumptive world and the significant work involved in rebuilding that world after it has been shattered through these kinds of losses.

Foster Realistic Expectations

The more success oriented a culture is, the more difficult it is to accept losses that do not have a defined closure (Boss, 2002, 2006, 2009). There is also the romanticized ideal of “overcoming” adversity that may be highly unrealistic for individuals who are facing nonfinite and ambiguous losses. The focus of counseling is to identify the strengths and resilience that is present, while understanding that there are realistic limitations to one’s tenacity and capacity. Clients learn to control what they can, and to let go of what they cannot control. This letting go is not something that is easily done, and there are very few role models in Western society to demonstrate acceptance of limitations instead of overcoming all odds through insurmountable difficulties – a message that readily becomes an expectation, reinforced through popular media, but that rarely occurs in real life. Relationships get redefined, and modalities that focus on awareness and acceptance of ambiguity, such as meditation, yoga, and mindfulness, may take on new meaning. Often, there is a redefining of the self that occurs, along with new interests, hobbies, and connections to others who understand experiences that are surrounded by ambiguity and uncertainty.

Reconstruct Identity

Patricia’s personal identity changed quickly from that of a woman who was embarking on the start of an exciting new phase of her life to the ending of her life as she once knew it and anticipated it would be as she became the caregiver to a man who now seemed much older than her. Janice was overwhelmed with sadness at the realization that the family she had always dreamed of having was not a source of safety and comfort, but a means whereby she was essentially made invisible and irrelevant to the people she loved the most in her world.

One’s personal identity changes in the presence of these types of losses. The work of counseling will involve redefinition of one’s identity in a way that is consistent with reality and also that allows for the recognition of the person as an individual with unique abilities, skills, and strengths that may need other avenues for validation and expression. Patricia will need to find value and worth in herself outside of her work, with a new network of friends who can accommodate her limitations, and she will need outlets to channel her needs for expression and meaning.

Normalize Ambivalence

It is not unusual to have mixed emotions when you do not know whether someone you love is here or not or whether a situation that seems intolerable will ever end. Patricia sometimes fantasized about James dying and then felt tremendous guilt when she would realize where her thoughts had taken her. She felt guilty for being angry that she was tied down, that James required so much attention and care, and that she was not free at her age to do what she pleased. Eventually, she realized that she felt both love and resentment for James, which was very difficult, and she was alone in these feelings because she did not think anyone in her circle of friends would understand her ambivalence. Janice often pondered just walking away from her family, wondering whether they would even miss her if she was gone – at least, until everyone got hungry and realized that nobody had made dinner! However, she also loved them deeply, and felt trapped in a situation where she loved them, but could not engage with any of them on a meaningful level. It is important for counselors to normalize these conflicted feelings, and to allow for the presence of opposing thoughts and emotions that will naturally arise from such situations. Although not how they may have perceived themselves in the past, it is important to recognize that it can be a normal reaction to resent others who seem unaffected by the same kind of losses, or who seem protected from adverse events in life (Harris, 2009; Harris & Daniluk, 2010).

Identify Resources

Helping clients with information about community resources and other supports is a high priority. Identifying potentially damaging triggers (both external and internal), and implementing strategies to reduce the effects of these triggers can be very useful. Emphasizing the highly individualized nature of grief helps to reduce self-criticism. It is also important to be aware that approaches to some conditions are inappropriate and may worsen responses to losses that are ambiguous or ongoing in nature (e.g., pushing for closure or resolution). In this regard, counselors need to understand that these individuals may have already had destructive experiences with prior professionals or well-meaning but uninformed helpers (Harris, 2010). As these types of loss experiences become more commonplace in our current society, it is vitally important for helping professionals to develop a basic understanding of these phenomena in order to avoid inadvertently pathologizing a normal response to these very difficult types of losses.

Identifying resources may also involve personal resources that are available to the client. For example, one of our clients whose husband had advanced Parkinson’s disease spent a session describing the intolerable situation she was in, being essentially homebound with a man whose declining mental capacity and functionality overwhelmed her strength and patience. The session turned into an opportunity to brainstorm how one of her husband’s friends could organize all of his other friends and extended family members to regularly come for “shifts” to do something with him at the house so that she could plan to do the things she wanted to do on her own or with her own friends away from the home. In her sessions, she began to realize that she was initially trying to protect her husband from embarrassment about his condition by not inviting people to their home. However, she realized that the shame over his loss of functionality essentially trapped them together in the home, causing more tension and stress for each of them. In recognizing that they both needed the support of others, she found a solution that provided relief for both of them.

CONCLUSION

Living losses occur with great regularity in everyday life. Some of these losses effect change in us in subtle ways, and the adjustments to our assumptive world are minimal. However, living loss experiences continually shift the sand where we are standing, resulting in an ongoing sense of disequilibrium and adjustment. Not only can we no longer be the same as we were before, but any ideas or dreams about what the future would hold have also been wiped out from our projections about what we hoped our lives would be like. Losses that are ongoing in nature require frequent accommodation and adjustment, and they provoke a profound grief response that is also ongoing and unpredictable in nature. When living losses require us to rebuild our assumptive world, counselors must be able to journey alongside a sometimes arduous and prolonged process, helping clients to see their deeper strengths and resilience as they grow and deepen in the midst of their ongoing grief and adjustment.

Glossary

Ambiguous loss – Loss that remains unclear, cannot be fixed, and has no closure. It can be physical or psychological. Present in losses in which an individual may be psychologically present but physically absent or in losses in which an individual may be physically present but psychologically absent.

Chronic sorrow – An ongoing response to losses that are continual and unending in nature; the chronicity of the feelings and the ongoing nature of the loss separate chronic sorrow apart from other forms of grief.

Living losses – Losses that will remain as an ongoing presence in the life of an individual; the individual will continue to “live” with the loss experience. The ongoing nature of the loss will require continual adaptation and adjustment.

Nonfinite losses – Loss experiences that are enduring in nature, usually precipitated by a negative life event or an episode that retains a physical and/or psychological presence in an ongoing manner.

Separation distress – The presence of yearning, longing, preoccupation, and searching for the deceased individual after a death.

Questions for Reflection

  1. Go back to the loss line exercise from Chapter 4. If you did not do this exercise before, complete it now. Once you are done, look at the losses that you have noted on your loss line. Which of these losses might be considered nonfinite losses – losses that forever changed you and that you continue to recognize in your life now? Can you think of any losses that were ambiguous in nature? How did you handle these losses? How did others respond to your experiences of these losses?
  2. Why do you think nonfinite and ambiguous losses are often not recognized or acknowledged socially?
  3. Think of some popular movies or television programs that provide examples of nonfinite and ambiguous losses. How were these losses portrayed in these films? Before you were aware of these concepts, how would you have viewed these kinds of loss experiences?
  4. One of the biggest challenges for individuals who face nonfinite and ambiguous losses is the ongoing nature of the grief and the anxiety that accompanies the uncertainty associated with these losses. What are some of the social implications for individuals who experience these kinds of losses? Can you think of ways to offer support to individuals like Patricia from our case study in this chapter?

 

 

 

CHAPTER 9 Working With Emotions – Yours and Theirs

Probably one of the biggest concerns for counselors who begin to practice in the area of grief counseling is how to work with strong emotions as they arise in clients. Although we have earlier shared that not everyone will grieve through the sharing and expression of their feelings, many clients will experience strong emotions as part of their grief. In this chapter, we explore the role that emotions might play in the grieving process, and how counselors can help their clients to benefit from working constructively with their feelings.

Many bereaved clients will feel overwhelmed by their feelings, and they will come to counseling in hopes of learning to contain their feelings. The good news is that clients can often learn how to manage their feelings, but the hard part is that they learn to do this by first having to focus on them. In their everyday world, bereaved individuals are often given much advice and receive many messages that minimize their experience, probably with the intent of helping them to manage their feelings. In the counseling process, however, we often do just the opposite, and a lot of time is often spent exploring and gaining insight from feelings rather than trying to avoid or minimize them. Thus, what may occur is that we might, at first, intensify the feelings because we pay attention to them, and even focus on them instead of trying to diminish and contain them for the sake of social propriety. The identification of and work with feelings can be very rewarding and empowering for clients, ultimately moving them into deeper work that allows them to recognize their strengths and potential for growth.

There is some discussion about the difference between feelings and emotions. Typically, feelings are viewed as faster than emotions in terms of response (the response time of the feeling; how fast it responds to real-world stimulation), and it takes someone less time to recognize feelings because they are instant reactions to stimuli that occur in the present moment. Emotions tend to be viewed as a longer term effort, after an individual has had an opportunity to reflect upon feelings that have surfaced, and meaning or significance has therefore been assigned to the felt experience. Feelings are closer to sensory stimulation; thus, if you touch something, you feel it almost instantaneously, which is a fast reaction. An emotion could represent a deeper experience because it might affect more of you, and you may become more invested in it because you have delved into and reflected upon the experience more, but that is only because it is now also attached to your cognitions and interpretations more. For example, depression will have more of an impact on you than just an isolated feeling of sadness. We find these distinctions are mostly academic, though, and for the purposes of this chapter, we use these two terms interchangeably, because both feelings and emotions are important in our discussion, and the work with feelings and emotions in the counseling setting is going to involve the same process.

THINKING CRITICALLY ABOUT FEELINGS

Individuals who live in Western society tend to think of feelings as primitive, irrational, weak, pathetic, and an indication that someone is out of control. Stop and think for a moment about how many derogatory terms and phrases there are to describe someone who readily expresses emotions and what these phrases imply:

“He lost it.”

“She was hysterical.”

“He went nuts.”

“I need to get a grip.”

The implication is clear: If you express strong emotion, you are out of control, and you need to regain your composure quickly. Stoicism and rationality are espoused as true virtues – for example, “He’s holding up so well,” or “She is staying strong for the kids.” Individuals who deny their emotions and function solely from an analytical, rational perspective are seen as smarter, more competent, and desirous. Feltham (2010) ventures to address the issue of emotion in counseling by stating that the most effective counselors tend to be those who are more naturally intuitive and emotionally responsive, both characteristics that are more acceptable to feminine socialization patterns. He concludes that most counseling theory is generated by men, and places cognitive processing at the top of what is most desirable in counseling practice. He also states:

There is a prejudice against raw emotion and direct knowledge, and a demand for theoretical justification. Crying remains an uncomfortable phenomenon and is rare in public and in educational institutions, as is expressed anger. Direct, heartfelt responses to the common human experiences of loss and heartache receive relatively little attention in counselling training. (p. 184)

We have previously discussed the importance of the counselor’s focused and compassionate presence within the counseling relationship. Genuine caring and compassion are feeling oriented, and clients are very likely to “know the difference between a counselor who really cares deeply and one who either struggles to do so or who is primarily cognitively rather than emotionally oriented” (Feltham, 2010, p. 184). Similarly, Levitt, Butler, and Hill (2006) reported that the counselor’s ability to perceive, share, and explore emotional content were reported by clients as the most valued components of their therapy work. Watson and Bedard (2006) compared outcomes in clients who received process experiential therapy (PET) versus those who received cognitive behavioral therapy (CBT) and found that clients who had received PET, with its focus on emotional content and expression, were more deeply engaged in the therapeutic process and more likely to positively engage with their emotions more readily afterward. These statements are not meant to indicate that counselors who are more cognitively focused are less effective, but to emphasize the importance of being open to the exploration of feelings as part of the counseling process and the ability to access your own feelings and intuition is important for you to be able to engage with clients’ feelings and emotional states. As counselors, we will be touched and moved by the pain and suffering of our clients, and we do share a common human lived experience with them. However, showing emotions, especially openly with clients, is often seen as a sign of weakness or lack of professionalism (Curtis, Matise, & Glass, 2003). It is important to place feelings into the appropriate social and cultural context – and in most modern Western societies, feelings are devalued and stigmatized, so it is important to look critically at how intellect and cognition are privileged and emotions and intuition are devalued – and yet both these entities are important aspects of the whole human experience.

FUNCTIONAL FEELINGS

In the therapeutic setting, feelings can be seen as valuable indicators of what is most important to the client’s process. They give an indication of what Gendlin (1978) referred to as the “felt sense” of the client in a situation, and when you are able to identify and focus on the client’s feelings, you are probably working very directly with the places of most concern and difficulty to the client. You may recall our earlier discussion of the use of immediacy in the counseling process in Chapter 6. Immediacy includes working in the here and now, with the feelings that are currently arising in the session. Yalom (2009) states that working in the here and now, noting feelings that are present in the client during the session, enables the most potential for insight, growth, and change in clients.

In the counseling session, it is important to help clients to learn to befriend their feelings and to try to learn from them. Although not everyone experiences strong feelings in response to significant life events, when intense feelings are present and we try to block them, we can end up feeling more anxious. Suppressing strong feelings takes a lot of energy and it can “backfire” when the defenses that function to contain the feelings are overloaded in some way, and the suppressed feelings can end up being released in a flood that can be overwhelming to the person and to those around him or her. We need to be able to experience feelings appropriately – in a way that is constructive, in the proper environment, with the ability to reflect upon them as well. It is important to connect compassionately with the feelings that are present in order for defenses to soften in a safe environment, and thus lessen the anxiety that they may cause. Feelings tend to “live” in our bodies, and we often experience a physical sensation when strong feelings are present. Sometimes, clients will experience a “charge” with an emotion, which can be described as a strong physical association with a certain feeling. We interpret this “charge” as the feeling attempting to get your attention that something important is happening and needs your focus. People often remark about feeling nauseous or their stomach being upset, jittery or shaky, hot or cold, clammy, or heavy in their chest. You may have heard of the “fight – flight” response to stress, which is the way our bodies respond when we feel acutely stressed, frightened, or threatened. There is a direct link between how we feel and how our bodies respond, and we can often use our bodies to help us identify our feelings and to channel them in ways that are healthy and constructive. In many ways, it is much easier to be “in our heads,” but experiencing life from a cognitive orientation alone means that we are denied the full and rich depth of being a complete person, which involves an integration of our thoughts, feelings, and physicality.

EMOTIONAL INTELLIGENCE

For the past century, we have become very focused on developing our intellectual abilities. With the introduction of the Stanford – Binet intelligence test in 1916 (SB5; Fancher, 1985) and the Wechsler Intelligence Scales (the WAIS in 1939 and the WISC for children in 1949; Frank, 1983), people focused on “IQ” as an indicator of who was smart, who was most likely to succeed, and who would be revered socially. Although Wechsler especially tried to look at more global capacities, such as the ability to solve real-life problems and to navigate successfully within one’s environment, the focus was still mostly on rationality and cognitive reasoning. Emotional components of the human experience were seen as mostly irrelevant to the measure of cognitive potential that was present in each individual.

The value placed upon cognitive and rational problem solving have become globalized to expectations about a person’s character, ability to navigate social situations, and a general belief that people who are “smart” by these standards are those who should be revered, emulated, and given social deference. However, in reality, these expectations do not exactly work out in terms of personal success and social integration, and in the cultivation of compassion and empathy with others. We can all think of individuals in various professions who would be considered brilliant in terms of their intellectual capacity, academic accomplishments, and rational problem-solving abilities, who, nonetheless, have a great deal of difficulty managing their personal relationships and getting along with others, or are not able to work with others in settings that require teamwork. So, intellectual prowess is admirable, but it leaves something missing in terms of relating to others. The examples of Dr. Gregory House in the television show House (Egan & Alexander, 2005) and Dr Sheldon Cooper in the popular show The Big Bang Theory (Galecki et al., 2008) provide good examples of individuals who are intellectually brilliant but who struggle socially and have a great deal of difficulty navigating relationships with colleagues and individuals who try to be their friends. Although these television shows are meant to be entertaining, they provide good examples of how our social emphasis on intellectual intelligence and cognitive processing are not the measures of a person who is necessarily successful in life.

The point to this discussion is that we live in a society that highly prizes intellectual capacity, while dismissing social and emotional capacities, which are not only important but also necessary assets for a person to live in harmony with others and to be able to engage in relationships that are meaningful and reciprocal. Most of our relationships with others are predicated upon our ability to care, to empathize, and to respond to others in mutual and meaningful ways. Most attachment behaviors are also demonstrated through emotionally mediated behaviors. Grief is often viewed as a wound to our attachment system, and the responses to separation and a broken attachment are often emotional ones. Thompson (2012) identifies that an effective practitioner needs to possess the ability to tune into the client’s emotions and then to help the client to make the link between these emotions and his or her experiences of loss.

The first use of the term “emotional intelligence” is usually attributed to a doctoral thesis titled A Study of Emotion: Developing Emotional Intelligence (Payne, 1985). Other authors later explored the concept of emotional intelligence (sometimes referred to as either EI or EQ; Goleman, 1995; Mayer, Salovey, & Caruso, 2008). Instruments were developed to measure various aspects of EI, including the Emotional Competency Inventory (ECI), which was created in 1999, and the Emotional and Social Competency Inventory (ESCI), which was created in 2007. There are also several self-report and self-assessment scales available to the public via the Internet (Bradberry & Greaves, 2009; Mayer, Roberts, & Barsade, 2008).

Goleman’s exploration of EI is probably the best known and popular because of the publication of his popular book of the same name (Goleman, 1995) and the release of a secondary book titled Social Intelligence (Goleman, 2006). According to Goleman, to be successful requires the effective awareness and understanding of yourself, including your feelings, intentions, and responses, as well as the ability to understand the feelings and responses of others. The awareness of EI and its cultivation are important in grief counseling because it is very important for both counselors and their clients to develop a capacity to work with emotions that fosters competence rather than flooding because of emotional overloading. Working intelligently with emotions that arise in clients is a process that involves assisting clients to:

  1. Identify the primary emotion(s) that is/are currently present
  2. Be able to name and/or describe the intensity of the emotion(s)
  3. Find a way to work with emotions in a healthy manner
  4. Seek to understand the message or meaning that comes from the emotion(s)

It is amazing to realize how little attention has been paid to the emotional content of our experiences and how readily we try to suppress or deny feelings rather than learning to work with them constructively. Many clients do not really know how to begin identifying their feelings and readily get stuck when asked what they are currently feeling. For example, a counselor might see a client clenching his fist, tightening his jaw, and becoming red in the face, only to find the client will respond to a question about how he is feeling with, “I don’t know… just upset, that’s all.” Learning to identify feelings may involve some education for our clients as to how to accurately describe what they are feeling and what to do with the feelings that they recognize in themselves. A good place to start might be to share with clients a “feeling vocabulary list” to help them to learn to identify what they are feeling (Figure 9.1). We often try to simplify things by suggesting that there are four basic feeling states: sad, mad, glad, and scared. You can then brainstorm different words that could be used to describe varying aspects of each of these feeling states. We often suggest that you begin with words that describe the least intense sensation of that feeling “cluster” and gradually progress to the most intense description of that feeling. For example, feeling words to describe mad might include irritated, annoyed, frustrated, angry, enraged, and furious.

There are many different ways to help clients to work constructively with their emotions. Sometimes, just naming the feeling and talking about it can be enough for a client to address what is being brought to the surface by that emotion. As mentioned in the previous section, emotions sometimes carry a “charge” with them that we experience physically. Clients can sometimes feel intimidated by this intense sensation, afraid that in exploring their emotions, they will lose control over them, or they will say or do something that is not congruent with how they view themselves. Choosing a way to work constructively with different emotions should be based on the client’s personality and comfort level with the counselor, and this process can be facilitated by drawing from the strengths and interests of the client, that is, if the client likes to write, draw, paint, enjoys music, and so on. We discuss more specific ideas later in Chapter 11. Some ideas about helping clients to identify and work constructively with their feelings are as follows:

  • Help clients express feelings – invite them to explore their feelings, talk about their feelings, and give an affirmation about their right to have feelings:

“That must have been a very stressful time for you. As you remember the events, how do you feel about what happened?”

  • Alert the client to the importance of nonverbal clues as indicators of feelings:

“You tell me you are pretty well over it, but I notice the tears in your eyes right now.”

  • Help clients to begin identifying feelings and their intensity when they are in the sessions with you:

“You have said that you were a bit upset by what happened, but as I watch the expression on your face, I wonder if you are really pretty angry.”

  • Help clients to sort out confused or conflicted feelings:

“If I were to draw a chart of how you are feeling, what percentage of your feelings would be angry, what part hurt, and what part afraid?”

  • Help clients to gain an understanding that they can have more than one feeling at a time, and that it is normal to have dichotomous feelings occurring at the same time (e.g., happy and sad, excited and scared): “I hear that you are looking forward to seeing your family again, but I also sense a part of you might be dreading this visit too … what do you think?”
  • Use feelings to help reconnect clients with the deceased person(s), if that would be beneficial:

“Pretend that you are your wife and I will pretend to be you. Can you think of what she might be feeling if she were with you right now?” Once a client has identified how he or she is feeling and explored the feeling in the session, there is usually a “message” that is behind the feeling. It may be simple, such as anxiety that results from realizing that you are now alone at night after your spouse died and you need to do what is necessary to feel safe and connected to others when you are home. Or it might be that what is happening has brought up previous experiences that have left you feeling abandoned or highly vulnerable, and you need to be in touch with someone from your past to work these issues through, if possible. As a counselor, remember that you are always listening with your intuitive “rabbit ears” (Yalom, 2009), both for the content that is being said in words and the experience that is occurring through the nonverbal cues and emotional tone of what the client is saying, as well.

WORKING WITH DIFFERENT EMOTIONS

Important guidelines for counselors to have in place are that they need to (a) be aware of their emotions when they come to the surface, (b) cultivate an ability to work constructively with their own emotions, and (c) be able to apply the same “rules” about honoring emotional content and material in their lives as they expect from their clients. These things will affect how a counselor will be able to facilitate emotional work and process with clients.

When you begin to sense that there is a lot of emotion present in the client, it might be helpful to try to slow the session down. Empathic responses or immediacy may be used, depending on what the client is experiencing. The client may only stay with the feelings for 5 seconds, but in staying with these feelings, even if for a very brief time, there is often a sense of competency and relief afterward. Emotions are often intensified in the sessions, and the client is invited to go to a deeper level, closer to his or her core feelings. Stay with the feelings as long as the client tolerates it and stays connected to them in the session. Once the client begins to shift out of the feelings, talk about what he or she felt and put it into a context. A good suggestion for follow-up with clients after they have gone deeply into emotional work is to first validate that it is hard work, and then to ask what the experience was like for them. Often, working in this way with emotions brings a sense of exhaustion, and also a sense of clarity. After exploring feelings, a shift may occur in the client’s perceptions, although it may not be apparent right away.

If your client is struggling with intense emotions, try to normalize the feelings and assure him or her that these feelings will not continue with this same intensity and magnitude forever. One helpful statement might be, “It is very difficult and intense right now for you, but it will not always be this way down the road.” If the client has attempted to keep emotions under control by suppressing them for a long time, initially experiencing the emotions may carry the fear that he or she will be overwhelmed or rendered nonfunctional or paralyzed by these feelings. Remind your clients that they have the choice about how they want to handle their emotions, and provide modeling in the session that allows them to focus on the emotions, and then get some distance from them in alternating waves. Normalize clients’ concerns that the feelings can be scary and that this is difficult work.

As we discussed earlier in the section on resistance, you must be respectful of people’s defenses, and your goal is not to insist that people emote, but to recognize when clients need your assistance in working constructively with the emotions that are present. You, as the counselor, need to be able to help the client find what he or she needs both internally for control and externally for release of the emotional material. There are times when clients need help in containing their emotions (different from suppression), especially when they are overwhelmed or feeling unsafe (Kennedy-Moore & Watson, 2001). The issue of containment is explored more in Chapter 10, where we discuss how trauma and grief overlap. Also, some specific therapeutic modalities that may help clients to work constructively with their emotions are discussed in Chapter 11. We recognize that once clients begin to focus on their story and what has brought them to counseling, feelings often rise to the surface readily. It is hoped that this chapter helps you, as the counselor, to be open to your clients’ experiences of emotional material, and be able to facilitate your clients’ process with quiet confidence and compassion. Remember that most people want a deeper connection with their inner self and that usually occurs by working with emotions.

SUGGESTIONS FOR SPECIFIC EMOTIONS

Because we believe that feelings/emotions serve a purpose, it might be helpful to look at some of the ways that feeling states might be reinterpreted as informative and positive to clients and their experiences, and to also provide some practical suggestions for counselors in working with emotions.

  • Fear – It functions to help in self-protection, and it often arises when we do not feel safe. It is important to sort out old fears from what has happened in the past versus anxiety about what is happening in the present, and listen to what has happened in the past as to how the fear is being interpreted in the current situation. For example, if a client has had a difficult situation with other helping professionals, the anxiety that is present in the session may be related to fear of how you might respond rather than to something more general in his or her life experience. It is important to remember that we become afraid for a reason, and the first consideration when a client is fearful is to ensure that he or she feels safe, first with himself or herself, then with you in the session, and then in his or her environment and experiences. There is a difference between fear and generalized anxiety. Fear is usually associated with something specific, even if the trigger for the fear may seem elusive at first. Anxiety tends to be more generalized and does not usually have a specific focus, although the anxiety may transfer to various situations when it is intensified.

When people are afraid, they may have a sense of “going cold” inside, and their hands and feet may also feel cold or numb. Some people are agitated by fear and others are paralyzed by it, so people may speak very fast and seem keyed up, or they may actually come across as very contained and shut down. It is only with time and gentle exploration you may have a deeper understanding of the source of the fear, or the background to the anxiety that your client is experiencing. Breath is associated with fear, and you will often notice that when a client becomes more anxious, breathing may become more rapid and shallow, or the person may actually hold his or her breath without even realizing it. It can sometimes be helpful for the counselor to breathe along with the client as he or she shares his or her story, and if the counselor notices that he or she is not getting enough air when following the client’s breathing pattern, it might be an opportunity to say something like, “Let’s just take a deep breath together and slow things down a bit, okay?”

When clients feel anxious, they often have a hard time hearing you or taking in what you are sharing with them, and they may not remember much of what has been said in the session. Keeping things slow and calm, and repeating things that are said a few times might be helpful. Be very clear when you speak, and make sure the client is able to hear and understand what you are saying by checking in several times during the session. People who are habitually in fear often dissociate, meaning they are physically in the room but seem to have become absent psychologically and/or emotionally. The task then is for them to stay with it, work gently and quietly at the source if possible, and reframe the experience as necessary. Frequent dissociation in the sessions may mean that the client has a history of trauma, and unless you are trained as a therapist in this area of work, you could risk more harm than good if you push a client who is re-experiencing traumatic material as a result of the sessions. This issue is discussed in greater detail in Chapter 10, but this would be a time when you as the counselor need to be able to identify if a client’s needs may be beyond your professional scope or abilities.

If you sense that your client is feeling overwhelmed by anxiety, you may also wish to help the person become more grounded in his or her body, or in the room with you, so first start with the breath, maybe counting breaths together for a minute to start. You can then go through a “body scan” with the person, identifying feeling the feet on the floor, the weight in the chair, the arms on the chair or on the lap, feeling the tips of the fingers, and the sensation of breath from the nose, and then suggest that the client look around the room and name out loud several things that the client sees, such as the lamp, chair, and picture. You can repeat this process as needed to help your client feel safe and supported by you and to help the client to feel physically and emotionally present in the session. Once the client is feeling more grounded, you can take the opportunity to talk about what you just did and why – and offer it as a tool that he or she can use if the anxiety returns and is overwhelming when not in a session. Relaxation CDs and digital downloads may be of help for clients to use when they are trying to go to sleep at night, or at times when they are on their own and feel intense anxiety or panic. It might be a good idea for you to be familiar with specific relaxation techniques that you can recommend to your clients, especially those that involve progressive relaxation and engage the body with the relaxing imagery or instructions.

  • Anger – It serves the purpose of a warning light and gives energy to get past blocks. Anger tells you that something is wrong, and it often comes up when a person feels that he or she has been violated or treated unfairly in some way. It can also be protective when a person feels threatened or vulnerable. It is very important that clients understand that anger is okay and that it is a natural part of the grieving process for many people. If you think of being robbed of something that is precious and irreplaceable to you, one of the first reactions you might experience would be anger toward someone who could do such a thing. Grief is no different, because when you lose someone you love, or when you experience a significant loss, there is often a feeling of being robbed, a feeling of being deprived, and a constant reminder of the unfairness in how events have unfolded – and anger would be a natural response to any of these scenarios. Care must be taken to disentangle anger from violence, and if your client has experienced violence associated with anger in the past, this emotion might be a scary and difficult experience.

A good image of constructive anger is to describe it as a life force that can be empowering and highly informative of when a client needs to attend to what is happening in a very conscious way. Anger is like the mushroom that pushes through the concrete in the sidewalk – we sometimes need this energy in order to get through the blocks that are present and preventing us from moving forward. Constructively channeling anger is what has been at the core of some very well-known advocacy groups and support organizations, such as Mothers Against Drunk Driving (MADD), so it is important to understand that a person can experience anger as a positive emotion.

Anger sometimes looks like fear because people may shut down out of fear of their anger. Often, the person who is angry turns red in the face, clenches the fists, tightens the jaw, and may physically shake. The counselor can help to facilitate an understanding of where the anger is coming from and help the client direct it and focus it in order to release it. Verbal expression of angry feelings may be enough. Sometimes, however, it is helpful to engage the body to physically release the anger in order to clear it to get to the underlying issues. People often feel better afterward. Writing or scribbling in a journal with heavy strokes, throwing paint at a canvas, breaking eggs with your hands in the sink, kneading and pounding bread dough, digging vigorously in the garden, hitting pillows, tearing paper, or yelling into a pillow may also help release it (these are all suggestions that have come from our clients!). The release is only really helpful if the client can then talk about the feeling and what is underneath it afterward; physical release without meaning being attached to the activity may not provide the client with the clarity and understanding that is needed afterward. Use of language is very important with anger as well. We have smiled as some of our most prim and proper clients choose very strong language to express some of their feelings, knowing that they would never talk like this outside of the session! Using strong language can be a form of release as well, so be aware of the possibility of expanding your feeling vocabulary in ways you might not have expected as a grief counselor!

  • Sadness – It is often more socially acceptable than anger, especially for women. In sadness, a person tends to retreat inside; sometimes, clients seem to “melt” into themselves when they express their sadness. It might be helpful for the client to have something to hold, such as a pillow, a small blanket or throw, or a stuffed animal. If clients experience deep, intense sadness, they may begin to sob heavily and rock back and forth. You are the supportive witness to their experience, and the importance of your presence should not be underestimated. Most people are very self-conscious when they are crying in front of another person, so rather than staring at the person when they are crying, we would suggest that you drop your gaze a little from their face to their shoulder or knees, and wait patiently. You can breathe with the person silently. You can gently let the client know that it is okay to cry and okay to feel this much. Let people breathe deeply and let the sadness out. Beginning counselors may feel a great urge at a time like this to jump in and “rescue” the person, but this may be the only time and place that the client can actually enter fully into the sadness without having to worry about what someone else thinks or feels as a result of the expression of such profound emotional pain.

After experiencing deep sadness, the client may want contact, and it is very important to be clear about what the client wants and needs (not what the counselor wants and needs!). In my (D.L.H.) client office, I keep a chenille throw over the back of my chair. If a client goes into a place of deep sadness, I will sometimes take the throw and wrap it around his or her shoulders as a gentle form of contact that is nonintrusive to the client’s process. There is a tendency to come out of this type of expression slowly. It is important to reassure clients that they will have time at the end of the session to “regroup” before finishing the time together. It is also the counselor’s responsibility to ensure that the client has returned to a sense of normalcy before leaving the office and driving a car. Some of our clients choose to go for a brief walk to regroup after an intense session before getting into their car and driving away.

One final suggestion for clients when they are experiencing strong emotions outside of the sessions is to find ways for them to recognize their feelings and work with them, but to also be able to contain them and bracket their feelings when necessary. Clients can have “grief drawers” in their homes, in which they can store pictures, music, memorabilia, and linking objects. When clients realize that strong feelings are arising, they can open the drawer and use these items to facilitate some of their process (Harris, in press). Some clients may light candles when they are actively involved in this work – when the candle is lit, they focus their attention and emotional energy on the contents of the drawer and the associated feelings that arise at that time. Clients may choose to write about this experience in a journal and share it with you when they come for their next session. When they are done, they can blow out the candle, and put the things back into the drawer, and close it shut. Clients can use music to do something similar – when a particular song is done, or the CD is finished, they actively move away from the emotional processing and consciously move into another room as a form of bracketing the experience. Clients need to know that they can enter deeply into their emotional experiences with competence and feel empowered by their emotions rather than crippled by them. Learning how to go deeply and then to come back out of the intensity is a valuable skill that can be helpful in this process.

WHAT ABOUT THE COUNSELOR’S FEELINGS?

Our students often ask us if we have cried with our clients, and how we feel about the counselor sharing his or her feelings with the client. On the surface, there is generally a perception that crying in professional settings is an indicator of lack of professionalism or a sign of weakness on the part of the counselor. The answer may be that it can be a good thing and it can also be an indication of the counselor’s need to attend to personal issues that may need to be addressed (Curtis, Matise, & Glass, 2003). Levitt, Butler, and Hill (2006) cite many clients’ positive responses to their counselors’ disclosures of their own feelings and indications of being touched by their clients’ stories. As counselors, we are human beings and we connect with our clients at a deep and empathic level. To hear stories of pain, suffering, and deprivation and not be affected would be highly unrealistic, and sometimes as we fully enter our clients’ world, we will be deeply moved by their stories and experiences (Yalom, 2009). A normal human reaction might involve tears that fall as we listen to a client’s painful story, and these tears simply validate the depth of the client’s experience and our shared human connection. Problems occur if the client’s story triggers an area of vulnerability within the counselor, and the feelings that come to the surface for the counselor are not those in resonance with the client but a personal reaction to the client’s material that is based on the needs and unresolved material in the counselor. Counselor’s feelings that take the focus of the session away from the client could be damaging to clients, and the counselor could inadvertently use the client to process his or her own unresolved emotional material, which is highly unethical. In Chapter 13, we discuss the role and value of supervision for counselors, which provides a safe place for the counselor to work through personal issues that arise in sessions with clients.

CONCLUSION

In this chapter, we have explored how feelings and working with emotions in the counseling process can be a very important and empowering aspect of counseling bereaved clients. Counselors must have an understanding of their own feelings and experiences, be comfortable working with clients when they enter into deeply intense emotional states, and be able to facilitate the constructive processing of these emotions as part of their work with grieving clients.

Glossary

Emotional intelligence – The level of an individual’s ability or skill in the identification, assessment, and management of the emotions of oneself and to the reactions of the emotions of others.

Feeling vocabulary – Ability to accurately identify and name a particular emotion in terms of its intensity and application to a given situation.

“Felt sense” – Term identified by Gendlin to describe an unclear, preverbal sense of something significant as that “something” is experienced in the body. It is not the same as an emotion, because it is typically unclear and vague; and it is always more than any attempt to express it verbally.

“Fight – flight” response – Also referred to as the acute stress response; bodily response to a perceived threat or acute stressor with a discharge of the sympathetic nervous system, priming the animal for fighting or fleeing in response to a threat.

Questions for Reflection

  1. What were you taught about emotions when you were growing up? How has this learning in your formative years influenced how you handle your emotions, and the emotions of others?
  2. Think of the four main domains or emotions (sad, mad, glad, and afraid), and look over the feeling vocabulary that was posted in this chapter. Which of these emotions is the most difficult for you personally? Which is most difficult for you to handle from someone else? How might your reactions to emotions affect your interactions with your clients?
  3. What do you think is the difference between containing/bracketing emotions and suppressing emotions in the context of counseling?
  4. Go to the following web link to access an online test for emotional intelligence and take the test. What were your thoughts and feelings as you took the online selftest? Can you think of examples in day-to-day functioning where emotional intelligence would be valuable?

 

 

 

 

 

CHAPTER 10 When Grief Goes Awry

With there being so much broad variation in what is considered “normal” grief, how do you know when something is wrong, or when a bereaved individual needs more specific professional help? When does grief become complicated and how do we recognize it? This is a question that continues to challenge researchers and clinicians alike. In the previous chapters, we have discussed how grief is a multifaceted experience, and its manifestation among individuals is highly unique and dependent on many interacting factors. But how can you tell when the bereaved cross that “imaginary line” from normal to complicated grief, and what are the implications of grief going awry? Most bereaved individuals find that the acute grief symptoms gradually diminish over time through a natural integrating process. However, approximately 10% of bereaved people experience grief that is ongoing and often debilitating for a long period of time (Shear, Boelen, & Neimeyer, 2011).

Recently, there has been a great deal of research that focuses on the group of bereaved individuals who experience unabated grief for a prolonged time, negatively affecting their ability to function and cope. In some instances, the bereaved individual may fear that if he or she stops grieving, the connection with the deceased person will be lost. Another aspect of this type of grief is that the person loses a part of himself or herself with the death of the deceased person and, as a result, feels completely lost. Being bereaved may also be a new defining role and identity for the grieving individual, because he or she now defines himself or herself by the loss and the role of being “left behind.” In these examples, being bereaved is experienced as a loss of self and identity.

In this chapter, we review some of the terminologies that are often utilized in the discussion of grief that has veered away from what would be considered a normal trajectory. We also describe some of the main features of complicated grief, as postulated by prominent researchers in this area. Because this book’s focus is on clinical work with bereaved individuals, we also explore some of the clinical implications for complicated grief and for grief that is intermixed with exposure to traumatic events. Finally, we provide an overview of the current treatment modalities that are being proposed for therapeutic work with individuals who are experiencing complicated grief.

WHAT IS COMPLICATED GRIEF?

The terminology that is used to describe grief that has gone wrong somehow can be confusing. Grief that has gone awry is sometimes referred to as complicated grief (CG), prolonged grief disorder (PGD), persistent complex bereavement disorder (PCBD), or traumatic grief (TG) in the published literature (although the loss itself may not be associated with a traumatic death; Parkes, 2014; Worden, 2009). These terms are often used interchangeably; their origin and association vary slightly depending on the backgrounds of the researchers who first proposed the discrete criteria for what we would call “difficult grief.” This difficult, complicated grief involves prolonged acute grief symptoms and situations in which the bereaved are unable to rebuild a meaningful life without the deceased person. Current consensus regarding the criteria for CG states that it may be present after any loss that is extremely personally devastating and that “The devastation can derive from sudden, unexpected death; from the quality of the relationship to the deceased; and/ or personal predispositions” (Tolstikova, Fleming, & Chartier, 2005, p. 295). In regard to the relationship to the deceased, CG is often thought of as a traumatic separation from the person who died, with pronounced separation distress and difficulties adjusting to life without the deceased being markedly pronounced (Gray, Prigerson, & Litz, 2004; Parkes, 2014; Rando, 2013).

Typical CG symptoms include persistent feelings of intense yearning or preoccupation with the deceased; shock, disbelief, and anger about the death; difficulties with trust; and engagement in behaviors and activities to try to either avoid reminders of the loss or to feel closer to the deceased (Exhibit 10.1). People with CG often ruminate or obsess over the various circumstances of the death, their relationship with the deceased person, or the events since the death and their feelings and reactions since that time (Boelen, van den Bout, & van den Hout, 2003, 2006; Neimeyer, 2014; Stroebe et al., 2007). Prigerson et al. (2009) have proposed criteria for the diagnosis of PGD (Exhibit 10.2). It is important for counselors to be familiar with these criteria in order to know when a client may need more intensive assessment and therapeutic support.

 

EXHIBIT 10.1. CLINICAL FEATURES OF COMPLICATED GRIEF

Acute grief symptoms that persist for more than 6 months following the death of a loved one, includes:

  • . Feelings of intense yearning or longing for the person who died – missing the person so much that it is hard to care about anything else
  • . Preoccupying memories, thoughts, or images of the deceased person that may be wanted or unwanted and that interfere with the ability to engage in meaningful activities or relationship with significant others; may include compulsively seeking proximity to the deceased person through pictures, keepsakes, possessions, or other items associated with the loved one
  1. Recurrent painful emotions related to the death, such as deep, relentless sadness, guilt, envy, bitterness, or anger that are difficult to control
  2. Avoidance of situations, people, or places that trigger painful emotions or preoccupying thoughts related to the death
  3. Difficulty restoring the capacity for meaningful positive emotions through a sense of purpose in life or through satisfaction, joy, or happiness in activities or relationships with others

 

Source: Shear (2010).

 

EXHIBIT 10.2. DIAGNOSTIC CRITERIA FOR PROLONGED GRIEF DISORDER

  • . Bereavement (loss of a significant other)
  • . Separation distress: Chronic and persistent yearning, pining, longing for the deceased, reflecting a need for connection with the deceased that cannot be satisfied by others; daily, intrusive, distressing, and disruptive heartache
  1. Cognitive, emotional, and behavioral symptoms: The bereaved person must have five or more of the following symptoms experienced daily or to a disabling degree:
  2. Confusion about one’s role in life or diminished sense of self (e.g., feeling that part of oneself has died)
  3. Difficulty accepting the loss
  4. Avoidance of reminders of the reality of the loss
  5. Inability to trust others since the loss
  6. Bitterness or anger related to the loss
  7. Difficulty moving on with life (e.g., making new friends, pursuing new interests)
  8. Numbness (absence of emotion) since the loss
  9. Feeling that life is unfulfilling, or meaningless since the loss
  10. Feeling stunned, dazed, or shocked by the loss
  11. Timing: Diagnosis should not be made until at least 6 months have elapsed since the death
  12. Impairment: The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning (e.g., domestic responsibilities)
  13. Relation to other mental disorders: The disorder is not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder

 

Source: Prigerson et al. (2009).

Risk factors for CG can be grouped into three main categories. The first of these includes personal psychological vulnerability, such as a personal or family history of mood or anxiety disorders (Gamino, Sewell, & Easterling, 2000), insecure attachment style (Van der Houwen, Stroebe, Schut, van den Bout, & Wijngaards-de Meij, 2010), and history of trauma or multiple losses (Gamino et al., 2000). This category can also include the bereaved individual’s relationship to the deceased, because some relationships tend to be associated more with difficulties in bereavement, such as parental loss of a child, followed by the loss of a spouse, sibling, and a parent (Nolen-Hoeksema, Larson, & Larson, 2013). The second category concerns circumstances of the death itself, such as untimely, unexpected, violent, or seemingly preventable death (Currier, Holland, Coleman, & Neimeyer, 2008; Currier, Holland, & Neimeyer, 2006; Gamino et al., 2000). And finally, the third category of risk factors focuses on the context in which the death occurs, such as social support that is inadequate or that is problematic in some way (Wilsey & Shear, 2007; Worden, 2009), or concurrent stresses, such as financial concerns or other hardships (Van der Houwen et al., 2010).

Complicated, protracted grief is more prevalent in individuals who have attachment difficulties, or whose models of the self or the world do not allow for the accommodation and integration of significant life events into how they view themselves, others, and the world (Davis, Wortman, Lehman, & Silver, 2000; Mancini & Bonanno, 2012; Prigerson et al., 2009). Who we are shapes how we grieve, and who we are is very much associated with how we relate to others. When we are highly bonded and possess a significant amount of attachment anxiety, there is a higher tendency toward complicated grief. The outcomes of complicated grief can be very serious and intervention is required to assist these individuals to preserve their health and their lives, and to counteract the potential negative sequelae that can result from its impact on the lives of these individuals (Parkes, 2014). It is important to be able to recognize when clients are experiencing this type of disabling CG, because it can have a significant negative impact on health and quality of life (Germain, Caroff, Buysse, & Shear, 2005; Hardison, Neimeyer, & Lichstein, 2005; Latham & Prigerson, 2004; Monk, Houck, & Shear, 2006; Neimeyer, 2014; Prigerson et al., 1997) and, therefore, requires treatment that may go above typical grief counseling and support.

According to Prigerson et al. (2009), controlling for depression and anxiety, CG is associated with the following:

  • Myocardial infarction (heart attack) and congestive heart failure (CHF)
  • Immune system dysfunction, placing individuals at higher risk of infections and illness
  • Substance use and abuse
  • Essential hypertension
  • Functional impairment
  • Reduced quality of life
  • Suicide attempts

On a more practical level, we often begin to consider a client to be experiencing a complicated grief response when (a) the intensity of the grief worsens instead of improving or the individual’s ability to compensate for the loss(es) begins to crumble after a period of time has elapsed, (b) the individual’s ability to function on a day-to-day basis is severely compromised, and (c) there is a sense of being completely “stuck” in a deep and unrelenting place of grief and trauma over the course of many months’ duration and the individual feels distress over the inability to move forward. Although it is always important to keep in mind that how we define “normal” grief is variable, depending on many factors that may originate in societal problems more than individual issues, clients who seek your assistance because they are truly struggling after experiencing significant loss(es) should be taken seriously and counselors need to know how to “sit with” the painful experiences of clients while also facilitating the processing of the difficult material (Neimeyer, 2014). It is at this point that many clients are referred for medical evaluation, and the practitioners (medical and psychological) need to have the appropriate knowledge and skill to discern how to best proceed.

OVERLAPS BETWEEN GRIEF AND TRAUMA

To some extent, all grief is traumatic, because significant losses require us to rebuild our shattered assumptions about the world that no longer exists as we once thought (Janoff-Bulman, 1992). When we lose someone whom we love, we also lose significant aspects of ourselves. Our world is never the same. We may feel frightened, powerless, and void of meaning. As mentioned earlier, the term “traumatic grief” has been used interchangeably with the term “complicated grief” because of the mechanism of psychic overload that prevents adequate coping and stress management in the bereaved individual and the resemblance to the models of traumatic stress disorders that are described in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013; Tolstikova et al., 2005). In fact, there have been many comparisons made between CG/TG and posttraumatic stress disorder (PTSD), even in the absence of a traumatic event to cause the death. Some researchers have compared normal grief to the DSM criteria for PTSD and found parallels between these two descriptions, indicating that experiencing a significant loss (whether or not it is the result of a traumatic event) can challenge a person’s ability to accommodate what has happened into his or her assumptive world because of the frequent reported disturbances in sleep, concentration, intrusive images, and the avoidance and estrangement noted in some bereaved individuals (Raphael, Jacobs, & Looi, 2013; van den Bout & Kleber, 2013). What mainly separates PTSD from CG/TG is the presence of separation distress, including intense yearning for the deceased person and intrusive thoughts of or pangs for the lost person is the dominant theme in CG/TG reactions (Prigerson et al., 2009). In contrast to individuals with PTSD who avoid reminders of the trauma, individuals with CG tend to avoid reminders of the absence of the person and thus will actively seek reminders of and focus on the deceased person (Forstmeier & Maercker, 2007).

It is important to note that traumatic experiences are subjectively assessed by individuals, and how a loss by traumatic means is perceived by an individual will vary, depending on the meaning that the individual attaches to that event and the nature of the relationship to the lost person (Neria & Litz, 2003). As counselors, it is important to remember that traumatic material and overlay is interpreted by the client’s perception of the event and not by whether the counselor (or anyone else) believes the event to be traumatic in nature or not. Because this discussion can be confusing, let us make some distinctions between some of the terms that are commonly used. A traumatic loss (death that occurs as a result of an event that would be seen as traumatic, such as a violent act, car accident, or an event in which there may be mangling of the body) is not necessarily going to lead to TG, although it can. Using the term traumatic loss places the focus of the bereaved individual’s experience on the events and the stressors that occurred around the loss and not necessarily on the response of the bereaved individual. The term “traumatic grief” delineates the degree of the separation anxiety and assault to the assumptive world that is experienced by the bereaved individual. In other words, this term focuses on the experience and response of the bereaved person and not on the events surrounding the death itself.

The clinical presentation of an individual with CG is often anxiety based, whereas in normal grief, the presentation is usually more dominated by sadness or anger. The common thread between TG and a traumatic response to an event is found in the propensity for psychological overload that is demonstrated in the similarities between the two responses. This distinction can be very confusing, but for practicalities’ sake, if your client describes feeling highly anxious or unsafe, or tends to focus on the events surrounding the loss rather than the person, you are probably dealing with traumatic overlay of some sort. The presence of CG/TG presents the counselor with the need to assess whether or not his or her training and background is appropriate for working with individuals whose lives are so deeply compromised and whose health and well-being may be at stake. If you are not trained in therapeutic techniques that require skill at both clinical assessment and the processing of traumatic material, a referral should be made to someone with more advanced training in work with grief and trauma. Some of the clinical implications for CG will now be discussed.

The Experience of Loss and Death Can Trigger Old Traumatic Experiences to Come to the Surface

The common denominator in experiences of grief and trauma is loss of control. When we lose something of value or someone whom we love, the overarching feelings often center on powerlessness, helplessness, and feeling robbed. Of note is that the core features of trauma also revolve around these same feelings. Profound, significant losses may lead to an intensification of feelings of vulnerability and anxiety. In clients with a history of trauma, a significant loss might cause reentry into the traumatic material and the anxiety associated with feeling unsafe (Crenshaw, 2006 – 2007; Siegel, 1999). In the diagnostic descriptions that were listed in the beginning of this chapter, a past history of trauma would be seen as a form of preexisting personal vulnerability in the bereaved individual (Gamino et al., 2000). Counselors must recognize when clients’ former traumatic experiences are “doubling” onto the current loss experience and normalize this recurrence for clients, while assisting clients to learn how to contain the traumatic material while exploring the grief related to the current loss.

There Is Often a “Dance” That Occurs When Trauma and Grief Coexist

An important rule to keep in mind is that traumatic material will tend to overshadow the grief-related symptoms at first because clients who are experiencing symptoms related to trauma will not be able to focus on other aspects of their experience until they feel safe, are able to trust the counselor (which may take some time), and have a semblance of control over what to share and how to share it with you. Clients must feel safe and know that there is a “container” for the traumatic material in place before they can do any form of process work, which is the basis for the work with most bereaved individuals. This principle is frequently described in literature related to trauma from abuse and terrorism (Herman, 1997) and in childhood traumatic grief experiences (Cohen, Mannarino, & Deblinger, 2006).

Traumatic material is mediated more by a primitive (primary) system of the brain than by grief (Crenshaw, 2006 – 2007; Perry, 2005). This primary system controls the fight – flight response, which drives individuals to seek safety and security quickly when activated. In his work with childhood traumatic grief, Perry (2005) states:

The key to therapeutic intervention is to remember that the stress response systems originate in the brainstem and diencephalon. As long as these systems are poorly regulated and dysfunctional, they will disrupt and dysregulate the higher parts of the brain. All the best cognitive-behavioral, insight-oriented, or even affect-based interventions will fail if the brainstem is poorly regulated. (pp. 38 – 39)

Clients who are dealing with trauma will often have a sense of unease, and they will often feel vigilant and anxious, but they may not be able to tie these feelings to a specific event, thought, or feeling, because the trauma response does not primarily work on cognition, but more on instinct. Counselors can keep in mind that emotional paralysis or an angry demeanor in a client may serve as a protection for a client who is feeling highly vulnerable and unsafe emotionally. Pushing or going too deeply before a client feels a sense of containment or control in the sessions may cause the client to emotionally flood, resulting in dissociation or the person feeling violated within the therapeutic setting.

Grief is primarily mediated through the attachment system and is tied into cognition, which is related to attributing meaning to events and sequencing events in a certain order (Parkes, 2006). Thus, grief is usually experienced in a more linear way than traumatic events in isolation (Davis, 2001; Shaver & Tancredy, 2001; Weiss, 2001). Clients who are experiencing grief will often be able to name the feeling(s) and tie the feeling(s) to an experience or experiences directly related to their grief, and they will usually be able to share about their loss experience in a mostly linear and cohesive fashion. You will often hear about the importance of bereaved clients being able to “tell their story,” which involves the ability to describe events in this way. As discussed in the previous chapter, grief is not always expressed as sadness – there is often profound anger at feeling robbed or deprived as a result of a loss, as well as the myriad number of other emotions that have been described previously. Bereaved individuals often go into their grief very deeply, and it can be helpful for the counselor to facilitate this deep exploration, which often involves emotional catharsis. We have also discussed earlier that not all bereaved individuals need to deeply explore their emotional responses to loss and “work them through”; it can probably be assumed that the majority of bereaved clients who seek grief counseling would tend to self-select as more representative of those individuals who would find this way of working with grief to be beneficial. This being said, attention to individual differences in client experiences, responses, and expressions is of paramount importance.

The “dance” between trauma and grief is obvious. If you try to engage in deep processing of grief-related material when the client is feeling traumatized, you risk the client shutting down, dissociating, or feeling more out of control and anxious – with the results being that the client may feel worse instead of better afterward. If you try to offer a means of containment to a client who needs to deeply explore his or her grief, you risk suppressing the experience and encouraging the client to remain superficially engaged or avoidant of grief that may need to be attended at that time. Most likely, effective counselors know when containment is needed, while also having the ability to gently explore and help the client to work through the raw grief when it surfaces.

OVERLAPS BETWEEN GRIEF AND DEPRESSION

Anyone who has experienced grief, personally or professionally, knows that people who are grieving are often extremely sad, weepy, confused, exhausted, and otherwise distressed. These behavioral manifestations of deep emotional pain are present, to one degree or another, in most of the people we see in our offices. So, how can we tell the difference between grief that is allencompassing and a major depressive disorder (MDD)? Parkes (2014) states that most individuals who experience depression during bereavement will have suffered similar episodes in the past and these individuals may actually be able to identify the difference between their grief and their depression. Other differences may include how grief and depression are experienced, with grief occurring typically in waves or “pangs” (Parkes, 2014), whereas in depression there tends to be consistently a persistent low mood that stays relatively the same all the time. Likewise, grief can be interrupted by times of positive feelings and even laughter, whereas in depression the misery and negative feelings tend to be felt as pervasive and unabating. Finally, whereas a bereaved individual may be focused on thoughts about his or her own death as the possibility of joining a loved one who has died, an individual who is depressed may consider ending his or her own life because of feelings of worthlessness, despair, or inability to cope with the pain of depression (Parkes, 2014; Searight, 2014).

In the recently released DSM-5 (APA, 2013), a controversial change in the section related to criteria for the diagnosis of a MDD was made. In the past there was a clear directive at the end of the list of MDD’s criteria to avoid diagnosing MDD if symptoms were better accounted for by bereavement (APA, 2000). In this earlier version of the DSM, even if the specific criteria and time duration had been fulfilled for a major depressive episode (MDE), this diagnosis was not made if the symptoms were associated with the death of a loved one and if they were of less than 2 months’ duration. The rationale for the exclusion, though not explicitly stated in the DSM, has generally been assumed to avoid placing a medical diagnosis on a normal, albeit emotionally difficult, life transition. It was assumed that when associated with bereavement, depressive symptoms would decrease without intervention in several months without formal treatment (Searight, 2014). Although there is no clear explanation for why this exclusion was removed in the most recent edition of the DSM, it is thought that concerns over not treating coexisting MDE/MDD in the presence of grief and the risks due to lack of treatment of the possible depression outweighed concerns over the potential to pathologize and medicalize grieving individuals. This area is obviously very controversial for individuals on both sides. Some of the related treatment considerations related to this issue will be further discussed at the end of this chapter.

SUICIDE BEREAVEMENT

Although there have been studies and complete books published on the topic of suicide and support for individuals who are bereaved through suicide (see Jordan & McIntosh, 2011, for a comprehensive review), there are unique features of suicide bereavement that we think warrant mentioning here. There has been a great deal of controversy over whether bereavement after suicide differs substantially from bereavement related to natural causes of death. For example, De Groot, De Keijser, and Neeleman (2006) completed a study comparing the experiences of those bereaved by suicide with those bereaved by deaths from cancer. They found that in comparison to those bereaved through natural means, individuals who were bereaved by suicide had a higher incidence of complicated grief, loneliness, health issues, associated social stigma, and self-stigma, as well as increased incidence of family dysfunction and conflict. The conclusion from their study was that individuals who are suicide bereaved are more vulnerable and potentially more in need of special supports than those who are bereaved from natural causes. McMenamy, Jordan, and Mitchell (2008) interviewed individuals who were bereaved after a family member died from suicide. They reported that those who were suicide bereaved experienced exceptionally high levels of distress at many points in their grieving process. For example, the majority of participants reported moderate to high levels of impairment in their daily activities at home or at work, in addition to significant symptoms of depression, guilt, anxiety, and trauma. In this same study, almost one quarter of the participants indicated that they had thought about suicide to a moderate to high degree.

Young et al. (2012) state that suicide survivors often face unique challenges that differ from those who have been bereaved by other types of death, citing that in addition to the inevitable grief, sadness, and disbelief that is common to all grief, there is often a prominent sense of overwhelming guilt, confusion, rejection, shame, and anger. Jordan (2001) suggests that suicide bereavement is distinct in three significant ways: (a) the thematic content of the grief, (b) the social processes surrounding the survivor, and (c) the impact that suicide has on family systems. Survivors are often left to struggle with meaning making, wondering (but never fully knowing) why the person chose to end his or her life; feelings of guilt and self-blame (i.e., questioning why they were not able to prevent the suicide from happening), and heightened feelings of abandonment and rejection by the person who chose to leave them by suicide.

There is also considerable evidence that the stigma attached to the person who died will “spill over” onto the family of the deceased as well (De Groot et al., 2006; Young et al., 2012). Individuals who are bereaved by suicide may feel the negative attitude toward suicide in our culture transferred to them. Thus, even if others feel and demonstrate compassion and sensitivity for the mourner, the survivor may assume or fear that others are judging him or her negatively and therefore withdraw or otherwise act in ways that inhibit social support efforts from others. It is apparent that these aspects of the grief experience after suicide are unique and deserve special attention from clinicians.

Another aspect of suicide bereavement that is unique is that there is sometimes a sense of relief, because many families that are bereaved by suicide have had a long history of problems with the deceased, often involving chronic psychiatric problems with repeated hospital admissions and relapses, difficult or unpredictable behavior, and, in some cases, previous suicide attempts. Jordan (2001) notes that these families would most probably show heightened stress (and elevated levels of symptoms), even if the suicide had not occurred because of these ongoing difficulties and the strain of the uncertainty and intensity of living with a loved one who is greatly compromised. In situations such as this, a sizable number of families stated that the death of their loved one to suicide was not completely unexpected. Important to this discussion is that the families of many suicide completers have experienced a difficult and often lengthy ordeal of living with an emotionally disturbed and self-destructive person, and the exhaustion and rollercoaster ride of the experience will often leave them depleted and conflicted about their loved one’s death.

Individuals and families who are bereaved by suicide often find talking with others who are bereaved by suicide to be beneficial. In light of the unique features of this type of loss experience, referrals to suicide support groups would be highly preferable over referral to general bereavement groups. McMenamy et al. (2008) also found providing educational information about suicide and grief after suicide beneficial as well. Education may help individuals to better understand their loved one’s choice, their process, and their experience within the social context of the stigma that is often part of their grief. Access to this type of information may also be empowering to individuals who have felt powerless in the loss of their loved one.

Most importantly, clinicians need to keep in mind that those who are bereaved as a result of suicide have been found to demonstrate a higher incidence of CG than others with bereavement from natural causes, increased risk of suicide themselves, and higher rates of depression and PTSD (Jordan, 2011; Young et al., 2012). We have stated throughout this book that grief is a normal, adaptive response to loss and we have also reinforced that uncomplicated grief does not warrant formal intervention in most circumstances. However, in light of the intensity of the experience, the social stigma (and self-stigma) that is prevalent, and the high degree of anger and guilt associated with suicide loss, the support and information provided by friends, family, and untrained individuals may not be sufficient. Because suicide survivors are at higher risk for developing PTSD and complicated grief and may be more susceptible to depression, it is important for clinicians to be cognizant of and address troubling symptoms should they occur. Treatment should include the best combinations of education and specialized support, including specific forms of psychotherapy and/or group support, as well as awareness of when medical assessment for possible pharmacotherapy may be needed to address coexisting symptoms of depression, guilt, and trauma (Young et al., 2012).

We would like to raise one further important point for counselors who work with individuals who are bereaved through suicide. Be aware of your use of language in referring to suicide. For example, an individual commits a crime; thus, terminology that states someone “committed suicide” reinforces the social stigma of suicide, implying that suicide is akin to a crime. Use language that is direct, neutral, and honest when communicating about suicide.

BEREAVEMENT BY HOMICIDE

As with bereavement after suicide, intentionality plays big role in the grief process after homicide. The key difference for those bereaved by homicide is that the unexpected and typically violent death of their loved one occurs at the hands of another person. Intentionality may be active (i.e., someone being targeted and killed by another person or group) or passive (i.e., death occurs because of another person’s actions, but the actions were not intended to kill another person, as in someone being killed in a car crash where the crash was caused by a drunk driver). Armour (2002) states that homicide death differs from other forms of death in the following ways:

  • The death of someone was caused by the willful, unexpected, and violent act of another person.
  • Murder is a public event; thus, family members are robbed of their right to privacy and how they are presented to the public by media.
  • Because murder is considered a crime against the state, family member’s needs are placed secondary to those of the legal system and the state.

Bereavement after homicide is not a private matter, and it is often fraught with the painful intrusion of traumatizing media coverage and implicit assumptions that can profoundly affect the grieving process. A major complicating factor in homicide bereavement is the involvement of police, investigators, and the court system. The stigma of homicide is perpetuated and increased when law enforcement personnel must repeatedly examine the scene of the death and question relatives, friends, and neighbors about the decedent and/or death. Family members and their support networks may be exposed to repeated intrusions by the media, each time having to relive the events of the death and circumstances surrounding the homicide of their loved one (Redmond, 1996). Armour (2002) further aptly states, “The press, criminal justice system, social networks, and the community – as well as social attitudes and the overall climate of investigation, manipulation, speculation, rumor, and delay – give family members less power to direct their fate” (pp. 379 – 380). In this same study, bereaved family members frequently described feelings of being betrayed by the media and legal process and neglected by those who were expected to provide support and that the entire experience was like a “nightmare that doesn’t end” (p. 374).

Homicide combines elements of traumatic loss (the death carries elements of violence, or of events that cause the bereaved survivors to feel distress over what their loved one experienced just before dying), traumatic grief (separation distress that is brought about by the suddenness of the death and feeling robbed of the loved one), and often CG (Currier et al., 2008). Most individuals bereaved by homicide will be bombarded with feelings of powerlessness and helplessness in light of an event that has a painfully devastating impact on them. These individuals will often describe a cascade of horrific images, feelings, and events that begin upon notification that their loved one has been murdered (Rynearson, 2012). After notification, family members may or may not be allowed to view their deceased loved one’s body. If they are able to view the body, they are often closely monitored and prevented from touching the body or clothing because of concerns over “tampering” with evidence. It becomes very clear that the body of the person they loved no longer belongs to them; many family members struggle with the knowledge that the last form of touch that their loved one experienced was of violence and harmful intent.

The justice system moves slowly, and it is common for families of homicide victims to have to wait a year or more for a trial to commence. During the time of waiting for the trial, family members exist in a liminal state, unable to move forward because of their need to know the outcome of the proceedings in order to process what has occurred. When the trial arrives, family members are often retraumatized by the testimony and images presented, especially those that are brought up by the defense for the individual charged with homicide. Families will frequently describe feeling victimized all over again when the politics of plea bargaining and sentencing seem to reduce the life of their loved one into a political game. Asaro (2001a, 2001b) recognized incidences of secondary victimization in survivors who participated in the legal processes surrounding their loved ones’ deaths. Their studies also revealed similar incidences of rejection, unrealistic expectations, and recognition of life changes of the survivors by family members and friends. Armour’s (2002) study further clarified and reinforced the concept and revelation of secondary victimization by identifying the concept of societal needs for safety as more imperative than the needs of grieving families.

The amount and quality of social support to family members of those who die from homicide is often based on the circumstances of the homicide. For example, if a family member was killed during a crime committed by an unknown assailant (robbery, burglary, innocent bystander), the survivors are often nurtured and comforted by support systems in the community. However, if the death was related to drugs or criminal acts involving the decedent, the surviving family members are typically isolated and viewed in part as condoning unlawful acts by the decedent (Vessier-Batchen & Douglas, 2006). In these scenarios, family members and friends are often viewed as somehow complicit in the actions of the deceased and may be subjected to scrutiny, judgment, and shaming by others in their community.

For counselors working with individuals and families bereaved through homicide, it is important to “hold” all of these issues in mind, validating their presence and normalizing the intensity of feelings that occur in the midst of a very abnormal situation. Survivors of homicide have reported a great need to find meaning in the midst of a situation that appears initially to be void of any sense or meaning (Currier et al., 2008). Working with family members together may also provide needed support for the family system and an opportunity to help the family to draw from the strengths and resources of the individual members (Harris & Rabenstein, 2014). It is important for clinicians to understand the legal process, the terminology used in the court proceedings, and the function of the court system. Many families find it very comforting for their counselor to attend portions of the trial for support if possible, or to offer flexible meeting times around the timing of the court proceedings. Armour (2002) reported that family members often felt helped when people from all aspects of the experience demonstrate even small expressions of sensitivity and caring. One participant in this study cited seeing tears in a judge’s eyes when speaking with him about what had happened, noting that this awareness of the judge’s concern for her meant a great deal. I (D.L.H.) have also had family members bring coroner’s reports to their sessions to read and review in the presence of a caring witness and in a safe place.

CLINICAL IMPLICATIONS FOR COMPLICATED AND TRAUMATIC GRIEF Counselors Need to Focus on Their Client in Order to Know How to Best Proceed

Above all, at this time we wish to reiterate that CG/TG is not evidence of pathology in the client. It is important that the grieving individual be given support and a safe space to explore the meaning of the loss experience and its associated ramifications for that person (Thompson, 2012). Thus, even identifying a client’s presenting issues with the proposed criteria for CG or PGD does not mean that something is wrong with your client; rather, the client may be lacking in something that he or she needs in order to grieve or there may just be a sense of being overwhelmed by the loss and its consequences. We do not just “flip into” a different mode of being with our clients when we sense the grief is traumatic or complicated. Instead, we continue to be fully present and engaged with our clients and use cues from their story to guide us in the therapeutic process. We would suggest that you use the information from this chapter to know when clients may need more structured support, but you should also always keep in mind the information we presented about the social context of loss and the politics of diagnosis in Chapter 4.

Listen to your client carefully. If your client is really mired down in his or her grief, gently assess whether the client’s distress focuses mostly on the loss itself (what/who has been lost), the events that surrounded the loss, and/or the process of grief itself, or a combination of these factors, and use your client’s focus as your guide in the sessions. If your client is sharing more about the event that happened or images of how the person’s body looked or was imagined to look, or seems highly anxious or uncomfortable, go slowly and provide stopping points to check in with the client in the session. Feelings of anxiety and vigilance indicate to you that your client is feeling unsafe and unsure. You may have clients describe nightmares about what happened to their loved one. These kinds of dreams may involve the context of an event in which the griever felt powerless and the loved one suffered harm, mutilation, or death or in which the person hears or sees the loved one, but there is an ominous overtone or a sense of something being terribly wrong.

The Interplay of Grief and Trauma

There is often an obsessive quality to what is shared by the client when the grief is complicated or traumatic in nature. Although most people who are bereaved yearn for contact with their deceased loved one, those whose grief is traumatic are often obsessed by what happened and the details surrounding the death, and they are often consumed by feelings of anger, rage, fear, or powerlessness. They may have intrusive thoughts that focus on what happened or they may relive the event(s) over and over in their minds. They may experience bodily symptoms either from the stress they are under or similar to those that might have been experienced by the lost person. They may be unable to go to the place where the event happened or find themselves avoiding similar sites (certain roads, certain types of cars, certain buildings or types of buildings). There is also often fear of being triggered by outside stimuli – television programs, songs on the radio, exposure to a similar event – and they may have an aversion or avoidance pattern in their daily functioning, such as a refusal or reluctance to drive through certain intersections or go near certain buildings. They may also feel a sense that they will die soon or have a sense of fatalism about life. In addition, their level of everyday functioning is usually profoundly affected and many of these individuals are just getting by in regard to their work functioning and in their everyday routine, which adds another tremendous stress on top of their process.

Traumatic loss and TG are often associated with feeling violated, powerless, angry, and out of control. These feelings must first be recognized and validated, and the individual needs to feel a sense of control – even if the control is how he or she chooses to disclose details, or how the sessions proceed. Counselors must be clear in working with individuals who are feeling unsafe and anxious that they only need to know what the client needs to share with them. Be careful about asking too many questions about details. If you want to know about a detail that the client has shared, ask and then wait before asking for more. Pushing for details and content when clients are hesitant or pushing back may be experienced as intrusive and further increase feelings of anxiety. Attempts to minimize or even reframe the magnitude of the client’s feelings, or to act as if the client’s anxiety and hesitancy are not important issues, will only demonstrate to the client that he or she cannot be open about feelings, thoughts, and difficulties with you. In families and certain groups in which there has been a suicide, there can be higher rates of suicide in the remaining members, so feelings about not wanting to continue living and possible thoughts of suicide should be taken seriously and not dismissed (Crosby & Sacks, 2002; Jordan & McIntosh, 2011).

Treatment Modalities

One important aspect of working with individuals who are experiencing traumatic overlay is the need to slow the process down and not to push the person to go deeper into feelings that could lead to flooding with potentially traumatizing images. Slowly, allow the person to share about what happened. Focus on breathing, taking breaks, and maintaining a strong presence in the room. Being able to talk about small “chunks” of the bereaved individual’s experience is sometimes referred to as “dosing” the experience – only dealing with small and selected segments of the painful and traumatic aspects of the client’s experience at a time (Jordan & McIntosh, 2011). Akin to this idea, complicated grief therapy (CGT) has been proposed as a means to assist bereaved individuals by a series of interventions designed to address some of the specific and more problematic areas of CG (Shear et al., 2011). In CGT, clients are asked to maintain a grief diary and to engage in imaginal exercises that are designed to revisit the death in increments, and situational revisiting exercises are used for avoided activities and situations. The revisiting portion of the treatment is similar to a form of exposure therapy that is used with the treatment of PTSD. (For more information on the clinical application of CGT, see Shear, 2015.)

Cognitive behavioral therapy (CBT) has also been proposed as a useful technique in working with CG, in which the bereaved individual is invited to address negative cognitions that have formed around the loss experience and to reframe these cognitions in a more realistic and meaningful way. According to Boelen, De Keijser, van den Hout, & van den Bout (2007), the goals of CBT in complicated grief include (a) integrating the loss with existing autobiographical knowledge, (b) changing unhelpful thinking patterns, and (c) replacing unhelpful avoidance strategies by more helpful actions and coping strategies (for further information about the use of CBT in complicated grief, see Boelen & van den Bout, 2012).

Meaning reconstruction therapy has also been proposed as a way to reduce some of the debilitating acute grief symptoms, providing clients with the opportunity to address their losses, relationships, and purpose in life in the context of the narrative of their life’s story with the deceased individual and without that same person (Neimeyer, 2001, 2014). The specific goals of meaning reconstruction therapy include the following (Shear et al., 2011, p. 154):

  • Finding a meaningful place for the event story of the death in the client’s ongoing self-narrative
  • Reviewing and revising the back story of the relationship with the deceased, both to address residual concerns and to reconstruct the attachment bond with the deceased in a way that does not require his or her physical presence
  • “Re-visioning” life and fostering creative problem solving
  • Reinforcing dedicated action through legacy work

It is important to remember that these descriptions are a very condensed overview of each of these therapeutic approaches, and each of these treatment modalities requires specialized training by a skilled and experienced therapist. These approaches are briefly described here for you to keep in mind if your client is struggling with the basic interpersonal counseling approach to grief that we have described in this book so far.

The Use of Medication in Complicated Grief

The use of medication is often a complex issue, and many clients will have strong feelings about the use of medication during this time. The counselor may suggest a referral for medication assessment when indicated, keeping in mind the importance of exploring clients’ feelings about the use of medication during this process. For instance, I (D.L.H.) worked with a client whose son died suddenly. Her grief was indeed very complicated and debilitating. I wondered whether she would benefit from an assessment for medication because of her inability to sleep and her descriptions of great difficulties functioning in her daily activities almost a year after her son’s death. However, when I suggested this referral, she became very upset, associating the use of medication with the experiences of her mother, who was very often depressed and required hospitalization for severe depression when my client was a child. After we discussed her concerns and she was able to separate her mother’s depression from her complicated grief response over the death of her son, she made an appointment with her doctor and agreed to a course of antidepressant medication. After a month, she seemed to have more energy to address some of the unfinished and unresolved issues that surrounded her son’s death in the therapy sessions. The other side of the medication coin has also occurred with some of my clients who were placed on antidepressant medication to assist with their grief symptoms, only to find that in taking the medication, they felt emotionally blunted, more numb, and too “contained” to process some of the raw parts of their grief that would come to the surface during their sessions. In essence, they reported that the medication helped them to maintain control over their emotions better, but it also prevented them from accessing these emotions when they needed to work through some aspects of their grief experience. In some of these clients, the use of medication seemed to prolong their grief because they were not able to access their feelings as readily as when they were not taking medication.

Important to this discussion is, as was discussed earlier in this chapter, that CG can co-occur with MDD and PTSD. Although depressive symptoms may respond to medication, symptoms of complicated grief typically do not respond to either antidepressive psychotherapy or antidepressants (Forstmeier & Maercker, 2007; Searight, 2014). Neimeyer (2014) aptly states that CG is often associated with intense separation distress, which is on the anxiety spectrum, and not within the range of depressive symptoms; so treating with antidepressant medication might not provide much benefit in this instance. For the purposes of this chapter, it is suggested that counselors pay attention to the level of functionality of the client, along with descriptions of sleep habits and patterns of thinking that tend to “spiral downward” without the client being able to recover in between times of deeper despair and despondency. For clients who, over a period of many months, have been unable to develop more regular sleep patterns and who do not tend to oscillate between grief symptoms and daily functioning, assessment for medication may be of benefit, and the counselor would be remiss in not exploring such a referral in these situations.

Social Support and Stigma in Complicated Grief

In clients whose grief is complicated or prolonged, it is important to keep in mind that individuals who would normally be the main sources of support to your client may be overwhelmed or frightened by the severity, intensity, and duration of your client’s reactions. In addition, individuals suffering from CG symptoms may find it daunting to navigate through the maze of social service agencies. The courage and energy it takes to find appropriate help can also be exhausting, with the potential to cause feelings of deeper isolation and despair. Thus, counselors could be of great benefit by keeping abreast of the local resources, programs, and supports that may be available to clients in specific situations (Dyregov, 2004). As in normal grief, social support is a key component to the healing process in complicated grief. Individuals who are experiencing uncomplicated grief often feel that their friends and family members do not fully understand the depth of their experience. Irrespective of how much more an individual is experiencing CG, he or she might also feel this way.

Advocacy and Empowerment in Complicated Grief

Advocacy is often an important way for the individual to feel that what has happened may have some meaning to it. Advocacy can be thought of as a form of “therapeutic activism” (Jordan & McIntosh, 2011, p. 32) and as a means to try to change things that have surfaced as inequities, injustices, or causal elements in the event that has happened. It is also a means for regaining a sense of personal power after experiencing an event where one felt powerless or helpless. Advocacy may also be a way to channel the intense emotions that have arisen as a result of being traumatized and for individuals who have experienced a similar event to support each other through identification with the common cause. The group, Mothers Against Drunk Driving (MADD) was begun by women who lost loved ones because of drunk drivers, and this organization has provided a powerful presence to lobby for stricter laws and penalties for driving while under the influence of substances. Many suicide prevention groups are formed by individuals who have been personally affected by the suicide of a loved one. The popular television show, “America’s Most Wanted” was hosted by John Walsh to help families find and convict perpetrators of violent crimes after his 6-year-old son was abducted and murdered. With the presence of online groups and Internet-based support, many people find joining online advocacy groups and blogging about their experience to be a way to voice their feelings and concerns so they may be heard and put to use in social contexts (Sofka, 2012). Meaning making through advocacy serves to integrate a traumatic event into one’s existing assumptive world, and it also creates a legacy for the deceased individual.

CONCLUSION

Currently, there is a great deal of research and interest in the description, diagnosis, and treatment of CG. The amount of research and written literature on this topic in the past few years alone is daunting. Counselors need to stay informed as new research findings are released and to keep current on present-day thinking regarding appropriate support and focused intervention to address these life-altering losses and grief responses. What is of most importance is not to focus on fitting a client’s experience into a diagnostic category. In fact, there are many concerns that are raised by clinicians that diagnostic criteria can place labels upon clients that would further stigmatize them. So, we reiterate that the focus of this chapter is to provide you with a means to recognize when a client’s situation may require more focused and intensive intervention. The ability to support bereaved clients from a therapeutic stance is only possible if the client is able to engage in therapeutic work fully, without the risk of being further traumatized by the process, while being given every possible and necessary consideration to function as fully as possible in the face of a crippling loss event. Counselors need to be able to identify when grief has gone awry and to assist clients in finding the best and most appropriate supports available to meet their needs. Counselors must also keep their focus on the bereaved person as a fellow human being who is struggling with a very painful experience. We are reminded that our goal is to be fully present to that person’s experience, while also being professionally informed and aware of the times when further support in other ways may be indicated for the client’s best interests.

Glossary

Complicated grief (CG) – Involves prolonged acute grief symptoms, and situations in which the bereaved is unable to rebuild a meaningful life without the deceased person; there is currently a movement toward the development of consensus criteria for CG because of confusion regarding differing terminology to refer to difficult grief, such as CG, TG, complicated mourning, and PGD.

Dissociation – Although the person remains physically present, there is a sense that emotionally and/or cognitively the person is absent. The continuum may run from daydreaming to actual amnesia about events or conversations.

Posttraumatic stress disorder (PTSD) – The presence of a proscribed set of symptoms and behavioral manifestations that are described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) that occur after exposure to a traumatic event and that remain present for at least 2 months after the event. Symptoms may include frequent reported disturbances in sleep, concentration, intrusive images of the event, avoidance, and vigilance.

Trauma – A deeply distressing or disturbing experience, or a situation that involves a threat of death, serious injury, or significant potential harm to an individual. Trauma may be experienced directly or vicariously.

Traumatic grief (TG) – Delineates the degree of the separation anxiety and assault to the assumptive world that is experienced by the bereaved individual. Some losses are traumatic because they focus on the experience and response of the bereaved person, and not necessarily on the events surrounding the death itself. For example, a palliative death of a very close attachment figure in certain circumstances may lead to TG if the loss causes the bereaved individual to feel unsafe, threatened, or highly vulnerable.

Traumatic loss – Places the focus on the events and the stressors that occurred around the loss, which are usually sudden, unexpected, violent, disfiguring, or out of the normal expectation.

Questions for Reflection

  1. List and describe client scenarios that would indicate a need for a clinician to have specific training and expertise in dealing with CG assessment. How would you know when you are “over your head” with a particular client? What would you do if you felt this way?
  2. What differentiates the experience of prolonged grief disorder (PGD) from chronic sorrow that accompanies nonfinite losses?
  3. Individuals with CG are often identified and diagnosed as depressed by some professionals. What are some of the ramifications for making this diagnosis in individuals with CG?
  4. It has often been said that “all grief is complicated.” Explore this statement, using the information you have read in this chapter.

 

 

 

 

CHAPTER 11 The Clinician’s Toolbox: Therapeutic Modalities and Techniques in the Context of Grief

In this chapter, we explore some therapeutic “tools” and techniques that may be helpful in working with bereaved individuals. We offer these ideas and suggestions with the recognition that there are many diverse ways for bereaved individuals to share their thoughts, feelings, and stories, and these ideas might help to facilitate this aspect of your work with clients. It is highly apparent that there is no such thing as “one-stop shopping” in grief counseling. Some clients will talk nonstop in a session for almost the entire time, whereas others will say very little and have a great deal of difficulty expressing themselves. Some clients will readily talk about their feelings and will be highly self-reflective in their encounters with you, while other clients may focus more upon events outside of themselves and/or be quite analytically oriented. Your job as a grief counselor is to facilitate the client’s process in a way that is most congruent to that person’s way of being in the world and to his or her needs and goals. In this chapter, we describe some therapeutic adjuncts, or different ways of working with clients and their grief. Some of these modalities require specific additional training, and we specify suggestions for additional resources and training opportunities for these modalities at the end of the chapter for your interest. This chapter is by no means an exhaustive review of counseling strategies for adaptation to loss. We have provided descriptions of these modalities because they are the ones with which we are most familiar. If you are interested in a deeper exploration of various exercises and strategies for working with bereaved individuals, we would refer you to Keren Humphrey’s book, Counseling Strategies for Loss and Grief (2009), as well as Robert Neimeyer’s edited volume Techniques of Grief Therapy: Creative Practices for Counseling the Bereaved (2012).

Before introducing work with clients that strays from a classical talk therapy orientation, we go back to a foundational point in counseling: The relationship that you have with your client is what is most important. We would never encourage a counselor to try an intervention or strategy with a client unless there is a sense of comfort in the relationship, where the client trusts the counselor, and the counselor feels that she or he has a solid grasp of the client’s concerns, values, and sensitivities. Remember, the relationship comes first, as the therapeutic alliance is the foundation for all of the work that occurs. The client must have a good sense of trust in you, an engagement with the process, and a motivation to work before you can introduce an exercise or different way of working together into the sessions. We have found that the well-timed introduction of a therapeutic adjunct can have quite dramatic results with some clients, often providing a catalyst for greater awareness, self-understanding, and reflection in the session and afterward. Thus, we want to share some of the things we keep in our “counselor’s toolkit” for you to consider in your work with your own clients.

RITUALS AND LINKING OBJECTS

Rituals usually involve an action that is initiated on the part of the bereaved individual to give a symbolic expression to certain feelings or thoughts (Lewis & Hoy, 2011). Rituals can provide a way for clients to both express and contain strong feelings, and they often give a sense of order and control within a situation where an individual has felt out of control and impotent. Rituals can be created privately by a client, cocreated by a client with a counselor, or culturally established through family and social contexts (Norton & Gino, 2014). Rituals often offer an opportunity to create meaning from what has happened (Neimeyer, 1999, 2012). In addition, rituals often provide a means of connection to the individual who is now gone, because the symbolic nature of the ritual often ties in to the continuing bond that may exist with the deceased loved one, and it may nourish a sense of the deceased’s presence that is ongoing in some way with the client.

The most common ritual in North America is probably the funeral, which serves many purposes: honoring the deceased individual’s life, providing a structured opportunity for social support to be offered to the family and close friends, reaffirmation of values and beliefs, and reintegration of the family into the community without the deceased individual. However, the funeral is a time-limited ritual, and it does not afford an opportunity to be revisited by the bereaved as the grieving process unfolds (Castle & Phillips, 2003). Certainly, the presence of a grave or marker for a deceased loved one can provide an opportunity for ongoing visitation by loved ones and possibly a sense of connection with the deceased individual or to a higher power. However, in the absence of an avenue for expression, this visitation alone may not actively engage the bereaved individuals into that process. That being said, we might suggest that a bereaved person complete a “rubbing” of a cemetery marker or plaque to bring to the session as a means of sharing this experience with you. For clients who do not live in the same city as where their loved one is buried, or who have difficulties with transportation, a rubbing might be a good way for them to “visit” their loved one’s memorial when they wish to do so, but are unable to travel to the site. Rubbings are made by placing tracing paper or thin paper over the marker and then “rubbing” a crayon, pastel stick, or chalk over the surface. The lettering and images of the marker are then transferred onto the paper. Pictures of the marker are often helpful as well, but the physical task of making the rubbing is often therapeutic for the bereaved individual.

Ritual activities may include visiting the grave, displaying photographs of the deceased, showing photos and speaking about the loved one to others, taking up an interest the deceased enjoyed, writing letters to the loved one, watching a particular TV program that evokes memories, creating something, wearing or interacting with something that belonged to the deceased, attending a particular event because the loved one would have attended it or honoring the loved one by attending an event (such as a memorial tournament), creating a memorial of some kind, lighting a candle in honor of the deceased person on specific dates and times, creating a memorial trust in the name of the deceased person, and planting a tree or special plant in honor of a loved one (Lewis & Hoy, 2011). There are as many rituals possible as there are individuals on the Earth, and these are just the more common examples that we see in our practices.

Keep in mind that rituals can also be used for losses that are not death related and for rites of passage, because the use of ritual provides a symbolic avenue for recognizing significance and to attach meaning to an event from which the individual may feel a loss of parts of himself or herself or of something that is highly significant, but not necessarily related to a death.

Perinatal Loss/Reproductive Loss

It is becoming more common for hospitals and health professionals to recognize the significance of the loss of an unborn child. Many clinics and emergency departments offer chaplain support services to women who miscarry or deliver a stillborn baby. These spiritual care providers may offer a blessing or say prayers for the baby and the family, and their presence highlights the recognition by others that a loss of significance has occurred (Kobler, Limbo, & Kavanaugh, 2007). Other rituals that are now commonly used in this type of loss include taking footprints of the baby and placing them on a card or providing parents with a “memory box” that contains items that were related to their baby, such as any clothing used, baby bracelets, footprints or handprints, and photos taken (if possible). Many of my (D.L.H.) clients have brought these memory boxes into their sessions and painstakingly gone through each item with me, with the presence of something tangible providing a means to physically touch the same materials that were in contact with their baby, or that held significance for them.

Another example of the use of ritual in reproductive loss comes from the work of a client who had gone through several years of unsuccessful infertility treatment. After one of her counseling sessions, she made a clay model of her uterus. She then formed several small balls of clay that represented each of the embryos that were transferred into her body during the various infertility procedures. She initially placed all of the “embryos” into the clay uterus, told them that she loved each of them, and then she took each of them out of the clay container, one by one, saying goodbye to the children that she would never bring into the physical world with her. She then buried each of these clay balls to symbolize her desire to recognize the significance of the loss of her children after these treatments were unsuccessful.

Commemorative Jewelry and Personal Belongings

Grieving clients often use special items as a means of maintaining a connection with what they have lost. More than simple keepsakes, these items are often imbued with a great deal of symbolic meaning to a person, relationship, situation, or a part of themselves. Often referred to as “linking objects,” clients frequently take items that they associate with their loved one and attach significance to them as reminders, or as a means of feeling connected to their deceased loved one (Harper, O’Connor, Dickson, & O’Carroll, 2011; Neimeyer, 1999; Volkan, 1981). Common examples of these items are clothing, photographs, personal items (e.g., a pet’s collar, a child’s stuffed toy, a lock of hair), items associated with a place of significance, such as where someone died or was given the news, and letters and gifts that were from a significant person. These objects are often worn or carried by the bereaved individual throughout the day.

One example of this type of object was shared by a mature client who wore a locket that her deceased husband had given to her before he died. She also confided that she had placed a very small pinch of his ashes in this same locket so that he was “always with her.” One client chose to place her prescription lenses into her deceased husband’s glasses and she then wore them herself. Clients will often wear jewelry that belonged to their loved one, or have jewelry made that represents something that is significant to them. For example, one client whose mother died took her mother’s wedding ring to a jeweler and added her mother’s birthstone as well as the birthstones of her sister and herself to it, and wore it every day as a reminder of the love her mother gave to her family. Many clients will wear the deceased’s clothing, use everyday objects that the deceased regularly used (like coffee mugs or pens), and keep specific objects on display that remind them poignantly of their deceased loved one, and this will often provide a sense of comfort and meaning for them.

It is often helpful to ask clients if they have any objects of connection that they find meaningful and, if so, to have them bring these objects to their sessions. It can be very powerful for the counselor to validate the existence and value of these objects with the client, and can often lead to a deepening of the therapeutic alliance because the client explores the meaning of the object(s) with the counselor (Humphrey, 2009).

Letters, Journals, and Electronic Communication

Several of our clients have written letters to their deceased loved ones, talking with them in ways that are similar to how they might interact with them if they were still alive. Often, writing letters helps the bereaved individual to feel connected to the deceased person, while processing the implications of their absence. In essence, the deceased person “hears” about the grieving process from the bereaved individual, who would most likely share this process verbally with the same person if she or he were still alive. There are numerous websites that allow bereaved individuals to post online memorials and notes to their loved ones, including their pets. Several of our clients have stated that these online memorials are very comforting to them, and that they have an added bonus of being readily available at all times of the day or night, and do not require transportation or venturing into a public place when privacy is desired.

More recently, electronic media are becoming a more common form of expression for bereaved individuals. Several clients have shared that they have created a memorial site for their loved one, often using the individual’s social media site to do so. Thus, a Facebook page that belonged to a deceased loved one may turn into a memorial page for that same person. A uniquely creative client established an e-mail account for his deceased wife and wrote to her regularly, using this e-mail account address. Intermittently, he would go into the account he had created for her and read what he had written, and then reply back to his own e-mail account what he thought his wife would say to him at various points in time in response to what he had shared.

Use of Ritual With Conflicted Relationships

In relationships in which there has been ambivalence or negativity, rituals can still be useful to work through some of the unfinished business that remains after death. In addition to writing letters to the deceased person to explore and express feelings and to the deceased individual, there are other possibilities. One client came for grief counseling after the death of her mother.

In the course of counseling, it became obvious that the relationship she had with her mother had been very conflicted, and that she had been subjected to verbal and emotional abuse from her mother for most of her life. When the client’s sisters were going through her mother’s things, they set aside her mother’s dark navy suit for her to have, saying that she was the same size as their mother. The client brought the suit to one of her sessions and talked about the memories she had of her mother wearing this suit, including a particularly painful time when her mother berated her in front of many people at church. Two sessions later, the client came in and said she felt “so much lighter.” When asked to explain, she stated that she chose to take a seam ripper and tear the suit apart at the seams. She then tried to burn it, but found it only melted because it was polyester, so she then chose to bury it along with a picture of herself from the time she had a memory of a particularly negative event when her mother had worn this suit. After she did this ritual, she described feeling that she was “finally free” from her mother’s oppression.

WRITING AND NARRATIVE AS THERAPY

Many current bereavement researchers and practitioners argue that meaning reconstruction is the central process involved in grief (Hibberd, 2013; Neimeyer, 2015). In this approach, human beings are seen as the “weavers of narratives that give thematic significance to the salient plot structure of their lives” (Neimeyer, 1999, p. 67). When a significant loss occurs, the assumptions that one has made about life can be dramatically shaken to the very core. When these assumptions are violated, or shattered by the death of a loved one or a significant loss event, the life narrative of the person becomes fragmented and incoherent. Significant losses require individuals to rewrite the narrative of their lives in a way that allows for an explanation of what has occurred within a context of personal meaning and congruence with how they now see the world, others, and themselves. Thus, approaches that focus on the person’s story of his or her life and the loss that has occurred may assist in creating a new, more meaningful selfnarrative that emerges from the loss experience itself (Neimeyer, 2012, 2015).

There are several possibilities for assisting a client in telling his or her story, and for beginning to identify where the person’s self-narrative has become fragmented as a result of a shattered assumptive worldview. We briefly discuss a few of the narrative strategies that may be of benefit in helping clients rewrite their life narrative in the context of grief counseling.

Clustering

Clustering is a form of brainstorming that may be very useful for clients who feel very stuck or who need to sort through many different competing thoughts and feelings. First, ask the client to think of a central point or aspect of their experience. Write that word in the middle of a sheet of paper and circle it. Then, begin to brainstorm about all of the different tangents that may extend from that central point – draw lines from the central point to a word that represents each tangent or feature of the central point, and circle these words separately. You can then expand further upon these secondary tangents as needed.

 

Figure 11.1. Clustering

This example of a cluster was completed with a client after her husband died from a sudden illness 2 years ago. The main (central) circle in the page started with the death of her husband, then the most important issues that were on her mind as a result of losing her husband. She then went to each of these issues and explored each further with more clustering.

 

Clustering is often very helpful in assisting clients in processing a great deal of material in a short amount of time in a way that is manageable. This is especially useful when a client feels overwhelmed and having difficulties staying on track with her or his thoughts, or when there are multiple and convoluted tangents to the client’s descriptions. Putting thoughts and feelings like this onto paper will often help clients to see their issues in a very condensed, but complete form. In the example provided (Figure 11.1), we have asked Mary to cluster her experiences related to the loss of her husband. Mary’s primary, core experience is the loss of Tom, her husband of 23 years. She then explores the major issues that surround this loss, and then focuses on some of the key aspects of each of these issues in secondary and tertiary clusters. Once complete, a client can look at a cluster drawing and often will feel a stronger sense of clarity in regard to what is most important, and what aspect of the loss needs her or his primary attention at that time. It might also be helpful to have clients complete a cluster of their lives before the loss experience and compare it to the cluster they have completed in their present situation.

Life as a Book

In this exercise, clients are advised to think of their life as a book. In setting up this experience, you might ask clients to think about what the elements of a good book are – such as the plot, the twists and turns, the characters, and what the book has to offer to the reader. Then, you ask the client to think of what the title of his or her “life book” might be. When going to the “text” of the book, you can ask clients to think of specific times or events in their lives as separate chapters of the book. This may take some time and reflection, so we often find it helpful to make this suggestion to a client in the session and to begin the process with them, with the counselor scribing for the client. When the session time is coming to a close, you can then turn your written page(s) over to the client and ask that the client continue to reflect upon the exercise and fill it in more before the next session. Clients often find this exercise to be a powerful way to reflect upon their lives and experiences, and it may be a useful tool to place the current grief-laden portion of their lives in the context of the entirety of their life experiences.

Use of Metaphor and Story

Metaphors allow clients to capture the essence of an experience or feeling through the use of descriptive imagery and symbolism. One suggestion for the use of metaphor is to ask the client to think of his or her loss, grief, or present life situation in terms of an image or an object. For instance, one client described his current situation as feeling like he was in a car that was out of control without a driver, while he was strapped in so tightly with the seatbelt in the backseat that he could not breathe. Descriptions such as this provide a rich source of material to explore with the client that can offer meanings on many different levels (Humphrey, 2009; Witztum, 2012).

 

EXHIBIT 11.1. VIRTUAL DREAMS

Clients are told to use two elements from each column (settings, fi gures, and objects) and to create a story that includes them, tailoring the elements to their own experience. Below are some sample virtual dream elements.

Situations/Settings Figures/Voices Objects
A wasting illness A wise woman A rose
A violent storm A mysterious stranger A burning fire
A troubled sea A booming voice An ancient chart
An early loss A choking sob An ambulance
A long journey An angel A mask
A secret room A dove An empty bed
A cool book A serpent A closed door
An unearthly light A wrinkled elder A coffin
A precipice An overheard song A naked sculpture
A cave A strong man A treasure box

Adapted from Neimeyer, Torres, and Smith (2011).

 

Another exercise that utilizes a similar method is the virtual dream story, which is a story told in figurative language (see Exhibit 11.1; Neimeyer, Torres, & Smith, 2011). This exercise may help clients to work with core issues, while using the figurative language to allow some distance from the personal aspects of their experience that may be overwhelming or too intense to discuss directly. In this exercise, clients are assigned a set of six elements (e.g., settings, figures, objects) of the virtual dream, and they are instructed to write a story that includes these elements, adjusting them to relate to their loss experience. For example, a client may be asked to write a story with a violent storm, an unearthly light, a dove, a strong man, a mask, and a closed door. After the client finishes writing, ask the client to read the story out loud to you, and then explore the various elements and their relevance to the client’s current situation. This exercise may take some time and a little bit of coaching, but it can be a powerful catalyst for exploration and meaningmaking by the client.

Letter Writing

There are many different forms and variations of this exercise. In its simplest form, clients may be asked to write a letter to the lost person (it may not be a loss from death only) to share their thoughts and feelings with that person.

The letters typically focus on the expression of thoughts and feelings about the loss and the clients’ grief. If a letter is being written to someone who is still alive, it is important to emphasize that it is being written for the client’s purposes, and not for the purposes of the other individual, and that the letter should not be sent. Letter writing can also be a very process-oriented exercise, with clients writing letters to themselves as they were in the past, perhaps forgiving themselves, or speaking with the voice of experience now to a younger and more naive version of themselves at an earlier time. Clients can write letters to their past or future selves as well, providing a way to work on past painful events or reminding their future selves about a time in their lives that they will remember forever. In some cases, a ritual to dispose of the letter – such as ripping it up, burning it, or burying it – may offer a sense of resolution to the client regarding issues that have been “hanging” in the client’s mind as unfinished or unresolved material (Humphrey, 2009).

ENERGY-BASED THERAPIES (“POWER THERAPIES”)

We include a brief section here to familiarize readers with energy-based modalities and how they have been used with bereaved individuals. Each of these techniques requires highly specialized training and supervision, so you would not be able to incorporate them into your practice without first immersing yourself into the understanding and use of each under the direct supervision of certified trainers/practitioners. However, because these modalities are often mentioned in both the scholarly literature and in popular venues, we think it is a good idea for you to have a basic understanding of them and to know when they may be appropriate for clients in the event a referral to another practitioner might be considered, or a client brings these topics up for discussion with you. Commons (2000) refers to these therapies as “power therapies,” due to their ability to rapidly assist some clients who are paralyzed by traumatic images and material.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR was initially introduced with a controlled study of Vietnam veterans and victims of sexual molestation (Shapiro, 2001). It was found that with the use of this procedure, clients could quickly desensitize traumatic memories and restructure irrational thoughts and negative self-assumptions, and that there was a significant reduction in debilitating symptoms (Solomon & Shapiro, 1997). Solomon and Rando (2007) discuss the use of EMDR with bereaved individuals to assist them in processing and reframing highly disturbing and/or painful material that has been stored in association with their memories of the deceased individual. Their research has demonstrated that using EMDR with clients who are experiencing symptoms of trauma and distress reduces the debilitation that can occur when the client’s functionality is affected by intrusive grief symptoms (Pearlman, Wortman, Feuer, Farber, & Rando, 2014; Solomon & Rando, 2007). EMDR is an eight-stage treatment method that involves elements of psychodynamic, interactional, and bodyoriented therapies along with cognitive behavioral elements. It is thought that the multimodal approach of EMDR elicits an ability to process traumatic and distressing material at an accelerated pace. It is very important to recognize that EMDR training is an intensive process for counselors who are already very skilled clinicians. EMDR should not be attempted without completion of the training and demonstrated competence in the method under supervision. We offer this brief description as a possible consideration for referral in clients with whom talk therapy does not seem effective, or where talk therapy tends to heightens anxiety.

Thought Field Therapy (TFT)

Thought field therapy was introduced as a treatment for distressing psychological-related symptoms. Callahan and Callahan (1997) concluded that the control mechanism of the emotions and all physiology of a person are accessible through the energy systems of the body that are utilized in acupuncture, called meridians. By stimulating meridian treatment points (in Chinese medicine, sites where the acupuncture needles or pressure are applied), TFT makes subtle changes in the emotional and physiological systems of the person. Different types of disturbances involve tapping different meridians and pressure points on the body. In the TFT treatment, clients focus on the emotional pain that is most disturbing to them in the grieving process. The TFT therapist asks the client to become attuned to the targeted emotion, and while the client is experiencing these feelings, the therapist directs the client through a specific set of tapping procedures on specified pressure points on the body. The procedure is usually brief. Afterward, subjective distress is reassessed and the procedure is repeated until the client describes a reduction in the distress level. Training for practitioners involves learning the correct procedures for different client presentations.

This procedure is not without its detractors. Many mainstream therapists and researchers cite lack of outcome evidence as problematic in the recommendation of the use of TFT. Proponents cite it as one of the “power therapies” that is beneficial for clients with severe and intractable distress (Commons, 2000; McNally, 2001). We have heard several clinicians who work with clients who have debilitating symptoms of trauma and complicated grief describe many benefits of this modality with their clients, which is why we have included a brief description of it here. We suggest that you consider investigating this modality and the recent literature on implementation and efficacy of TFT if you are interested in its application to bereaved individuals.

Emotional Freedom Technique (EFT)

The emotional freedom technique (EFT), developed by Craig (1995), takes TFT a step further by using a single comprehensive procedure, thus eliminating the need for a complicated diagnosis and specific treatment protocols. Supporters of EFT allege that by tapping on all the meridian points, problems associated with the misdiagnosis of underlying emotional distress due to poor or ambiguous definitions are eliminated. Craig states that successful treatment of patients, even when the order of the tapping was changed, is proof that the diagnosis of a particular disorder is unnecessary and even problematic for treatment effectiveness. During EFT persons are instructed to focus on their fear while they tap different meridians on various parts of their bodies. It is thought that focusing on fear while tapping is akin to imaginal exposure and distraction, respectively. EFT incorporates the same fundamental components as systematic desensitization and distraction. Therefore, a decrease in subjective units of distress (SUD) ratings by group EFT may be due to a combination of exposure and distraction, rather than to the specific tapping locations.

USE OF PERSONALITY AND TEMPERAMENT INVENTORIES

Although we do not usually recommend the use of measures and instruments as part of grief counseling practice, we often find that clients who embark upon a process of trying to sort themselves out might benefit from the self-exploration that can be facilitated by the completion of self-scoring personality questionnaires. We find it helpful, at times, to think of how clients process information and generally prefer to interact with their everyday world so that our way of being with them is consistent with their needs and preferences. Most of the inventories that we discuss in this section are available as free online versions (we list the websites at the end of this chapter), which allows clients to complete them at home and to read about their results and absorb the information on their own before doing so with the counselor. In addition to assisting clients to develop a deeper awareness and understanding of themselves, working together on the material that has surfaced as a result of completion of these inventories can assist the counselor to choose language, imagery, interactional style, and therapeutic suggestions that might be more congruent with the client’s values, beliefs, and strengths.

The Myers – Briggs Type Indicator (MBTI) was developed as a personality measure based upon Jung’s theory of psychological types (Myers, McCaulley, Quenk, & Hammer, 1998). The authors, Isabel Myers Briggs and her mother, Katharine Briggs, built upon Jung’s theory of personality types when they designed the measure. The MBTI sorts psychological differences into four opposite pairs, or dichotomies, with a resulting 16 possible psychological types. None of these types are better or worse; however, Myers and Briggs theorized that individuals naturally prefer one overall combination of type differences (Myers et al., 1998). In the same way that writing with the left hand is hard work for a right hander, so people tend to find using their opposite psychological preferences more difficult. The MBTI is not a tool to assess psychiatric diagnoses or personality disorders; rather, it is used to help individuals to better understand themselves and how they perceive their world. It is broken down into four different indices that reflect individual preferences in these various areas.

  • Extraversion/introversion – How are you energized and where is your focus (it is not necessarily about whether you like people or not). Do you prefer time alone to recharge or do you get energy from being with others? Do you tend to “think out loud” or prefer to work and reflect privately?
  • Sensing/intuition – What do you pay attention to? How do you “take in” information? Do you tend to focus on your five senses and be more concrete in your thinking or do you pay more attention to your “gut instinct” and things that are more in the realm of your imagination?
  • Thinking/feeling – How do you make decisions? How do you come to a conclusion? Do you tend to organize and structure choice in a logical and objective way or do you prefer to organize and structure information in a more personal, value-oriented way?
  • Judging/perceiving – What kind of lifestyle do you prefer? How do you deal with the world? Do you tend to make lists and plan your schedule or do you prefer to “wing it” and leave your options open?

If you look at these four areas, there are conclusions you might be able to make regarding a person who is grieving based upon that person’s type. People who are introverted may need some “down time” to process their grief. Extroverted individuals may find attending a support group with others who are sharing and interacting with them to be highly beneficial. People who tend to score higher on the thinking portion of the scale may have difficulty dealing with strong emotions that arise, or they may feel uncomfortable with others who express emotion. These individuals may also struggle with others who attempt to get them to emote in order to “feel better.” Individuals who tend to be stronger in sensing scores may have difficulty if they did not get a chance to see the body after death, whereas highly intuitive individuals may be more prone to engaging in a deep quest for existential meaning after a significant loss. Individuals who tend to score higher on the judging portion of the scale tend to appreciate organization and routine; obviously, the disorganization and chaos that is often a part of grief has the potential to be especially distressing for them.

These generalizations, of course, have to be checked with the person to make sure they are accurate. However, just thinking in terms of individual preferences and differences takes away the language of grieving in a “right” or “wrong” way and helps to identify both difficulties and strengths. These differences may also be a source of stress for family members who are grieving differently because of their personality types. The Keirsey Temperament Sorter (Keirsey, 1998) is very similar to the MBTI and may offer a more simplified way for clients to understand personality typology, and to see how knowing their preferences may assist them in finding their own unique path through their grief. Other inventories we have used that may be helpful in a client’s self-discovery include the True Colors characterization (Kalil, 1998) and the Enneagram of Personality (Riso, 1996).

MINDFULNESS-BASED INTERVENTIONS

Although often associated with Buddhist thinking, mindfulness meditation does not require an individual to embrace Buddhist beliefs in order to practice mindful awareness. In therapeutic work, mindfulness practice incorporates elements into the client’s experience that may be of great benefit, including learning to cultivate an intentional focus on the momentto-moment experience as it is in the here and now; detached observation of thoughts, feelings, and sensations; and nonjudgmental acceptance of one’s experience exactly as it is (Humphrey, 2009; Kumar, 2013). The mindfulness practice that has been adapted to psychological work in the West is also sometimes referred to as insight meditation, or Vipissana. Rather than teaching clients to shut out their experiences, thoughts, and feelings, the cultivation of mindful awareness allows clients to enter these experiences and states fully, but without being overwhelmed by them. Clients who engage in mindfulness practice often describe feeling that they are very in touch with their direct experiences, but that they no longer find these same experiences as distressing or distracting as they once were. Western therapies, such as Gestalt, psychodrama, and the Internal Family Systems (IFS) model (which are discussed in the next section) draw upon elements of mindfulness, bringing the client into a full awareness of the present experience in order to heal or work through experiences or issues from the past (Johanson, 2006).

There are numerous clinical applications for mindfulness practices. Levine (1989a, 1989b, 1989c, 1998) has written several books on the topics of death, dying, and grief and mindfulness. We have found Sameet Kumar’s book, Grieving Mindfully (2005), to be a good resource as well. The actual Mindfulness-Based Stress Reduction (MBSR) program was developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center. The MBSR training involves an 8-week introductory program, which includes both didactic training and daily meditation practice (Kabat-Zinn, 1990; Sagula & Rice, 2004). Our chapter on therapeutic presence incorporates many aspects of mindfulness practice, and you may want to revisit it to review the ideas presented for the counselor to practice in relation to the client. The most common, basic techniques used are the body scan technique and following the breath.

Body Scan Technique

One of the first techniques learned and practiced in the MBSR program is the body scan. It seems we have a tendency to neglect our body unless there is something wrong with it, which is unfortunate because what is called the “felt body sense” – awareness of body sensations, which are often quite subtle – can give us valuable insight into what is going on with our bodies and with our whole being as well. The body scan is a practice of devoting moment-to-moment attention to our body just as it is. Typically, the body scan is performed lying down but can be practiced in any position. Clients are instructed to first direct broad, expansive attention to the body as a whole, then very focused attention in a systematic fashion to various regions of the body, and then once again an expansive awareness of the entire body. Through this process they will often discover much about how the body feels, its sensations, and their mental reactions to paying attention to various parts of the body. Clients are instructed to pay attention in this way, without trying to fix or change anything, in order to become less critical of their body’s perceived imperfections and responses to the environment, and to cultivate greater acceptance and appreciation for their bodies at that very moment (KabatZinn, 1990).

Following the Breath

In this practice, clients are asked to find a comfortable sitting position, and to bring the attention to the sensation of breathing. They should breathe in long and out long a couple of times, focusing on any spot in the body where the breathing is easy to notice, and on which the mind feels comfortable focusing.

This could be at the nose, at the chest, at the abdomen, or any spot at all. The client should stay with that spot, noticing how it feels as he or she breathes in and out. The client should not force the breath, or bear down too heavily as he or she focuses. Let the breath flow naturally and simply keep track of how it feels. Savor it, as if it were an exquisite sensation to prolong. Clients will often express that it is difficult to control their thoughts – that their minds wander a lot, and that they find it difficult to stay focused on their breathing. We let them know that this is normal and that if their mind wanders off, simply bring it back. We encourage them and tell them that if their mind wanders 100 times, simply bring it back 100 times. We emphasize being compassionate with themselves as they begin this process, and to not be focused on whether they “did it” as much as they are doing it and learning it.

Many people do have a hard time with their thoughts, and they may get discouraged. We are so used to our hyperactive minds that we barely notice the fact that they are usually churning with activity. So we tell clients that when they first sit and meditate, they may be caught off guard by all the activity. Some people find it helpful to use a little imagination to help themselves meditate. For example, instead of counting or following their breath, they might prefer to imagine a peaceful scene, perhaps floating in a warm lagoon, until the noise of their minds quiet down. One especially useful image has been that of sitting on the edge of a fast-flowing river, where all of your thoughts, feelings, worries, and concerns are the water as it rushes by you, as you sit on the river bank and watch it.

Clients can experiment with different kinds of breathing. If long breathing feels comfortable, they should stick with it. If it does not, they should change it to whatever rhythm feels soothing to the body. They can try short breathing, fast breathing, slow breathing, deep breathing, shallow breathing – whatever feels most comfortable to them at that time.

THE INTERNAL FAMILY SYSTEM MODEL (submitted by Derek Scott, RSW)

The internal family systems (IFS) model of therapy (Schwartz, 1995) is one in which treatment is based on an understanding that the personality exists as a system of parts to which compassionate curiosity may be brought in order to facilitate healing. The “parts” in this model may be understood to be autonomous aspects of the personality that have specific roles. Schwartz defines one of these parts as the “exile” or “protector.” The exiled parts hold extreme feelings and/or beliefs about themselves that may threaten to “blend” (i.e., overwhelm and define the system). When this occurs an individual may identify solely as the blended part (e.g., “I am sad,” or “I am ashamed”). When these vulnerable parts get triggered, other parts jump up to distract us from them, and these reactive protective parts are termed “firefighters.” Common firefighter distractions might include using TV, sleep, alcohol, drugs, sex binging, food binging, rage, and so on to keep the system occupied until the agitating energy of the vulnerable parts is no longer as present. The other group of protectors in the system are referred to as “managers,” which seek to ensure that the vulnerable exiles do not get triggered. The managers do this by attempting to manage the outside world and/or other people. For example, in grief, the decision not to visit the gravesite is commonly manager led; that is, seeking to avoid the inevitable triggering of the parts that are holding distressing affect.

In addition to the parts of the personality system, we also have a Self, and the salient aspects of the Self in terms of the therapeutic work are curiosity, compassion, and calmness. It is Schwartz’s (1995) position that everyone has a Self and the work of the IFS therapist is to help the client’s Self to respond to the parts of the system that are holding distress. Once these parts are compassionately witnessed in terms of the burdensome feelings and/or beliefs they are holding, their burdens may be released and they may choose a new role in the system, bringing great relief to the bereaved and helping the system to return to balance.

When working with grief, the IFS therapist will become sensitized to the typical burdens held by the cluster of parts connected to attachment and loss, which are typically parts that are holding depression, sadness, missing/yearning, protest (anger), guilt, powerlessness, and despair. Many of these parts hold burdens from unresolved losses in childhood, and they are activated by the present loss. Consequently, the feelings have the intensity of a child’s response, and the protective system becomes engaged to prevent the person becoming overwhelmed. By attending to the typical managing protectors – honoring their strategies of postponing, displacing, replacing, minimizing, avoiding, somaticizing, numbing, and shaming (which is particularly prevalent in disenfranchised losses); and reassuring them that the client’s Self can hear the exiled pain without becoming overwhelmed – the protective parts of the system may then step aside and allow access to the burdened exiled parts.

This model is nonpathologizing; every part is recognized for its beneficent intent for the system. Proponents find it to be an efficient, effective, and inherently respectful therapeutic modality. For more information and to witness a role-play of working with complex grief, please see the web links and resources listed at the end of this chapter.

SANDTRAY WORK

Sandtray therapy (or “sandplay”) is a technique based upon practical, creative work in a sandtray. Use of sand as a therapeutic method was originally developed by Dr. Margaret Lowenfeld in the 1920s. She was influenced by

  1. G. Wells, who wrote about observing his two sons playing on the floor with miniature figures and his realization that they were using these figures to work out their problems with each other and with other members of the family. After reading about Wells’s descriptions of his sons at play, she added miniature figures to the shelves of the playroom of her clinic. The first child to see them took them to the sandbox in the room and started to play with them in the sand. Dr. Lowenfeld felt she had found a method to help children express the “inexpressible.” Dr. Lowenfield eventually formalized the play with miniature figures, sand, and water in a blue-bottomed, aluminum container in her London-based play-therapy clinic to work with children to help them to express and work through emotionally charged issues. One of the children with whom she worked stated that the tray gave her “a whole world to play with,” which inspired Dr. Lowenfeld to call it the “World Technique” (Lowenfeld, 1979).

The current use of the sandtray with adults began with the work of Dora Kalff, a student of Carl Jung who later studied Lowenfeld’s World Technique. She recognized that the archetypal content and symbolic process involved in this medium could make it readily adaptable to Jungian theory, and she used the term “sandplay” therapy to distinguish it from Lowenfeld’s work (Kalff, 2004). As with the World Technique, sandplay therapy is now used with both adults and children. There is now an International Society for Sandplay Therapy and another organization called the Sandplay Therapists of America, and there is an extensive training and supervision process for therapists to become qualified in the formal modality of sandplay therapy.

Most clinicians who use sandplay therapy with adults still use figures as representational models of either intrapsychic processes or of situations that are brought up in verbal (talk) therapy prior to the work in the tray. Sand can be either dry or wet. Some clients talk as they work and others remain silent. The meaning of the work emerges as the client experiences it and shares it with the therapist. For the client, working in a sandtray translates personal experience into a concrete, three-dimensional form. Just as a picture can say more than a thousand words, a figure or scene can express feelings, emotions, and conflicts that previously had no verbal language. Thus, sandworlds that are created can offer a rich and highly personalized vocabulary for preverbal or nonverbal experience. Without having to depend upon words, clients can increase their capacity for expression through the tray. Often, clients experience a sense of awareness and clarity that was not possible in talk therapy alone.

Once some aspect of the self has been made tangible in the sandtray, the ability to experience it, share it with another, experiment with it, play with it, revise it, and learn from it is possible. Internal struggles and tensions can be “played out.” Familiar “stuck” patterns may be loosened and the beginnings of new, more satisfying ways of being may emerge. There are two different ways of using sandtrays that may serve as helfpul adjuncts in working with bereaved individuals (Harris, 2012).

Hands in the Sand

Sand itself has many connotations for individuals. In her book, Healing and Transformation in Sandplay, Ammann (1991) states that “Sand is matter ground by the infinity of time. It makes one mindful of eternity. Sand is matter which has been transformed and has almost become liquid and spiritual” (p. 22). Sand in its dry form is almost like liquid. It is light and when we touch it with our hands, it feels soft. In this type of sandtray work, clients are simply asked to immerse their hands in the sand and to work with the sand in whatever way comes to them. The exercise is nonverbal; clients are asked to focus on their hands, the sensations that their hands experience, and what they are feeling as they do the exercise. They are usually given about 5 minutes to work the sand with their hands. When a client’s hands enter the sand, deeper thoughts and feelings often come quickly to the surface. The tactile sensation of the sand may also remind someone of their desire to be touched and to gently touch someone else – something that may be missing after the loss of a loved one. For some, the act of immersing their hands in the sand or feeling it as they lightly touch the surface changes the tone of the session immediately, often intensifying it and focusing it completely on the client’s experience. The use of music during this time can help to foster the process of the client nonverbally. Music can be chosen by the client in advance, or the counselor can choose a piece that may fit the client’s situation or mood. At the end of the session, we “debrief” the process, with the clients being able to integrate the affective and tactile experience with their own personal stories of loss.

Another use of the “hands in the sand” approach is to help clients remain grounded when there has been a tendency to dissociate in the session or the client begins to feel overwhelmed by the material brought up in the session. Several of my (D.L.H.) clients instinctively now reach for the tray in my office and keep it in their laps while we are in the session, often working their hands in the sand while they are talking as a means of feeling “grounded” and more present during the session. This way of using the tray is similar to grounding methods that help clients to remind themselves that the story they are recounting is not happening in the present, such as rubbing their feet on the floor or naming objects in the room as a means to stay connected in the present when talking about traumatic material (Figure 11.2).

Figure 11.2. Hands in the sand – working the sand nonverbally with the hands. The client places the hands in the sand and works the sand as he or she feels drawn to do so, while the counselor remains silent and fully present to the client’s work. Evocative music is often used in this process. After 5 minutes, the client is gently asked to complete the work and the counselor asks the client to describe the thoughts and feelings that arose during this process.

 

The Tray as Metaphor

The other method for which I (D.L.H.) use the sandtray is similar to how sandplay therapists use the tray – by having a client place representational figures into the tray to better visualize a situation or to better describe it. This method has been very helpful when clients remain “stuck” on a particular issue or situation. However, the use of such representational figures involves training in the use of the tray for that purpose, so we suggest the use of representational objects that are natural and more symbolic in nature, such as rocks, leaves, pictures, or objects that may be brought in by the client. Clients may choose a particular rock, shell, piece of wood, feather, or other item from a bowl that is kept near the tray, and they usually explain why they chose a particular object to represent a certain person or situation. The tray may be seen as their life, their loss, their family, or whatever topic is the focus of that session (Figure 11.3)

The advantage of this method is that it allows clients to project their own interpretations onto the objects themselves and this becomes part of the “process” of the tray. Both ways of working in the tray often help to slow the session down, especially when there is a lot of anxiety or intense emotion present. The “hands in the sand” method is very tactile and is useful for clients who need touch to stay “connected” to their emotions. The tray as metaphor method allows clients to be “outside” of the situations or relationships that are being represented while having an opportunity to focus directly upon them. Often, subtleties in the situations that are being represented in the tray may not be readily accessible for the client in typical talk therapy, and the sandtray seems to give expression to words, events, feeling, and experiences in a way that might otherwise have been difficult for the client to name or describe.

 

Figure 11.3 – The sandtray as a representation or metaphor.

In this tray (left), the client used the four objects across the middle to represent the four seasons since her husband had died – the gray rock was winter, the silk flower was spring, the shell was summer, and the broken red leaf was fall. Below these four objects represented her life before her husband died – a shell with a deep purple interior, a pink quartz heart, a seed pod, and feathers. The objects at the top represented her life after her husband died – a dark piece of flat slate, a piece of wood that looked like a “woman who was crying,” and a broken piece of dried wood “which is what my life feels like now.” The client worked in this tray off and on for several sessions.

The tray at right was done by a mother whose child had died in a car accident. She brought some of the cards that she had received from her daughter’s friends, a few dried flowers from the funeral, a candle, and a poem that was also written by one of her daughter’s friends. After working with the sand in the “hands in the sand” mode, she lifted her hands out of the sand and noticed that the pattern looked like a butterfly. She placed the items around the tray and took this picture when she was done. She described feeling that her daughter would like what she had done, and that in doing the sandtray work, she felt closer to her daughter’s presence.

 

GROUP WORK

Talking with others who have experienced loss can help clients to navigate their grief with supportive others who may uniquely understand what they are feeling. Grief support groups offer acceptance, information, connection with others, and an outlet for those who are a little further along their path to help others who are new to the grieving process. Many grief support groups are funded or provided as a public service for specific types of loss issues, and so they may provide an affordable option for clients who need additional support. Grief is often viewed as a wound of attachment – we lose someone to whom we have a significant attachment, and there is often a gaping hole and sense of emptiness that is left behind. Being able to share about these feelings with others who understand and empathize relieves some of the emptiness and may foster a sense of hope in clients who feel the despair of going through this process on their own. Grief support groups can decrease clients’ sense of isolation, help to normalize the grieving process and the significance of the loss that has been experienced, and provide opportunities for bereaved individuals to find ways to cope with the complexities associated with a significant loss. Online support groups are increasing in both availability and popularity and these groups may be a good resource for some clients, especially if transportation or child care responsibilities interfere with attendance at a regular face-to-face group (Barak, Boniel-Nissin, & Suler, 2008; Feigelman, Gorman, Beal, & Jordan, 2008; Lynn & Rath, 2012).

Most grief support groups function on a self-help model, but some are professionally facilitated by an individual who is a counselor or a professional helper. It is beyond the scope of this book to explore all the intricacies of grief support groups. We strongly suggest that you obtain a list of grief support group resources and referrals in your community for your clients, so that you can make informed suggestions to clients who may benefit from being involved in a grief support group. Often there are groups for particular types of loss experiences, such as the loss of a child, a suicide survivors group, widow/widower groups, and groups for various ages, such as specialized children’s groups or groups for seniors. It is important to note that there are no guarantees regarding the quality of these groups and typically there is no form of accountability or monitoring of the Internet sites on a regular basis.

CONCLUSION

In this chapter, we have described some possible therapeutic techniques and adjuncts that you may find helpful either for directly working with bereaved individuals or for consideration when referring certain clients. Please keep in mind that no technique or modality can ever replace the healing potential of the relationship that exists between the client and the counselor. Sometimes, clients need the opportunity to see their experiences through a different lens, or to be able to process their material in a way that defies words. We hope you will use the resources, suggestions, and exercises at the end of this chapter to explore some of these ideas more thoroughly.

Glossary

Clustering – A form of therapeutic writing that calls for brainstorming and drawing to make connections between feelings and events in a concise manner.

Internal Family Systems (IFS) model of therapy – Based on an understanding that the personality exists as a system of parts to which compassionate curiosity may be brought in order to facilitate healing. The “parts” in this model may be understood to be autonomous aspects of the personality that have specific roles.

Linking objects – Items that individuals associate with their loved one and to which significance is attached; may serve as reminders or as a means of feeling connected to the deceased loved one.

Metaphor – Literary figure of speech that uses an image, story, or tangible thing to represent a less tangible thing or some intangible quality or idea.

Mindfulness practice – Includes learning to cultivate an intentional focus on the moment-to-moment experience as it is in the here and now; detached observation of thoughts, feelings, and sensations, and nonjudgmental acceptance of one’s experience exactly as it is.

Narrative – The telling of one’s life story in a way that draws meaning and coherence into difficult events and circumstances.

“Power therapies” – Therapies that rapidly assist clients who are paralyzed by traumatic images and material; refer to EMDR, TFT, and EFT.

Ritual – Usually involves an action that is initiated on the part of the bereaved individual to give a symbolic expression to certain feelings or thoughts.

Questions and Activities for Reflection

Complete one of the narrative exercises for yourself. After you have completed the exercise, think about how you felt as you were doing it. If there is someone with whom you feel comfortable sharing the exercise, talk about it with that person, and discuss between yourselves what it was like to complete the exercise that you chose. Was there anything surprising? What types of clients and contexts of counseling do you think might benefit from completing one of these exercises? As the counselor, how would you use these exercises with clients?

1. Awareness exercise (contributed by Derek Scott, RSW)

The only time that exists is the present moment, yet we tend to spend much time ruminating about the past, which only exists as memory, or the future, which is fantasy. This exercise is designed to begin the practice of paying attention to the moment. We may consider that there are three “zones” of awareness: external sensory (the five senses), internal sensory (feelings), and internal cognitive (thoughts). We tend to spend a lot of time in the cognitive space, with our minds “cluttered” by various thoughts, analyzing our experiences, and thinking about the past and the future instead of directly experiencing these things.

This exercise is done with a partner. Find a quiet space without the possibility of interruption. Face your partner and take 5 minutes to share what you are aware of by saying, “Now I am aware… ,” then switch. As your partner is sharing with you, simply nod and offer nonverbal encouragement.

After you complete this exercise, share with your partner what it was like to do this exercise. What were you aware of? Was there laughter? If so, what was it about? Did you find yourself censoring anything? If so, do you know why? You can also use this exercise with clients after you know them well and believe they can tolerate focused attention with you in this way. Can you think of client situations for which this exercise might be helpful in a session?

2. Touch and sensation exercise (to explore mindful awareness)

The purpose of this exercise is to introduce the element of being in the here and now, and to cultivate awareness with clients (for the counselor), and for clients (guided by the counselor).

Raisin exploration. Take a raisin and hold it in your hand. Begin by looking at it carefully, as if you have never seen a raisin before. Notice its texture, color, and the surface. Pay attention, as well, to any thoughts and feelings you have about raisins – such as liking, disliking, self-consciousness about doing this exercise. Next, smell the raisin. Notice any sensations that arise in your mouth or body as you smell the raisin. Then, bring the raisin to your lips. Notice your arm moving to bring your hand to your mouth, and the anticipation of eating the raisin. Place the raisin on your tongue. Roll it over in your mouth to feel the texture on your tongue. Finally, chew the raisin slowly, noticing the actual taste of this one raisin. When you are ready to swallow, notice the impulse to swallow as it comes up. Tune into your thoughts as you swallow. Are you anticipating another raisin? Does your mind or body begin to anticipate more? What did you experience as you did this exercise? (Adapted from Kabat-Zinn, 1990, pp. 27 – 28)

3. Video clips from YouTube and the Internal Family Systems model

The following websites describe and demonstrate the Internal Family Systems (IFS) model. The first clip demonstrates the use of the IFS model with a bereavement-related issue. The second link takes you to a website that provides video clips to provide more information and demonstrations of the model in various applications.

www.youtube.com/watch?v=ybRi78VzWTk www.youtube.com/watch?v=qo_DebUQgmA

  1. Can you identify the “parts” that arise during the sample session with a grieving client?
  2. What did you like/dislike about how this model works with clients?
  3. Can you think of some of your own managers, firefighters, and exiles? How do these interact within your own system?
5. Personality inventories and self-assessments

The following are URLs of websites with popular self-assessments that explore typology and preferences in people. Choose one of them and take the self-assessment. Once you have completed one and have the results, explore how that particular inventory describes individuals with your (or other) types. Does it make sense to you? Did you feel it was an accurate description? If you know of other individuals who would be willing to complete the same inventory, would you think that their results are accurate? How can these inventories be used in your work, both with yourself and with your clients?

Myers – Briggs Type Indicator: www.humanmetrics.com/cgi-win/ JTypes2.asp

Keirsey Temperament Sorter: www.keirsey.com/sorter/instruments2. aspx?partid=0

Enneagram: www.enneagraminstitute.com/dis_sample_36.asp?discover

 

 

 

 

CHAPTER 12 Ethical Issues in Grief Counseling Practice

Exploring ethical issues in grief counseling is more than taking a look at complex cases that involve intriguing or confounding issues for the practitioner. To be a safe clinician, and to form a professional relationship with a client that is real, but clearly defined in regard to expectations and boundaries, is the foundation of competency and integrity in this work. Ethics is not something that we “tack on” to our practice, but something that comes from the core of how we practice and the choices and decisions (both small and large) that we make in regard to our clients and our profession. Gamino and Ritter (2009) state:

Ethical practice of grief counseling means helping clients and their families while operating from an internalized code of conduct and adhering to the highest level of professional standards and mores. To do so, the grief counselor must start from a position of personal integrity and responsibility and then be aware of and follow ethics codes, statutory regulations, and case law that pertain to their realm of practice. (p. 1)

We form relationships with clients that are dynamic and that engage our personal feelings and reflections. Clients entrust us with their deepest feelings, thoughts, dreams, and fears, which then places them in a position of vulnerability with us. This concept of trust is essential for understanding the context of the therapeutic relationship. Inherent in that trust is the dynamic of a power differential, where the therapist has the power to betray or abuse the trust of a client, with serious implications for how that trust and power are handled. The training and perceived expertise of the counselor, and the willingness of the client to choose to open to the process with the hopes of improvement, imbue the counselor with a great deal of power and authority, no matter how much the counselor may ascribe to an empowerment-based or egalitarian person-centered approach. Therapeutic relationships are unique because they exist for the benefit of the client. Many bereaved individuals are at a vulnerable place in their lives, and our adherence to ethical standards of practice ensures that this vulnerability will be respected and protected within the therapeutic relationship that is established.

In this chapter, we explore some of the ethical issues that are pertinent to the counselor, the therapeutic relationship with clients, and the profession of grief counseling.

COUNSELOR ISSUES The Shadow Side of Counseling

Many authors have written about what we would refer to as the “human” side of helping professionals and how these human aspects of the counselor can affect the therapeutic relationship and the counselor’s everyday decision making and interactions with clients. Egan (2013) writes about the “shadow side” of the helping relationship, describing the most common flaws of counselors to be manifested in (a) lack of knowledge of ethical practice standards, (b) being unaware of personal biases toward specific types of individuals that will have an impact on interactions with certain clients, (c) lack of reflection upon the therapeutic process and recognition of when there is a problem in the therapeutic alliance, (d) lack of self-awareness in thoughts and feelings about specific clients, (e) lack of transparency and disclosure about the helping process with clients, which keeps the counselor in an elevated status as one who possesses “secret knowledge” and promotes client dependency rather than independence, and (f) rigid adherence to a specific approach in counseling without a willingness to assess whether this approach is actually appropriate or effective with a client. Page (1999) describes the “shadow” of the counselor as those darker aspects of the counselor’s personality, role, and experiences that emerge in the context of working with clients that may potentially affect the client in a way that can be harmful.

Gamino and Ritter (2009) refer to the presence of “blind spots,” where the counselor “can get in a hurry, skip an important step, make an erroneous assumption, overlook a conflict of interest, neglect to consider a consequence, or rationalize an action as good for the client when it is really the counselor’s own interests that are being served” (p. 3). These lapses in awareness can be the source of a great deal of harm to a client, and so we once again emphasize the importance of regular supervision and self-reflection for the counselor to protect the interests of the client. Pope and Vasquez (2011) cite many examples where breaches of the client’s trust may occur as a result of treating the therapeutic relationship too casually, or of not maintaining rigorous standards of ethical practice. These authors discuss common breaches in ethical practice because of lack of self-awareness, failure to recognize the influence and importance of the innate power differential in the therapeutic setting, lack of application of codes of ethics to client interactions, and failure of counselors to engage in ongoing professional development and training to maintain competency in practice.

The influence and impact of the personal issues and needs of the counselor are discussed in more detail in Chapter 13. However, it is important to keep in mind that most individuals who enter the profession of counseling typically enjoy being with people and they wish to help others. As a result, there is often a very strong inherent desire to be liked by others, to be seen as helpful by clients, and to be respected by colleagues in the field. The shadow side of these good intentions is that if they are not placed in their proper perspective, they have the potential to lead to unhealthy and potentially damaging patterns, such as avoidance of difficult topics with clients, use of their work with clients to try to impress others, allowing perfectionistic tendencies and unrealistic expectations to drive the process and take over the needs of their clients, and setting up situations that could contribute to the misuse of the client – counselor relationship to fulfill unmet personal and social needs.

Counselor Self-Awareness

In order to practice with competence, counselors must know themselves and be familiar with their own needs, feelings, thoughts, behaviors, and sensitivities. If you do not have this awareness of yourself, you will have difficulties separating out your personal needs and feelings from your client, which could result in harm to your client. Counselors who are not self-aware will not have an understanding of how they may influence clients in ways that are unhealthy or even potentially manipulative (Page, 1999). Often, these counselors’ nonverbal responses to clients convey bias, judgment, or discomfort. They may avoid particular topics or they may attempt to control the session in ways that prevent the client from exploring necessary topics or material, resulting in the client essentially being manipulated by the unconscious needs of the counselor. See Exhibit 12.1 for an overview of how counselor self-awareness or lack of awareness can affect the client.

ISSUES RELATED TO THE THERAPEUTIC RELATIONSHIP Boundaries

 

 

EXHIBIT 12.1. SELF-AWARENESS
Counselors With Self-Awareness Counselors Without Self-Awareness

 

 

 

 

 

 

 

Identify and label their personal feelings

Know where their feelings end and those of their clients begin

Recognize and accept areas of vulnerability and unresolved issues

Understand personal values and their influence on the counseling relationship

Recognize and manage internal dialogue

Understand and control personal defense mechanisms

Know when and how clients are reacting to their style

Realize how they influence outcomes

Modify behavior based on reactions of clients

Set professional goals based on knowledge of personal skill strengths and limitations

Avoid or are unaware of their feelings

Project personal feelings onto clients

Respond inappropriately because unresolved problems interfere with their capacity to be objective

React emotionally to their clients, but do not understand why or how

Unconsciously use clients to work out their own personal difficulties

Remain blind to defensive reactions

Behave nonassertively (using excessive

caution, placating behavior, etc.) because they are unaware of the limiting effects of self-defeating thought

Remain unaware of how their behavior influences others

Behave based on personal needs and style rather than in response to the needs and reactions of clients

Avoid or limit goal setting because they are unaware of personal and professional needs

Source: Shebib (2003). Used with permission.

 

 

The relationship between the counselor and client is unique, although there are similarities to other types of relationships. Because of the unique boundaries and purpose of the counseling relationship, the process of counseling should be discussed with clients as you begin your initial sessions together. It is important for you to be transparent with your clients in regard to the therapeutic relationship. Clients need to understand how the process works, what the expectations are of them, what they can expect from you, and how the relationship parameters are defined. We cannot always assume that a client knows what the counseling process entails; therefore, it is important that it be explained and discussed as you begin your work together. The therapeutic relationship is very complex, and sometimes it is the relationship itself that forms some of the material of the counseling process (Yalom, 2009). Keep in mind that no matter what theory of therapy to which you ascribe or how many tools or interventions you use with clients, the therapeutic relationship itself is of paramount importance. Think of the things a client needs to know at the beginning and how you would explain the process to a client. Here are some possible examples of what might be helpful:

“I believe deeply that you are the one who knows what is best for you.”

“My role is to help you understand what you want more clearly.” “This is what you can expect from me…” (time, attention, availability).

“What I would hope is that you…” (can try to be as open as possible, attend to yourself and your needs, let me know if something does not feel right as we work together, be honest with me about how you think things are going in our sessions).

Clients need to be able to understand that this is a real relationship and that the feelings, thoughts, and reflections that you share with them are genuine and real as well. However, clients often feel some confusion about this aspect of counseling. Are you like a friend whom they are paying for services? Are you like a teacher who is imparting knowledge? Are you like a parent who gives advice and will comment on their behavior? The therapeutic relationship differs from other relationships in regard to:

  • Boundaries – the relationship occurs within the context of the session times and professional settings
  • Purpose – the therapeutic relationship exists for the benefit of the client rather than for the needs of both individuals within it
  • Compensation – there is usually payment of some type given to the counselor for this time
  • Goals – the client’s needs and vulnerability guide the process, not the counselor’s agenda
  • Structure – there is a set time and place for the relationship to occur

Following are some comparisons between the counseling relationship and other types of relationships that the client may consider to be similar.

Similarities and differences to a friendship or an intimate relationship:

  • Clients may feel the counseling relationship is an intimate one because they share deeply of themselves with the counselor and often feel a sense of closeness with the counselor that they may not have experienced in their other relationships.
  • The counseling relationship is one-way, oriented toward the client’s needs, and not two-sided, as would be expected in an intimate relationship.
  • Advice is given in friendships and intimate relationships, but not in the counseling relationship.
  • The counselor’s personal feelings and needs would be out in the open in a friendship or intimate relationship, but shared in very limited amounts with a client for the purpose of therapeutic self-disclosure for the client’s interests and not the needs of the counselor.
  • The therapeutic relationship involves expectations of confidentiality that are not explicit in a friendship or intimate relationship.
  • The professional relationship has an ending – the goal of counseling is to end the relationship, which is different from the goal of a friendship or intimate relationship.

Similarities and differences with a parent – child relationship:

  • Similar in that the client is sometimes seeking guidance in the counseling setting.
  • Differential in terms of power and the goal of allowing the client to no longer need you are similar to a parent; however, in the counseling relationship, the counselor tries to equalize the power and give control over to the client.
  • The unconditional positive regard of a counselor is similar to a parent’s love for a child.
  • Differs in that there is no ongoing relationship after the client – counselor relationship ends.
  • The feeling of safety is common in both relationships.
  • The counselor often provides mirroring to a client in a similar way that a parent might; in so doing, the client is better able to see who he or she really is, especially in clients with very poor self-image and who have never had a chance to know themselves well.
  • The client takes the lead in the counseling relationship; whereas in a parent – child relationship, the parent directs the child.
  • We do not tell clients what to do and do not impose rules on clients as a parent might with a child.
  • The goal of counseling is to teach the client to parent himself or herself if there have been deficits or inadequate parenting in the client’s past.
  • Although the counselor’s values are often explicitly stated in regard to the process, the counselor’s personal values are not imparted to the client in the way they are by parents, because the goal is for the client to become aware of his or her own values and to be able to respond

in ways that are congruent with these values rather than those of the counselor.

Similarities and differences with teacher – student relationship:

  • Often imparting knowledge is an aspect to both relationships.
  • Modeling is a form of teaching, which can also occur in counseling.
  • The client is not being judged or graded by the counselor as a student might by a teacher; you cannot do it “wrong.”
  • In the counseling relationship, the client is seen as the expert in his or her life, not the counselor, whereas the teacher is seen as being the expert in a particular area that is being taught.
  • In counseling, the topic is the client’s life and feelings, not an extraneous subject.
  • Both relationships are structured and have boundaries that are different from friendships.
  • Boundaries around the teacher – student relationship are probably not as rigid as those in a counselor – client relationship.
  • The teacher – student relationship can lead to collegial relationships later on; however, the counselor – client relationship is a distinct relationship that will not evolve into another type of relationship.

We think it is very important to think about how the counseling relationship can be confusing to some clients and to be prepared when clients misunderstand the boundaries and the unique structure of the counseling sessions. A client may not understand why you do not accept an offer to attend a social function to which they invite you, or they may mistakenly believe that the intimacy of the counseling relationship indicates that your relationship is also one of friendship or another type of relationship. Because the counseling relationship involves a power differential, no matter whether the counselor attempts to equalize the power, there is the potential for abuse of that power, with the potential for harm to the client. The role of a counselor is one that involves a sacred trust, with clients willingly sharing their deepest selves and most personal vulnerability. This vulnerability and openness must be protected and safeguarded by the counselor.

Confidentiality

Probably one of the most important aspects of the counseling relationship is the trust that is established with the client through the knowledge that what is shared with the counselor will not be repeated to another person outside of the session. Because most clients are much more accustomed to having people share information with them and about them in everyday encounters, it is important to make the understanding and limitations of confidentiality explicit from the very beginning of the sessions. Essentially, confidentiality means that what is discussed within the confines of the session stays there – with the counselor. Unless you explain the nature of confidentiality, clients will often assume that you will share their information with your partner, your associates, or with others, and that assumption may limit their ability to share freely with you and to trust you with their deepest feelings and thoughts. Thus, it is important that you spell out specifically what confidentiality means, and what the limits of that confidentiality may be. For example, in a first session, we often begin by asking clients whether they have any questions about us or how we work in our practices. After these questions have been answered, we describe that the counseling relationship is one that involves confidentiality, which means what you say here will stay here and will not be shared with anyone outside of this room, with the following exceptions:

  • You ask me to share information with another professional, and you specify in writing what information is to be shared, to whom, and in what context.
  • I, or my records, are subpoenaed by a court of law for court proceedings.
  • If I have concerns for your safety or the immediate safety of another person that might involve life-threatening harm, I will have to share information about you for your protection or the protection of another person.
  • If in the process of your sharing, I am given information that causes concern that a child under the age of 16 is in a situation where there is abuse or neglect, I am required to report these concerns to the local child welfare authorities.

All jurisdictions in North America have legislation that requires counselors to report suspicions of child abuse and neglect to the appropriate authorities. We will also sometimes discuss how clients may wish to handle a scenario if they see us in a public place, offering that we would let the client decide whether he or she wishes to acknowledge us and/or introduce us to others in their presence. Another aspect of confidentiality is the disclosure of supervision and how that is sought by the counselor. You do not need to identify the individual who functions as your clinical supervisor, but you may tell the client that you regularly seek supervision to discuss issues that occur in your practice where you feel it is best to obtain support, additional resources, and clinical recommendations. You should clarify that you do not share the client’s name or identifying information with your supervisor, and that the supervisor is bound by the same constraints of confidentiality as you. Another important caveat to this discussion is the recognition that clients are not bound to the same adherence to confidentiality as the counselor. Thus, if you choose to self-disclose to a client because you believe this disclosure may be beneficial to the client in some way, be aware that the client is not bound to confidentiality with you.

One additional aspect of confidentiality is the disclosure of how you keep your records, and who has access to these records/files. In most situations, you would be the only person who would have access to files, and they should be kept in a locked drawer. However, if you work in a team in which other individuals have access to any information that you have written, or if you discuss client cases with other team members, then the client has a right to know that. Another place where confidentiality may become an issue is with phone and e-mail contact. Clients should be asked whether they are comfortable with the counselor leaving a voice message for them if there is a need for contact or if they are returning a call made by a client, because not all clients disclose that they are seeing a counselor to other members of the household. In addition, if clients use e-mail to contact the counselor, then the counselor must use a secure e-mail address that is private and for which the counselor is the only one with the password to the e-mail account. Once again, clients should be asked whether their e-mail address is private, and if they are comfortable with the counselor sending a reply back to that e-mail account. In addition, some professional regulatory bodies require counselors to print off any electronic communication to include into the client’s file. If that is the case with your registration requirements, then clients need to be informed that their e-mails will become part of your documentation in their file. Finally, the setting where the counseling sessions occur must provide privacy, and be soundproof so that others who are outside the room where you are meeting with the client cannot hear what is being said. Calls to clients should not be returned in an area where others may overhear the conversations, and if there is any possibility that a client who is leaving your office may be familiar to another client in your waiting area, either provide an alternate exit for the client or adjust the scheduling of appointments so that these two clients will not be placed in an awkward position of undesired disclosure. If the phone used for your client work has call display that stores caller information, this information must be cleared before leaving your office each day. See Exhibit 12.2 for a summary of confidentiality guidelines.

Many clients will describe complicating issues in their lives and in their relationships, such as secrets that they have long held close, situations that cause them embarrassment, or things they have said or done that cause them to feel a great deal of pain or discomfort. It is vitally important that clients understand that you will not disclose these stories or situations to anyone else so that they will feel a sense of safety and trust in sharing such vulnerable material with you.

 

EXHIBIT 12.2. CONFIDENTIALITY GUIDELINES

Explain what is meant by confidentiality in the counseling setting, including the limits of confidentiality. Ask clients about specific instances where confidentiality may be an issue for them (i.e., seeing the client at a public event, leaving phone messages, and replying to e-mail messages).

  • Be aware of relevant legal statutes that may limit confidentiality (such as child abuse reporting and necessity of disclosure in the event of potential imminent harm to the client or another individual).
  • Be familiar with codes of ethics in your professional association and adhere to these guidelines.
  • Protect client records with secure filing systems and/or password protection on electronic files. Do not access phone messages or electronic messages in a place where they may be overheard or seen by others.
  • Seek regular supervision with a trusted colleague or mentor in a private and formalized setting. Do not discuss client situations or information with anyone in a social gathering or in a public place.
  • Ensure that the setting where you meet with clients is private and free from interruptions.
  • Disclose to clients if you are working as a team with other professionals, and in that context, specify who will have access to information about them and what they share with you.

 

Dual Relationships

A dual relationship is one that involves both a counseling relationship and another type of relationship (e.g., friendship, business relationship, supervisory capacity). Dual relationships have the potential to place the client at risk by imposing another set of values that may not be congruent with the therapeutic relationship and where the needs of the client may not be foremost, which is one of the primary definitions of a therapeutic relationship. The client may be placed in a position of compromise with self-disclosure, negating the core conditions of safety and nonjudgment in the counseling relationship. In dual relationships, the counselor has a personal interest that may not be consistent with the client’s interests. This alternate focus may lead to intended or unintended exploitation, harm, manipulation, or coercion of clients (Herlihy & Corey, 2015; Shebib, 2013). Many scholars and clinicians believe that some dual relationships are unavoidable, because of location (such as in a small community where interactions with others may be limited geographically), specialty, or happenstance. Instead of advising avoidance of dual relationships, Herlihy and Corey (2015) suggest that counselors learn how to manage their occurrence, especially when they are unavoidable. The terms multiple roles and nonprofessional interactions may also be used to describe these types of relationships and encounters. Although there are few specific guidelines in various codes of ethics in professional organizations and memberships, all agree that any form of sexual contact between a client and counselor is strictly prohibited and morally unethical, even after the client is no longer seeing the counselor for assistance.

The most common form of dual relationship that we encounter is that a former client may choose to take a course in which we are instructors. Because the counseling relationship has revolved around a stance of nonjudgment and nonevaluation of the client’s material, the immediate issue of duality is that the counselor is now placed in a position of having to evaluate a former client’s learning, and that the instructor knows very personal information about one student in the class that may place the client or the other members of the class at a disadvantage. In situations such as this, in which no other faculty member is teaching the same course, we often meet with the student and suggest that another faculty member read and mark the assignments for that student, and we discuss concerns about the dual relationship to see what types of accommodation should be made for the former client who is now a student.

Another relational conflict may arise if a counselor is asked to see another member of the same family, where disclosure by one member may compromise the therapeutic relationship that is established with the other family member(s). Some counselors may adamantly refuse to see members of the same family individually, whereas others may agree to do so, as long as there is an understanding among the family members regarding the sharing of common information. This can be a very tricky scenario to navigate, because even if the issue seems to be clearly identified by all of the family members (such as the death of a family member), there are often secrets in families that are kept by members, and the counselor could be in a very difficult position of holding multiple confidences that are relevant to each of the clients that are being seen, without these individuals being aware of the counselor’s knowledge. This “insider knowledge” could compromise the counselor’s relationship with all the individuals involved. For further reading about the complexities of dual relationships within therapeutic encounters, we refer the following books to the readers: Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey, 2015) and Speaking the Unspeakable: The Ethics of Dual Relationships in Counselling and Psychotherapy (Gabriel, 2005).

COMPETENCE IN GRIEF COUNSELING

We have stressed the importance of the counselor’s self-awareness in working effectively and competently with clients. We now expand further on the personal self-awareness of the counselor to include awareness of the ethical issues that may have an impact on the profession of grief counseling. These issues include staying current with the research and literature in the field, knowing the limits of your scope of practice and training, and honoring the tangible limits that are present because of personal needs, family requirements, and physical demands. The following list was extracted from the codes of ethics for the Canadian Association of Social Workers (CASW) and the Canadian Counselling and Psychotherapy Association (CCPA), and it provides general guidelines for working with competence (CASW, 2015; CCPA, 2007; Shebib, 2014):

  1. Counselors should offer services that are within the limits of their professional competence, according to their level of education, training, and professional standards. Competent counselors know that the support and assistance of other professionals are necessary for issues that exceed their expertise and training.
  2. Counselors should monitor their work and seek supervision, training, or consultation in order to evaluate their effectiveness. Continued professional development should be pursued in order to increase competence and to remain current with best practices, research, and literature in the field.
  3. Counselors should not work in specialized areas of practice without proper training and acquisition of the specialized body of knowledge for that area.
  4. Counselors should seek to base their work and practice on accepted theory and empirical knowledge (see discussion following).
  5. When access to other professionals is limited or unavailable, such as in rural settings or in centers where there are long waiting lists, the substitution of other services that are not equal in comparison to access to a professional in a formal setting is not a viable or sound practice.
  6. Counselors need to know when particular topics or problems are sensitive or delicate for clients. They need to be aware of when their clients’ problems are similar to sensitive or difficult areas in their own lives. This knowledge is of paramount importance for counselors to know when to seek consultation or supervision, when to refer clients to another counselor, and when to enter counseling to address their own needs. Clients have a right to expect that their counselor’s judgment and abilities to work with them will not be impaired by unresolved personal problems or issues.

Issues that may interfere with counselors adhering to these guidelines could include lack of time or lack of available programs to engage in professional development that would enable the counselor to remain current in best practices, heavy caseloads that do not provide an opportunity to reflect upon counselor – client interactions and to have regular access to supervision and consultation, and inadequate training or preparation to work with a specific client or clientele.

In many of the previous chapters, we discussed newer ways of thinking about grief and bereavement, based on current literature and research. In her review of counselor practices, Breen (2010 – 2011) found that the majority of the grief counselors that she interviewed based their practices on theories and research that were outdated and no longer considered relevant to the profession. Indeed, in the past 5 years alone, the amount of research and discussion on the topical areas of complicated grief, the efficacy of grief counseling, and the diversity of grief responses has dramatically changed what would have been considered sound and competent practice in the specialized area of grief counseling in the past. Although we think it is probably not feasible to always be able to provide evidence-based practice in a field in which many of the constructs involved are not concrete and readily measured, it is unethical to continue to practice with clients in a way that may have been cautioned as potentially harmful in research that has been reported with this clientele. The only way to know how to identify when clients need additional resources and whether your work with clients is truly from a place of best practices is to remain current in the field, within both domains of counseling practice and bereavement research and theory.

CONCLUSION

Ethical practice as a grief counselor involves an ongoing commitment to self-awareness, self-care, and professional development in the areas of counseling and bereavement. It is important to protect the trust that our clients place in us and to ensure sound and competent practice by our adherence to published ethical standards and guidelines in our professional association(s). Staying current with the research and literature in the field also helps to ensure that we engage in best practices when we meet with the clients who seek our support, because competency in ethical practice includes knowing what your scope of practice will include, being aware of effective interventions, and the ability to recognize when a client requires the skill of someone with different training or more experience with a particular issue. In essence, ethical practice includes both diligence and humility in the profession, in addition to the ability to be transparent with oneself as both a person and a practitioner.

Glossary

Boundaries – Limits or guidelines that define the counseling relationship and denote the limits of acceptability in the therapeutic relationship. They outline the expectations in the therapeutic space and mark the point beyond which neither party is expected to go.

Competence in counseling – Includes accurate representation regarding the limits of scope of practice, involvement in ongoing and continuing education in the field, maintenance of accurate knowledge and expertise in practice, and the ability to address personal issues that could potentially hinder effectiveness.

Confidentiality – The ethical principle or legal right that a physician or other health professional will hold secret all information relating to a patient, unless the client gives consent permitting disclosure; confidentiality can be broken in a number of circumstances, including: consent/request from the client, if the information is already in the public domain, when referring to another professional (with the client’s consent), when the interest to protect another outweighs confidentiality, prevention of terrorism, instruction by a court, or during supervision.

Dual relationship – One that involves both a counseling relationship and another type of relationship (e.g., friendship, business relationship, supervisory capacity). Sometimes also referred to as multiple relationships/encounters and nonprofessional interactions.

Questions for Reflection

  1. Joanne, a client who comes to talk with you after the loss of her husband from a traumatic accident, discloses in her first session with you that not just her husband died from a very tragic incident, but his best friend, Steve, also died in this incident. When she tells you his best friend’s name, you recognize that Steve was a client of yours in the previous year, and you did not know he had died. Joanne then proceeds to tell you that she knew that you had seen Steve for counseling, and that he spoke of you often to her husband. She then begins to ask you questions about Steve and details regarding his life and his relationship to her husband. How would you respond to this scenario?
  2. You have been seeing Carol for about 6 months to help her as she grieves the loss of her son 2 years ago. Carol has good supports in place, and she is feeling better, although she still feels deep grief frequently. She tells you that she thinks she is ready to finish her sessions with you. You review your time together and Carol shares that your assistance has been invaluable to her being able to get through this time, but she also says that she will miss the ability to keep in touch with you, and she asks whether you could meet her for coffee sometime to catch up. How would you respond?
  3. Think of the following personal needs that many people who are counselors have. As a counselor, look at each of these needs and think of how each could be potentially harmful to your clients:
  4. Need to be liked and to be helpful
  5. Need for status, prestige, or recognition from others
  6. Need for control
  7. Perfectionism
  8. Need for relationships/need for connection with others
  9. Use the ethical guidelines that were posted in this chapter to discuss the following situations:
    1. A client who has been seeing you after the death of his wife asks you to talk to his adult daughter when he begins dating someone.
    2. You have just had a very difficult session with a client who is very depressed and angry. He directs some of his anger at you, saying that you really do not care about him and that you just see him because you are being paid to do so. After the session, you go into the lunchroom of the counseling center where you work. One of your colleagues is eating her lunch and when she sees you, says, “Wow, you look awful. What just happened in there?” How should you respond?
    3. Your client asks whether you are in a relationship.
    4. You are invited by a friend to a dinner party. When you arrive, you are introduced to the other guests, including a man who is your client. How would you handle this situation?
    5. As your last client of the day leaves your office, it begins to pour rain and thunder. You know that she does not have a car and that she will be walking for blocks in the pouring rain to get to the bus stop. She asks whether you could give her a ride to the bus stop. How would you respond?
    6. Your client shares a very moving story about her relationship with her deceased son. She is crying as she tells you this story, and you realize that you have tears spilling onto your cheeks as you listen.
  10. The following questions are to help you to explore your values, beliefs, and sensitivities. You may want to work with a small group to discuss your answers to these questions.
    1. Do you think people are basically good or bad?
    2. What do you think motivates most people?
    3. Should people have the right to take their own lives?
    4. What kinds of clients would you like to work with the most (include information about age, gender, personality type, culture, religion, ethnic background)?
    5. What kinds of people do you find most problematic for you personally?
    6. When you die, how would you most like to be remembered?
    7. Are some religions better than others?
    8. When should a counselor discuss religion with a client?
    9. Do you often feel responsible for the feelings, thoughts, or behavior of others?
    10. Imagine that you are a client. What would your counselor need to know about you in order to work effectively with you?
  11. Write a two-page summary that answers the question, “Who am I?”

 

 

III: CURRENT ISSUES AND TRENDS

CHAPTER 13 Caregiver Issues for Grief Counselors

Every form of helping and caring is accompanied by its own unique emotional burden. For counselors, not only is caring a motivation or desire, but it is also a requirement in order to work effectively with clients. In essence, a counselor’s livelihood is dependent upon his or her ability to profoundly engage with this capacity for caring and empathy without losing these abilities along the way. Grief counselors are especially prone to the accumulation of occupational stress and subsequent loss of their caring capacity as they continually witness people’s deep pain and despair; frequently hear clients’ stories that highlight the unfairness of life events; are often exposed to the traumatic images and material that clients share; and are engaged in the processing of intense images and emotions of their clients. An additional drawback to the counseling profession is isolation. Even though they may be seeing clients all day, there is often a sense of seclusion that counselors describe in their work, as contact with other clinicians and colleagues is often limited by differing work schedules and the fact that most of the work occurs behind a closed door in private with their clients.

To many counselors, the “work” of counseling is a natural extension of who they are. In addition to typically being highly empathic and caring, most grief counselors highly identify with the choice to work in such an intense field. People who are drawn to grief counseling are usually not foreigners to the experience of loss and personal pain, and their desire to do this type of work is often a result of experiencing their own personal losses. Thus, it may be impossible to separate the person who is the grief counselor from the profession of counseling. This unique blending of who you are with what you do can be incredibly rewarding. However, it can also have unique drawbacks, as being so highly identified with your work can lead to difficulties with boundaries, a strong need to be valued in your work in order to feel validated as a person, and difficulties with balance in other areas of life if those other parts of your life are not consciously cultivated. Implicit in this statement is that some counselors will attach great value to their caring role, and when this role is impaired by stress or when there is frustration with one’s work environment, significant damage can occur to the counselor’s self-esteem and sense of meaning in the world.

SOURCES OF OCCUPATIONAL STRESS

In a study by Osipow, Doty, and Spokane (1985), three different dimensions were identified in the occupational stress of those engaged in helping professions:

  1. Internal stressors, including the internalized attitudes toward work and how problems are perceived and interpreted by the individual
  2. External stressors, which include the individual’s perception and experience of stress in the work environment itself
  3. Coping resources available to counter the effects of the occupational stresses, and the individual’s ability to draw upon these inner resources at various times

Internal Stressors

Stresses that come from internalized sources may be the most difficult to identify, because they are often not readily apparent, are often not seen as problematic by the person, and the counselor may not necessarily be aware of their presence and influence upon his or her choices and experiences. Some of the more common internal stressors for counselors include having unrealistic expectations of themselves, or a need for this type of work to provide completion of unfinished business from the past. In grief counseling especially, a history of significant losses, personal death experiences, a high degree of emotional investment in clients without an opportunity to have time to pull back and be replenished, and feelings of powerlessness and lack of control in regard to life events can take a big toll over time. Caregivers also may struggle with self-induced stress, which can include tendencies toward perfectionism, fear of failure, and the need for approval. Counselors’ needs for success and approval in the client setting may interfere with their being totally present and attentive to the needs of their clients. These needs are often manifest in the counselor having difficulties with boundaries. Signs that the counselor’s needs are driving the process rather than the client’s may include some of the following examples:

  • Excessive self-disclosure on the part of the professional caregiver, including detailed discussions of the counselor’s personal problems or aspects of intimate life
  • Beliefs in the indispensability of the counselor to the client that are perpetuated by the counselor
  • Encouraging personal communication and dependence by the client upon the counselor, including the counselor giving out personal information
  • Repeated or lengthy calls to clients outside of the session times
  • Giving preferential treatment to a client to the detriment of others
  • Buying gifts or accepting gifts from clients that are more than token or symbolic gestures
  • Lending money or personal belongings to clients
  • Flirtatious behavior with a client or a member of the client’s family
  • Failure to seek supervision when a boundary has been crossed or is being “skirted” by the counselor (Egan, 2013; Herlihy & Corey, 2015; Wogrin, 2013)

It is these often unspoken but very real issues that can cause the counselor to alienate himself or herself from others and consequently not receive the needed peer support or supervision to ensure that the counselor does not take advantage of a client’s vulnerability or allow his or her needs to usurp those of the client.

Herman (1997) refers to the problem of unrealistic expectations in counselors as narcissistic snares. The most common snares include the aspiration and expectation of the counselor to heal all, to know all, and to love all. In addition, she discusses the concept of traumatic countertransference, in which the counselor can become overwhelmed by bearing witness to the client’s intense emotional experiences. She states that any person who thinks he or she can work with people who have undergone traumatic experiences without having a good support system and time for personal care is setting up a very unrealistic scenario for doing this type of work over the long term.

Counselor self-awareness is a key component of the work of grief counseling. In fact, we think self-awareness and self-care are professional competencies that good counselors must cultivate and practice on a regular basis. Think about why you wanted to do this type of work. What draws you to this field? We mentioned earlier that the field of grief counseling often tends to attract people who have experienced significant life losses and/or death experiences. Working through such experiences can enable you to enter into practice as the wounded healer, which can be a very powerful and effective place from which to work with the bereaved (Nouwen, 1996). However, it is important for counseling professionals to have examined the impact of these wounds and to experience a sense of healing from them before attempting to participate in another individual’s healing process. We have all known individuals who mean well and who truly wish to help others in this field, but who would be more aptly described as the walking wounded, because their wounds are still readily apparent and need focused attention and tending. Others, who take on the identity of being damaged goods as a result of their wounds, may continue to need others’ validation to feel better about themselves because of the overlay of shame onto their experience(s). If these latter scenarios are actively engaged for a counselor, there is the potential to bring harm upon clients, because it would be impossible to completely focus on the client’s issues and experiences when wounds such as these in the counselor are still glaring and prominent (Figure 13.1).

 

Figure 13.1. Differentiating how personal loss experiences may affect counselors.

 

Worden (2009) states that working with bereaved individuals may affect counselors by (a) making them more aware of their losses, (b) causing them to be more “tuned in” to losses that they might fear (such as losing a child), and (c) heighten their awareness of personal mortality and existential anxiety. When working so closely with clients who are dealing with significant loss experiences, it is important for counselors to be very aware of their own loss history, their attitudes about death and grief, and to be able to identify any topics that may present an especially difficult challenge due to personal experiences or vulnerabilities. This personal inventory for the counselor should also include whether or not the counselor can be fully present to the feelings of powerlessness, helplessness, and frustration that can arise in working with bereaved individuals. As we highlighted in an earlier chapter: You cannot take away the pain, you cannot bring back the loved one who died, and you cannot change what has happened. Counselors can be triggered into their personal pain when they witness the pain in their bereaved clients, and this discomfort can cause them to shut down emotionally, or worse, attempt to shut the client down to stop this discomfort (Worden, 2009). Both Worden (2009) and Wogrin (2013) suggest that counselors complete a personal loss history (Exhibit 13.1), and that they share this history with a friend or colleague to ensure that there are no “lurking shadows” that may impede their ability to work effectively with bereaved clients.

 

External Stresses

 

EXHIBIT 13.1. ELEMENTS OF A PERSONAL LOSS HISTORY

Ask yourself the following questions. Then take the time to review your responses with a trusted friend or colleague. Think about the ways that these losses and your responses to them might affect your interactions with bereaved clients, or clients who are struggling with loss issues.

  • Complete a loss line of all the losses that you have had in your life (death and nondeath related).
  • What are the most significant losses that you have experienced? How are these losses more significant to you?
  • How did you react to these losses? Do you tend to have similar reactions to loss experiences?
  • How did the people around you react to these losses and to you during these times?
  • What have you learned about death, grief, and life from your experiences?
  • What are your religious or spiritual beliefs about death? About life events?
  • What are your cultural beliefs and assumptions about the expressions of grief, especially in regard to feelings and social obligations?
  • Based upon your own experiences, what do you believe people typically need from others as they attempt to cope with grief and loss?

 

Sources of stress that are external to the counselor can have a very big impact upon the counselor’s effectiveness and ability to be fully present with clients. Some of the more common external stressors include the high demands placed upon individuals to see clients expeditiously even when their schedule is full, unrealistic expectations of the workload for counselors (especially when these counselors are in institutional and agency settings), limited or inadequate resources of clients to be able to afford counseling, and limited professional support and awareness of the intensity of the work by other professionals (Wogrin, 2013). On a more practical level, counselors in private practice often face the realities of the ebb and flow of people’s lives, schedules, and financial reserves, which can lead to a wide fluctuation in income from month to month, causing difficulties in budgeting time and resources consistently. Choosing to practice in an agency or institutional environment may offer greater financial stability, but with a tradeoff of one’s ability to have control over his or her time, schedule, and workload.

In her study of palliative care providers, Vachon (2004) found that contrary to what had been expected, working with terminally ill patients and families did not cause the majority of the stress that the staff reported. Instead, the main sources of stress for caregivers were unrealistic workloads, low consideration of the input of caregivers in decision making, and little time for staff to offer support to each other. Previously, Vachon (1987) noted that much of the stress experienced by caregivers who worked with this population was related to their work environments, and what they felt were unrealistic occupational expectations of supervisors and administration, rather than their work with individuals and family members who were terminally ill or bereaved.

Working environments that create a sense of depersonalization, demoralization, and moral distress can deeply challenge the assumptive world of those who practice in such an atmosphere. In essence, work situations in which there are unrealistic demands and expectations such as these can lead counselors to question the reasons why they entered this profession, whether the work they do really has any meaning or purpose, and whether or not they really do help others. It is almost impossible to be person centered in your counseling practice if you, the counselor, are being objectified in the environment where you practice.

Coping and Internal Resources

The concept of coping implies some attempt at adaptation, either by the ability to reappraise stressful or negative experiences in some way, or by reintroducing aspects of benevolence, meaning, and self-worth into situations that may otherwise challenge the existence of these values to an individual. Corr (2002) emphasizes that coping is seen as a process of attempting to deal with challenges to one’s assumptive world and situations that are perceived by the individual as stressful or even threatening, although coping strategies may or may not be successful. Perhaps the most important point to make about coping strategies in stressful work environments is the ability of the counselor to (a) identify the source of the stress, (b) explore if there is anything that can be done to either eliminate the stress or to change one’s relationship to the stress, and (c) to know when a situation has reached a “critical mass,” where ongoing attempts to grapple with a situation that is draining precious internal resources will eventually deplete the counselor of his or her ability to work competently and with a sense of integrity.

The ability to clarify how to respond to a stressful work environment requires the counselor to be comfortable recognizing when personal limits can be pushed and expanded, yet to also be realistic in regard to personal limits that should not be compromised. The difficulty here is that the longer you are exposed to ongoing stress and pressure in a situation, the more exhaustion you will experience, and this exhaustion can have a profound impact upon your ability to decide how you need to respond to the ongoing and significant stress in the work environment. Thus, a vicious cycle can be set up where you are chronically exposed to stress, and you become so depleted that you lose your ability to see yourself and the situation clearly, lessening your ability to know how to respond in a way that is congruent with your original intentions and values. Losing yourself in this way only adds more suffering to a stressful situation; thus, it is important to know yourself, to be able to discuss issues and concerns with colleagues who are not in the same environment, and that you maintain a healthy and realistic view of your expectations of yourself and your workplace.

SPECIFIC MANIFESTATIONS OF OCCUPATIONAL STRESS

Many counselors enter the field with very good but idealistic hopes about helping others and being successful in their chosen profession. Very few would probably even consider the possibility that they could experience negative repercussions from doing work that they have envisioned as highly rewarding. In fact, many individuals consider their profession of counseling as something akin to a “calling,” which implies that a high degree of investment and sacrifice are expected as part of being a good counselor (Yalom, 2009). This desire to help others and to be so highly identified with the profession is both laudable and concerning, because a high degree of commitment and a deep capacity for empathy usually allow the counselor to be effective with clients, but can set up the counselor for unique forms of personal harm that are insidious in nature. In this section, we explore how exposure to certain stressful situations in counseling can deeply affect the assumptive world of the counselor, with the potential to harm the counselor personally and professionally. We will specifically discuss burnout and secondary traumatization (sometimes referred to as compassion fatigue).

Burnout occurs as a result of cumulative and ongoing emotional drain, trauma, and disappointments associated with an imbalance between the counselor’s resources and the demands (both internal and external) placed upon him or her. Burnout is seen as an evolutionary, cumulative process that starts with this imbalance and progresses to chronic emotional strain and exhaustion, depersonalization, and a sense of reduced personal accomplishment and satisfaction. The counselor who experiences burnout typically begins to cope with the emotional overload by distancing himself or herself from those who need help in order to feel more protected emotionally. What eventually happens is that the counselor can end up being and doing the very opposite of his or her primary motivation for entering the profession in the first place, and a devastating form of indifference and loss of human warmth begins to preside where there used to be empathy and concern. In addition, there is often personal shame and fear of the judgment of others on how this change in attitude has occurred, which may prevent the counselor from being able to reach out and get the support and care that he or she needs from others. An unrelenting cycle can become established in which the needs and expectations that the counselor has for himself or herself are compounded by the needs and demands of clients and/or the work environment, within a vacuum of resources for the counselor’s renewal and energy, triggering the counselor to “try harder” to overcome the obstacles alone. This effort only results in further, deeper depletion of the limited resources that are present.

Burnout is a state of physical, emotional, and mental exhaustion. The symptoms are caused by the ongoing stress that caring professionals can experience in their careers, which is cumulative and often predictable (Maslach, 1982). Burnout tends to occur when professionals experience a low level of control over decisions regarding how they will provide care, whether it is because of autocratic/bureaucratic factors, lack of input into how their workload and responsibilities are assigned, or being given more responsibility or a higher work volume than a person feels is possible to handle (Maslach, 1982). Recognizing and addressing burnout may involve looking at both internal and external factors. Professionals who are passionately devoted to their work often have a strong desire to be successful, and feelings of repeated disappointment or inadequacy may foster high levels of stress and burnout. What is more common is an interaction between these factors, especially when high workload demands are in conflict with the time requirements and needs of people who are in emotional pain and crisis (Wogrin, 2013).

Secondary traumatization (also sometimes referred to as vicarious traumatization or compassion fatigue) refers to a state of tension and preoccupation with the individual or cumulative trauma of clients (Figley, 1995). Pearlman, Pomeroy, and Garcia (2009) define vicarious trauma as “the negative transformation that takes place in a therapist through empathic engagement with traumatized clients and a commitment or sense of responsibility to help” (p. 254). Ironically, it is those counselors who have the greatest capacity for feeling and expressing empathy that tend to be at highest risk for compassion fatigue. Professional work that is focused on the emotional suffering of clients means the counselor is often exposed to information that is deeply troubling, which may also lead the counselor to absorb the suffering as well (Figley, 1995; Pearlman et al., 2009). In addition, the “work” of counseling involves the opening of one’s self to another, which could increase the counselor’s level of vulnerability as he or she opens to the pain and suffering of his or her clients. Factors that can affect the counselor’s level of vulnerability to vicarious traumatization may include the amount of experience of the counselor, the counselor’s personal experience of trauma (all types), the presence of concurrent stressors, the counselor’s attachment style as well as the attachment style of the client, perceptions of the therapeutic alliance with specific clients, and the percentage of clients in the caseload that are perceived as “difficult” for a number of reasons (Hunter & Schofield, 2006).

The variety of symptoms associated with vicarious trauma include re-experiencing the patient’s/client’s story in a way that is intrusive, personally traumatizing, or overwhelming; a feeling of dread when faced with working with certain people; difficulty separating work from personal life; and guilt for being free of pain or suffering. Secondary traumatization implies a physical, emotional, and spiritual exhaustion with a decline in the ability to experience joy as the body becomes exhausted. Pearlman et al. (2009) refer to the disruption in spirituality as a hallmark of vicarious trauma, meaning a loss of connection to a sense of meaning, loss of hope, and loss of coherence with the bigger aspects of life. Those who experience secondary traumatization may have associated feelings of hopelessness, blame, anger, and physical fatigue, and they may also engage in substance abuse to deal with these difficulties. They may feel irritable and have difficulty sleeping. Lack of sleep, along with the other symptoms, may put not only their jobs in jeopardy but also their clients’ well-being. Counselors who experience secondary traumatization are at a higher risk for depression, anxiety disorders, avoidance, and leaving the profession (Showalter, 2010).

The type of stress encountered with secondary traumatization is different than what is experienced in burnout in that it is a result of vicariously experiencing the pain and trauma that your clients may share with you. Although secondary traumatization is detrimental to personal and professional functioning, it is preventable. If the counselor is highly self-aware and knows how to remain grounded even when in the presence of situations that are empathically challenging, he or she will know when a client has shared something that is personally challenging or that leads to feelings of helplessness, hopelessness, and/or powerlessness. At these times, if the counselor readily addresses what has been taken in from the client and has cultivated the ability to quickly become grounded in these moments, traumatic overlay is much less likely to occur.

SELF-CARE AS A PROFESSIONAL COMPETENCY

Since our most important asset as counselors is our ability to care and to share in human compassion, it is of vital importance that these aspects of ourselves be nurtured, guarded, and protected so they will be available when we want and need them in our lives, both professionally and personally. We write this chapter with the assumption that in order for self-care to have any benefit, it must be recognized as a professional competency for effective counseling practice. It is not an option or something you do only when you have time. In the helping professions, there is always the need to establish a functional balance between taking care of others and taking care of self. Others’ needs tend be apparent, insistent, and pressing, and can easily overshadow the needs of the self. Rigorous self-awareness and contemplative practices encourage the balance to remain level and may buffer clinicians from the onset of burnout, secondary traumatization, and/or debilitating numbing/ flooding (Halifax, 2013; Pomeroy & Garcia, 2009).

Self-care for counselors and the regular seeking of peer support are imperative when your everyday practice involves intensely working with individuals who are suffering, or whose situations evoke your own feelings of helplessness and powerlessness. Helping others to help themselves requires that the counselor accept his or her own needs as well as the needs of others. The greatest resource a counselor has is the ability to relate on a human level with his or her clients. In order to do this, the counselor must be comfortable with his or her own “human-ness,” which includes having needs and recognizing limitations. In fact, many counselors would say that the degree to which we take care of ourselves often reflects directly on our ability to foster the well-being of our clients. Preventing burnout requires that the counselor is self-aware of his or her own needs and is proactive in taking care of these needs in a healthy and constructive way. Unrealistic expectations, unmet needs, unfinished business, and the “need to be needed” must be addressed in an accepting and open way that allows the caregiver a chance to explore his or her own motivations and wounding in order to come to a place of healing and balance. Counselors need to cultivate a personal philosophy that will allow empathetic involvement with others while maintaining individuality and clear boundaries between the needs of self and the needs of others.

Professional peer support groups are an excellent resource for helping professionals to provide a place for the development of self-awareness, self-care, and interactions with others who are like-minded and share similar values. Being engaged in peer support with other clinicians counteracts the isolation and alienation that can occur from providing care to clients, and it also provides a place to receive much needed support and validation. Our society values the highly individualistic, self-sufficient “superman/ superwoman” image. However, this image is completely unrealistic and denies our human need to both give and receive from others. Counselors must recognize that being able to find support and receive it from others is in itself a strength that can be cultivated in the presence of a supportive network. Counselors also need to be able to find supportive persons in their lives that will allow them to ventilate feelings, share frustrations, find successful coping strategies, and observe positive role models in order to become empowered providers. The following are guidelines for counselors to assist them in engaging in reflective practice with necessary support and self-care strategies:

  • Recognize and honor your limitations; you are a human being whose capacity to care for others hinges upon your ability to care for yourself.
  • Have a place to go for support and debriefing that will respect the confidentiality of you and your clients.
  • Have regular supervision with someone who is experienced in this type of work.
  • Cultivate self-awareness of your issues, feelings, and values so that you will be able to separate them from those of your clients.
  • Engage in a regular contemplative practice that allows you to disengage from being mired down in feelings of powerlessness, helplessness, and reactionary feelings and that supports your ability to reflect and tap into your deepest intention toward yourself and your clients.
  • Take advantage of professional development opportunities, such as workshops, courses, reading journals, and new materials.
  • Align yourself with a professional code of ethics and standards of practice within a counseling-related field.
  • Monitor your own health and well-being. Develop your private world in a way that is nurturing to you.
  • Give yourself permission to not always work well with everyone.
  • Monitor your working hours and time spent focused on client-related topics.
  • Recognize your own philosophy of life and how that impacts your work as a counselor.
  • Be aware of the unique signals from your body that may indicate you need to attend to work-related stress, such as disturbed sleeping patterns, changes in eating patterns, bodily aches and pains, and frequent illnesses that may indicate your immune system is being challenged.

Halifax (2013) has proposed the A.B.I.D.E. model of compassionate response to suggest a way of working with others that is self-sustaining and energizing rather than depleting and potentially traumatizing. Defining compassion as “the capacity to be attentive to the experience of others, to wish the best for others, and to sense what will serve others” (Halifax, 2014, p. 121), compassion is viewed as a natural outcome that arises from the interaction of a number of interdependent processes that are somatic, affective, cognitive, and attentional in nature, and all of which are amenable to development through training. Halifax’s focus is upon cultivating aspects in the caregiver that would be protective in potentially traumatizing situations, while at the same time enabling helpers to deeply engage with the suffering of others. The foundational cornerstone of this model is for the caregiver/helper to regularly engage in some form of contemplative practice that allows for a sense of perspective, reminders of one’s deepest intentions to be present to the suffering of others, and the ability to see the “real world” experiences of injustice but not get caught up in unrealistic expectations or clinging to outcomes that cannot be obtained. Contemplative practices can vary widely, and individuals who wish to explore these practices may need to try various modalities to see which are a good “fit” and are realistic for regular engagement. Examples of contemplative practices may include meditation, journaling, yoga, tai chi, immersion in the arts, retreats, and specific rituals (see Figure 13.2 to explore some of these practices).

CONCLUSION

Counselors are professionals who are also human beings. The profession of counseling relies upon the ability of the individual counselor to nurture and cultivate a capacity to care and connect with clients empathically. Counselors who work primarily with individuals who have faced painful losses, traumatic events, and the death of loved ones will be exposed to levels of human suffering and pain that can profoundly affect them at a personal level. Professionalism in counseling does not mean that the counselor will not be touched by this suffering; rather, being a professional in this field means that you have developed effective ways to take care of yourself, ground yourself, find balance, and to find necessary supports that will enable you to stay fully present and respond compassionately to clients’ pain. Self-awareness and reflection are key components in the ability to identify when you need to attend to your personal feelings so that these responses do not interfere with your clients’ process. Protecting your capacity to care may also involve an honest appraisal of your professional working environment and its impact upon your ability to be fully present to yourself and your clients. Having proficiency with the body of knowledge and completing a rigorous training program in this field are both very important. However, these factors will only be of benefit to the client if the counselor is able to stay connected with his or her intentions in order to engage with the client in a meaningful way. The relationship that forms between the counselor and the client is often stated to be the most important aspect of this work. Thus, attending to the personal aspects of the counselor is of paramount importance to maintain competency in this profession.

 

Figure 13.2 Tree of contemplative practices.

 

Glossary

Burnout – Occurs as a result of cumulative and ongoing emotional drain, trauma, and disappointments associated with an imbalance between the counselor’s resources and the demands (both internal and external) placed upon him or her. Burnout is seen as an evolutionary, cumulative process.

Contemplative practices – Various practices that allow practitioners to reflect and connect with their intention and a sense of presence in a moment-to-moment way. Contemplative practices may assist counselors to remain grounded when bearing witness to painful or potentially traumatic material from clients, and can be protective in situations where a sense of powerlessness, helplessness, or injustice could otherwise overwhelm both the counselor and the client.

Coping – The process of attempting to deal with challenges to one’s assumptive world and situations that are perceived by the individual as stressful or even threatening, although coping strategies may or may not be successful.

“Narcissistic snares” – Unrealistic expectations by counselors to heal all, know all, and to love all.

Secondary traumatization (also sometimes referred to as vicarious traumatization or compassion fatigue) – A state of tension and preoccupation with the individual or cumulative trauma of clients.

Traumatic countertransference (also called vicarious trauma) – A state in which the counselor can become overwhelmed by bearing witness to the client’s intense emotional experiences

Questions for Reflection

  1. After reading through this material, allow yourself to think of the following questions. If you have a trusted peer or colleague, see if you can answer these questions and review your answers with each other.
    • How would you know if you are burned out or if you are too involved in your work?
    • What are appropriate boundaries with others in this work?
    • How much of yourself that is personal do you share in the professional setting?
    • Why are you doing this work? What are you getting from it or what is in it for you?
    • If you are an “innate helper,” have you explored what may be the reason for your being this way?
    • Does your work give you a sense of belongingness or a sense of meaning?
    • What “feeds” you in your life?
    • Are you able to attach comfortably at times and also detach comfortably when you need to do so?
  2. The Professional Quality of Life Scale (ProQOL; see Appendix 13.1), was developed to measure compassion fatigue, burnout, and compassion satisfaction (Stamm, 2005). Fill out the scale and then score it. What do you think about this scale and the items listed on it? Are there areas where you are aware that you may have some vulnerability as an individual who works with individuals facing death, loss, and grief on a regular basis?
  3. Awareness Exercise:

The only time that exists is the present moment, yet we tend to spend much time ruminating about the past, which only exists as memory, or the future, which is fantasy. This exercise is designed to begin the practice of paying attention to the moment. We may consider that there are three “zones” of awareness: external sensory (the five senses), internal sensory (feelings), and internal cognitive (thoughts). We tend to spend a lot of time in the cognitive space, with our minds “cluttered” by various thoughts, analyzing our experiences, and thinking about the past and the future instead of directly experiencing these things.

In pairs, face your partner and take 5 minutes to share what you are aware of by saying, “Now I am aware … ,” then switch. As your partner is sharing with you, simply nod and offer nonverbal encouragement.

Debrief: How was that to do? What were you aware of? Was there laughter? If so, what was it about? Did you find yourself censoring anything? If so, do you know why?

  1. Meditation Exercise:

Becoming aware of the present moment, close your eyes and drop your awareness into your body with your breath. Let any places of tension leave your body on the outbreath. Remember that the only place is here, the only time is now, and you are safe. The only expectation is that you breathe.

After a while, start to imagine or feel energy coming into the center of your chest on the in breath. As you experience this energy say to yourself, “I am loved.” Now with your outbreath, imagine it leaving your body from your perineum and going straight into the earth. As this energy flows from your body say the words to yourself, “I belong.” Maintain this gentle, deep relaxed breathing for 5 minutes.

Gradually return your attention to the room, what you notice from your senses, the thoughts scurrying across your mind. As you open your eyes and return to the room, write down your experience of this exercise. If you have a trusted peer or colleague, ask this person to also do this exercise and discuss your experience with each other.

 

 

PROFESSIONAL QUALITY OF LIFE SCALE (ProQOL)

 

COMPASSION SATISFACTION AND COMPASSION FATIGUE

(PROQOL) VERSION 5 (2009)

When you [help] people you have direct contact with their lives. As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a [helper]. Consider each of the following questions about you and your current work situation. Select the number that honestly reflects how frequently you experienced these things in the last 30 days.

1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often

 

  1. I am happy.
  2. I am preoccupied with more than one person I [help].
  3. I get satisfaction from being able to [help]
  4. I feel connected to others.
  5. I jump or am startled by unexpected sounds.
  6. I feel invigorated after working with those I [help].
  7. I find it difficult to separate my personal life from my life as a [helper].
  8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I [help].
  9. I think that I might have been affected by the traumatic stress of those I [help].
  10. I feel trapped by my job as a [helper].
  11. Because of my [helping], I have felt «on edge» about various things.
  12. I like my work as a [helper].
  13. I feel depressed because of the traumatic experiences of the people I [help].
  14. I feel as though I am experiencing the trauma of someone I have [helped].
  15. I have beliefs that sustain me.
  16. I am pleased with how I am able to keep up with [helping] techniques and protocols.
  17. I am the person I always wanted to be.
  18. My work makes me feel satisfied.
  19. I feel worn out because of my work as a [helper].
  20. I have happy thoughts and feelings about those I [help] and how I could help them.
  21. I feel overwhelmed because my case [work] load seems endless.
  22. I believe I can make a difference through my work.
  23. I avoid certain activities or situations because they remind me of frightening experiences of the people I [help].
  24. I am proud of what I can do to [help].
  25. As a result of my [helping], I have intrusive, frightening thoughts.
  26. I feel «bogged down» by the system.
  27. I have thoughts that I am a «success» as a [helper].
  28. I can’t recall important parts of my work with trauma victims.
  29. I am a very caring person.
  30. I am happy that I chose to do this work.

 

YOUR SCORES ON THE ProQOL: PROFESSIONAL QUALITY OF LIFE SCREENING

 

Based on your responses, place your personal scores below. If you have any concerns, you should discuss them with a physical or mental health care professional.

 

 

Compassion Satisfaction _____________

Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective caregiver in your job.

The average score is 50 (SD 10; alpha scale reliability .88). About 25% of people score higher than 57 and about 25% of people score below 43. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 40, you may either find problems with your job, or there may be some other reason – for example, you might derive your satisfaction from activities other than your job.

 

 

Burnout_____________

Most people have an intuitive idea of what burnout is. From the research perspective, burnout is one of the elements of Compassion Fatigue (CF). It is associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be associated with a very high workload or a non-supportive work environment. Higher scores on this scale mean that you are at higher risk for burnout.

The average score on the burnout scale is 50 (SD 10; alpha scale reliability .75). About 25% of people score above 57 and about 25% of people score below 43. If your score is below 43, this probably reflects positive feelings about your ability to be effective in your work. If you score above 57 you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.

 

 

Secondary Traumatic Stress_____________

The second component of Compassion Fatigue (CF) is secondary traumatic stress (STS). It is about your work related, secondary exposure to extremely or traumatically stressful events. Developing problems due to exposure to other’s trauma is somewhat rare but does happen to many people who care for those who have experienced extremely or traumatically stressful events. For example, you may repeatedly hear stories about the traumatic things that happen to other people, commonly called Vicarious Traumatization. If your work puts you directly in the path of danger, for example, field work in a war or area of civil violence, this is not secondary exposure; your exposure is primary. However, if you are exposed to others’ traumatic events as a result of your work, for example, as a therapist or an emergency worker, this is secondary exposure. The symptoms of STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event.

The average score on this scale is 50 (SD 10; alpha scale reliability .81). About 25% of people score below 43 and about 25% of people score above 57. If your score is above 57, you may want to take some time to think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a health care professional.

 

© B. Hudnall Stamm, 2009-2012. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). may be freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is not sold. www.proqol.org to verify that the copy they are using is the most current version of the test.

 

 

WHAT IS MY SCORE AND WHAT DOES IT MEAN?

 

In this section, you will score your test so you understand the Interpretation for you. To find your score on each section, total the questions listed on the left and then find your score In the table on the right of the section.

 

 

 

CHAPTER 14 Current Issues and Trends for Grief Counselors

As we have stated throughout this book, new discoveries and ideas about grief are continually emerging in a very dynamic way. Staying current and aware of this new information and the associated implications for grief counseling practice, along with the controversies that may accompany the same, is an important aspect of our work. We now further the discussion regarding current issues in the field to provide a springboard to reflect upon the dynamic nature of the practice of grief counseling.

ACKNOWLEDGE INNATE RESILIENCE; OFFER APPROPRIATE SUPPORT

There are several criticisms of the development of grief counseling as a unique area of specialization in clinical practice. At face value, it makes sense for clinicians who work primarily with bereaved individuals to have in-depth knowledge and understanding of the wealth of literature and research on bereavement that would be difficult for a generalist to achieve. It also would follow that a high degree of experience with bereaved individuals through a specialization in grief counseling would likely hone the skills of the counselor in working with the unique clinical features that may accompany grief in clients. However, the result of the development of grief counseling being identified as a unique specialization is the tendency to focus on the negative aspects of grief – those aspects that require intervention – or to see grief as something to be “treated,” rather than an adaptive process that usually does not require professional intervention (Coifman, Bonanno, Ray, & Gross, 2007; Neimeyer, 2014).

Most research focuses on problematic adaptation to loss and grief, and yet we know that this type of difficult grief occurs with the minority of bereaved individuals, thus skewing expectations of difficulties inadvertently onto individuals who are coping adequately with their loss. In addition, research measures that track the grief experience of participants are typically designed to identify problematic areas rather than good coping, growth, and resilience. Few, if any, grief measures will ask about laughter and moments of joy, but almost all of them will ask about sadness, crying, and loneliness (Bonanno, 2004).

Even when clients contact a grief counselor for assistance because they are having difficulties with their grief, there are innate strengths and resilience that can be identified, and upon which the client can learn to draw upon in the counseling process. Grief counseling needs to be focused on the client’s positive coping and inner resources, while recognizing that there are aspects to this experience that challenge the bereaved individual’s view of the world and that do cause distress as well. It is very important to keep in mind that the majority of individuals who experience a significant loss will eventually continue with their lives in ways that will be fulfilling and meaningful. Because the overall conclusions of the recent research on the efficacy of grief counseling have indicated that the majority of bereaved individuals possess a good degree of innate resilience and do not require the intervention of a professional for support, how do we know when grief counseling should be sought? As stated previously, approximately 10% to 15% of bereaved individuals will experience symptoms of prolonged, ongoing grief that can be debilitating and cause significant health problems and that is related to higher mortality. Thus, it is very important for professionals whose counseling practice includes working with bereaved individuals to become very familiar with the symptoms of complicated grief/prolonged grief (CG/PG) disorder so that individuals who have this form of debilitating grief will be able to access intervention that is appropriate for their distress.

Most of the literature does not support preventive or proactive grief counseling, that is, offering unsolicited support and counseling services to those who may be newly bereaved but are not requesting professional support (Gamino, Sewell, Hogan, & Mason, 2009; Schut, Stroebe, van den Bout, & Terheggen, 2001). Individuals who seek counseling on their own or who are referred by another clinician, such as a family doctor, tend to benefit from therapeutic support, much in the same way that individuals with other issues benefit from interpersonal therapy (Larson & Hoyt, 2009). Of further interest is Altmaier’s (2011) premise that empirical research cannot “capture” some of the variables in the therapeutic relationship that are dependent on client and counselor attributes. She states,

The background of best practices is important in selecting counseling approaches for a grieving client, keeping in mind that there is controversy over whether grief counseling is appropriate for everyone, only for the persons seeking treatment, or only for persons experiencing complicated grief. Moreover, though in general some counseling approaches may seem to be effective, research should not imply that the personhood of the counselor, the relationship of client and counselor, or the client’s own selfhealing processes are insignificant aspects of change. (p. 35)

In other words, she cautions about empirical studies that focus on client symptoms and effects of specific interventions without taking into account aspects that are relevant to the therapeutic relationship and the characteristics of both the client and the counselor in the process. At this time, the current thinking based on research findings is that (a) there is no evidence that preventive or proactive grief counseling in individuals who are adequately coping with their loss is beneficial, (b) grief counseling may be helpful to clients with normal, uncomplicated grief in the same way that other counseling therapies benefit people with generalized, everyday stresses and problems, and (c) there is support to indicate that specifically designed grief counseling/therapy support is for individuals who experience symptoms of complicated or prolonged, debilitating grief (Neimeyer, 2014; Neimeyer & Currier, 2009).

CURRENCY AND COMPETENCY

Unlike any other field in counseling, grief counseling tends to draw people who have experienced significant losses in their lives to become “helpers” to others who are facing loss and grief. Indeed, the helper-therapy principle is a well-known phenomenon, and this personal experience by grief counselors may be of benefit for the cultivation of empathic connection between the counselor and a client (Brown, Shepherd, Wituk, Meissen, & Brown, 2007). However, it can also be fraught with many drawbacks. For instance, what actually qualifies someone to be a grief counselor? If you lost your child and attended a self-help or support group and then “graduated” from that group, are you now qualified to counsel other bereaved parents? When I (D.L.H.) took my first university course on the dynamics of grief support groups, I was taken aback when the instructor, a widow of 5 years, indicated that it was her belief that only another widow could truly understand what she went through when her husband suddenly died. I did some checking on the background and training of this “professor” for the course. She had a bachelor’s degree in English, and she had taught high school until her husband died. She then quit her job with the school board and began running grief support groups for widows out of her home. Because she was recognized in the community as someone who worked with bereaved widows in a group format, she was asked to teach a university level course on this topical area. However, she was not familiar with the current research or literature on group dynamics and had no formal training in counseling or group work. She did not know about the writings of some of the main scholars or clinicians in the field, nor did she incorporate alternative views related to group dynamics and grief support into the course.

This instructor’s experience was valuable for us to hear and understand, but we left that course with a very limited understanding of the ways that grief could be expressed (based on a feminine view of a widow’s experience), and a sense of despair that if we had not experienced the same loss as a client, we would be completely unable to be fully effective with that client – a view that is certainly not supported in the literature in counseling practice, nor upon accounts of clients’ descriptions of what they found most helpful in their counseling sessions (Altmaier, 2011; Norcross, Beutler, & Levant, 2005).

A recent study by Ober, Granello, and Wheaton (2012) explored the issue of grief counselors’ training, experience, and competencies. Professionals who self-identified as specializing in grief counseling were interviewed to ascertain their background and currency in the field. More than half of the respondents indicated that they had never taken a course or program that focused on the unique aspects of grief or grief counseling. Similar to the experience of the university instructor cited earlier, several of the grief counselors cited that their own experiences of personal loss were what informed their practice. In another study of grief counselors’ descriptions of their work with clients, Breen (2010 – 2011) interviewed clinicians who currently had counseling practices that specialized in the area of grief. In her study, most of the grief counselors who were interviewed were not informed of current best practices in grief counseling, with many citing adherence to stage theories of grief and a continued belief in the “grief work” hypothesis for all of their clients, emphasizing the need for all bereaved individuals to talk about their loss and their emotions in order to “recover” from their grief.

Earlier in this book, we discussed the lack of empirical and anecdotal relevance of stage theories of grief to the actual experience of most bereaved individuals. The grief work hypothesis, which we also discussed earlier, has not been proven applicable to many bereaved individuals in empirical studies (Stroebe & Schut, 2010). However, many clinicians have not availed themselves of this current research in bereavement, and they will still insist on the necessity of emotional catharsis and confrontation with the loss for bereaved individuals to “recover” from a significant loss.

This type of theory-bound, cookie-cutter approach to grief counseling can cause more harm than good, completely undermining the unique needs and personal characteristics of the bereaved individual who may seek assistance through grief counseling. Some studies have identified that some individuals actually fare better by not talking about their feelings or the loss itself (Coifman et al., 2007; Neimeyer, 2000; Stroebe, Schut, & Stroebe, 2005). Probably what is most important in this discussion is the need to recognize that there are many variables that affect the experience and needs of bereaved individuals, and an effective grief counselor will assist clients to find ways to recognize and cope with loss that are congruent with the individual client’s personality, strengths, and needs as they are identified and stated by the client.

The need to stay current in the field of grief counseling is of paramount importance, because there is a great deal of research and writing about when grief counseling is helpful and, when it is not, what approaches may or may not be indicated for which groups, and when further referrals for other professionals are indicated. Many counselors cite problems with accessing research findings because they are not affiliated with institutions that carry scholarly journals that would report the most current findings in the field and their lack of time to read published research (Altmaier, 2011; Breen, 2010 – 2011). Recently, the Association for Death Education and Counseling (ADEC) negotiated with publishers to be able to include subscriptions to several of the most well-known journals in thanatology as a benefit of membership in order to address this issue of difficulty in access to current literature and research that has been raised by clinicians who wished to have access to scholarly writings in the field. Some grief counselors have formed professional online networking groups to share and discuss current information and controversial issues that are relevant to practice. The availability of such online networking and sharing may be of benefit to counselors who might otherwise not have the time to seek out these resources during their everyday working hours.

In the past few years, various professional groups have suggested that there should be published standards of practice for grief counselors, and we are frequently asked about what credentials and training are appropriate for someone to provide grief counseling. The first issue to be addressed is for anyone who is interested in becoming a grief counselor to check locally to see what laws and restrictions that apply to individuals who are counselors. The requirements for someone to practice counseling and/or therapy will vary from state to state and from province to province. Most states/provinces will specify a minimum level of education (usually involving a certain minimum number of clinically supervised hours in a counseling setting) that is necessary for practice. Another issue pertains to the recognition of credentials by insurance companies to qualify for reimbursement for services. This recognition usually includes affiliation and/or licensure with a regulatory body of some type (e.g., College of Therapists, American Psychological Association, College of Social Workers), and as part of your membership with this regulatory body, minimum standards for licensure are usually specified. These standards would most likely include the level and type of education and preparation required, continuing education requirements and compliance with ongoing standards of current practice, and adherence to ethical standards of practice that are developed from the membership. There are difficulties in standardizing credentials (e.g., requirement of a graduate degree in a clinical area) because some very rigorous clinical training programs are offered through institutes, and although they are equivalent to postgraduate training, they are not recognized because they are not affiliated with a university setting. Programs that train in psychoanalysis and Gestalt are such examples. This can be a very tricky and controversial topic, because having an advanced degree (such as a doctorate degree) does not necessarily mean you will be the most effective clinician to work with a certain population. However, the valid issue of protection of the public and the adherence to ethical standards of practice somehow needs to be addressed.

Because there are many different forms of education about grief, and the information that is offered can range from a weekend workshop on grief recovery to undergraduate and graduate degrees in thanatology, it is important to be informed about the requirements in the area where you plan to practice in order to know what educational process would be the best to provide you with the necessary training and experience to be a competent practitioner. Currently, most people who provide grief counseling have advanced degrees in fields that provide training in clinical work, such as nursing, psychology, pastoral care, social work, and medicine. Once this training is completed, these students usually engage in another program of study that will immerse them into current theory, research, and practice related to death, dying, and bereavement, which provides a more specialized form of learning and training to focus on issues related to grief and loss.

There is much confusion over the titles and terms that are used to describe people who provide bereavement support. Konigsberg (2010) expounds on this confusion, stating difficulties differentiating among individuals who call themselves “grief specialists” and “grief facilitators,” along with “grief counselors” and “death educators.” Generally, individuals who volunteer or who do not have formal education in counseling or bereavement theory provide peer support. These individuals may assist as lay volunteers in their faith communities to provide outreach and visitation to bereaved individuals whose needs focus mostly on activities of daily living, sharing experiences, grassroots support, and faith-based companioning. Individuals who provide peer support have often moved further down the road in their grief, and use their experiences to assist in the organizing and running of grassroots support groups, with the self-help model in mind. It is our view that once someone is providing a service in which there is a referral base, receiving a fee for service, and the focus is on a skilled helper model, the individual providing that service should have basic training in a counseling-related field, be affiliated with a regulatory body for ongoing competency requirements, and have some form of accountability with established ethical standards of practice. Psychotherapists typically have graduate-level training in a counseling-related field, along with a minimum number of supervised clinical hours while in training, in addition to affiliation with a regulatory body (usually in the form of licensure).

ADEC has introduced a certification program to designate individuals who have demonstrated that they possess a foundational body of knowledge in the field of thanatology (identified as “certified in thanatology,” with the initials “CT”). Individuals who apply for the CT credential with ADEC are required to have a minimum of a bachelor’s degree, to have completed a minimum number of hours working in a relevant field in thanatology, and to provide two letters of reference from individuals who have been in close proximity to their work, and they must pass a written examination to demonstrate proficiency with the current understandings and principles of practice within thanatology. Unfortunately, this credential is often misunderstood as the completion of a training program, an indication of clinical competence, or as a certification with a clinical component, and none of these assumptions is reflected in the designation or purpose behind the CT designation. The CT credential simply indicates that the individual has demonstrated competence with a specific body of knowledge related to death, dying, and bereavement and has completed formal or informal education in a relevant area for a minimum number of hours.

With all that we have stated so far, we think that counselors who specialize in working with individuals who are grieving should, at the minimum, have the following:

  • Knowledge of current theory and research in grief/bereavement, as well as awareness of the current issues in the field
  • Understanding of the unique aspects of grief counseling that make this form of practice different from other forms of therapeutic support
  • Recognized training and demonstration of competence in counseling skills under supervision
  • Affiliation with a professional body that includes adherence to a standardized code of ethics, as well as the provision of and documentation for continuing education in the field
  • Ability to recognize when grief is complicated and requires further assessment and intervention
  • Awareness of issues related to diversity and cultural sensitivity in the provision of grief counseling
  • Provision for supervision from a qualified colleague who is involved in the field
  • Recognition of the role of self-awareness, reflective practice, and self-care in professional competence

We strongly suggest that if you wish to be a grief counselor then you must ensure you have fulfilled all of these criteria to ensure the best practices and best care for your clients and you.

THE NEUROBIOLOGY OF GRIEF

In the past few years, there has been a great deal of interest in the application of neuroscience to experiences that were previously explored only in psychological venues. Likewise, although grief has been described primarily as a psychological phenomenon, there is evidence to suggest that grief also has physiological correlates and that these biological aspects of the process may have consequences for health and the quality of life in bereaved individuals. The physiological/neurological mechanisms that may accompany bereavement and morbidity/mortality are an important area of inquiry because they may lead to better identification of those who are most likely to experience untoward outcomes as a result of bereavement.

Reviewing current research in the area of grief and biology can be challenging for those who are not well versed in neuroscience and neuroanatomy. Rather than giving specific details that identify particular portions of the brain and complex neurochemical processes, we summarize some of the current research that explores the relationship between grief and physiological processes.

Some studies have explored the various areas of the brain that are stimulated by specific aspects of the grief response, such as yearning (Freed, Yanagihara, Hirsch, & Mann, 2009; O’Connor et al., 2008). Others have focused on the role of the brain in the regulation of the immune system and inflammatory responses through various biomarkers after the death of a significant attachment figure, finding evidence of increased release of hormones in the body related to immune function and inflammatory responses when the individual was presented with grief-laden material (Miller et al., 2008; O’Connor, Irwin, & Wellisch, 2009; O’Connor, Wellisch, Stanton, Olmstead, & Irwin, 2012).

One study (O’Connor, Irwin, & Wellisch, 2009) suggested that the major neurocognitive difference between complicated and uncomplicated grief is that reminders of the deceased may activate the neural reward system in individuals with complicated grief. Findings from this study suggest that bereaved individuals with both complicated and uncomplicated grief feel pain upon presentation of grief-related stimuli, but in those with complicated grief, an area important for reward processing was also activated when there was exposure to cues of the deceased. The reward system remained activated while the bereaved individual recalled memories of the deceased, very similar to how the reward centers in the brain may be activated in addiction behaviors. The addiction-relevant aspect of this neural response may help to explain why it is hard for these individuals to resist reminiscing and ruminating about the deceased even though engaging in these activities may prevent those with complicated grief from adjusting to and coping with the realities of the present. Although not trying to imply that the unrelenting grief is pleasurable, these authors surmise that actively reminiscing and thinking about the deceased loved one may serve as a craving response that may make adapting to the reality of the loss more difficult in individuals with complicated grief.

Biomarkers are also studied because they may relate to the grieving process. Biomarkers are biological molecules that are found in blood or other body fluids, or tissues that may provide an indication of various processes in the body. The study of biomarkers may help to better understand the physiological variables in the similarities and differences between acute uncomplicated grief and complicated grief. Similarly, studying the underlying aspects of the body’s stress response to a death event may reveal distinctions between complicated grief and posttraumatic stress disorder (PTSD) or major depressive disorder. It is hoped that studying biomarkers may help to understand how the death of a loved one can lead to the “broken-heart phenomenon” or the unexpected death of a recently bereaved individual (O’Connor et al., 2012). Given that morbidity and mortality are physical events, some interaction is occurring between the individual’s knowledge of the loss and his or her physical body, and although the mechanisms linking them are not well understood, the immune system is seen as a likely intermediary. It is also thought that biological markers potentially associated with grief might help to better understand the mechanisms of complicated grief, which may lead to improved treatment for this disorder. Although the development and use of medication/pharmacological treatments seems like the most obvious way to use this information, psychological treatment that takes advantage of these biomarkers may also be possible (O’Connor, 2013). For example, O’Connor (2012) cites that psychotherapy for PTSD has taken advantage of the discovery that when a patient’s heart rate is high at the beginning of the first exposure treatment, therapy outcomes are better. Although the exploration of the neurobiology of grief is certainly in its infancy, there may be significant implications for the treatment of various forms of difficult grief as these studies progress.

RECOGNITION OF DIVERSITY WITHIN GRIEF AND GRIEF COUNSELING

It is important to keep in mind that the predominant views about grief and grief counseling come from research and literature that are published predominantly in the United States, followed by sources from mostly Westernoriented industrialized countries. The problem is that there is a tendency to apply the descriptions of grief and appropriate expectations and interventions related to grief to individuals in societies and cultures that may not share the same values and experiences. Konigsberg (2010) brings this point well to the forefront as she explores how individuals in Western society tend to view grief practices in non-Western cultures, implying that we “export” our grief theories and impose Western norms onto these cultures. Her descriptions are reminiscent of colonialist practices, where the invading group would claim dominance over the local culture and norms to establish a “better” and more “moral” life for the indigenous population. However, in the area of grief counseling, the “better” way is sometimes imposed on the indigenous culture without acknowledgment that these cultures may have an effective way of approaching loss and grief; thus, the teaching of bereavement theory and practice in this way, without cultural awareness and sensitivity, has a distinctly narcissistic tone to it.

Many cultures do not see sadness or suffering to be things that an individual should rally against; rather, these experiences may be quietly accepted as just a part of life. Even within Western cultures, there is a great deal of diversity in regard to the expressions and rituals surrounding death. The Irish wake can be a celebration of the life of the individual who died, which can be punitively misinterpreted by outsiders as a grand form of denial and an excuse for a party, whereas the British emphasis on stoicism may be judged by others as a socially sanctioned form of suppression.

In addition to cultural differences and variations, much is written on the influence of gender socialization on the grieving process, which explores variations between how men and women grieve (Doka & Martin, 2010; Golden, 2001; Lund, 2001; and Staudacher, 1991). Although gender socialization is still a very strong influence on men and women in Western societies in regard to expression of affect and the cultivation of relationships, the changing roles of both women and men in the last generation in regard to work, education, and income means that there may now be more similarities than differences in grieving patterns and styles with both men and women. It is important to note that most of the research on grief is still influenced by the fact that more women than men tend to volunteer for research studies, and that the majority of bereavement research still draws heavily upon participation by individuals from middle-class/upper-middle-class, Western-oriented cultures.

What is most important to consider here is that our tacit understandings of what constitutes “normal” grief are often based on descriptions and research from samples that cannot be readily generalized across cultures into a wide-ranging global context. As we have stated previously, the focus in grief counseling needs to be on congruence for the individual – can this individual experience and express his or her grief in a way that feels consistent with his or her personality, beliefs, culture, and experiences?

TECHNOLOGY AND GRIEF COUNSELING

The rapid growth of the use of technology in almost every sector of life has also had a big impact on how grief is studied, experienced, and supported. Many university-based programs are offered through an online interface and almost all journals and most of the books that have been published in the past 5 years are available in both hard copy and online versions for easy access. The ability to find current literature and research with (literally) the push of a button allows us to overcome many logistical barriers to current knowledge that were common in the past. As stated in the previous section, some professional organizations provide electronic access to important journals for their members. There truly is a knowledge exploration in general, and the ability to stay current in the field is now quite easy with this accessibility made possible through technology.

The practice of grief counseling has certainly been affected by this burgeoning technological access. Not only do professionals have access to information and continuing education online but clients also have access to a wealth of material and information. In our practices, we try to keep abreast of good online resources that our clients might be able to utilize. These resources include information web pages that are written about various aspects of grief, online support groups, forums, and blogs that provide solid and monitored assistance for specific types and aspects of grief, videos that are posted about grief and aspects of the grieving process, and links to selfassessment measures that may be used to heighten self-awareness or provide further groundwork for discussion in the counseling session.

Another aspect of technology is the widespread use of social media that is often used by clients to process their grief. Many of our clients maintain their deceased loved ones’ Facebook sites, using them as a memorial sites and discussion boards for themselves and those who were close to their loved ones. Hieftje (2012) cites the importance of the use of social media and social networking online in the grieving process for emerging adults, functioning much like a virtual ongoing support group among those who knew the deceased individual. These online social networking sites allow bereaved individuals to feel connected to others who share their loss and, similar to forum sites and blogs, they have the added benefit of being available at any time of the day and are readily accessed from anywhere in the world.

The uses of e-mail and texting have also changed how we practice. Many of our clients no longer call our offices to inquire about our services or to set up their appointments, preferring instead to send e-mails or texts for this purpose. It is not uncommon for a new client to come for a first appointment after e-mail contact only, with our first actual conversation occurring when they are in our office. This change has both positive and negative aspects to it. On the one hand, it is convenient to be able to answer e-mails and texts when you are available to do so and to not have the interruption of the phone and the frequent occurrence of phone tag, leaving messages back and forth to try to reach someone who has called. On the other hand, the counselor can find himself or herself somehow available to clients 24 hours a day/7 days a week because there is no filter for the times when you are not in your office, and it takes diligence to set your boundaries in place so that your personal time is protected. Some clients will also use e-mail to process their feelings in between sessions, which can become lengthy and time consuming for the counselor. In addition, the counselor is at a disadvantage in using e-mail to respond to clients during these times because much of the work of counseling involves the interactional component between the client and counselor, and many intuitive and more nuanced aspects of the communication can be lost in electronic communication. We thus will often advise clients that any electronic communication of substance sent to us between sessions will be reviewed in the session times, unless there is an emergency or urgent issue that requires immediate attention.

Another new area in counseling is Internet counseling, using an application such as Skype or Facetime. This type of counseling can be advantageous to clients who otherwise would not be able to go to a counselor because of location, disability, difficulties with transportation, or unavailability of a grief counselor in their locale (Gamino, 2012). Training programs and workshops in how to offer counseling online are now very common, with many of these educational opportunities being provided by professional organizations whose members are involved in online counseling. Caution must be used with online counseling because of issues related to confidentiality and concerns that others may be able to “hack into” an unsecured wireless connection, and there must be consideration of where the client and counselor are both located at the time the online session occurs to ensure that their conversation is private. The Internet connection must be stable and allow for clear and accurate exchanges between the client and counselor. There is also concern for counselors who are located at a great distance from a client who is in acute distress, and the ability of the counselor to assist the client to get appropriate urgent help if necessary. Offering online counseling is also dependent on the ability of the counselor to feel comfortable in being able to engage with clients satisfactorily in order to attend to the client in a similar way that he or she might in a regular face-to-face session. Obviously, Internet counseling is not going to appeal to everyone, but you will no doubt be asked about your ability to offer this type of support at some point in your practice. For more information about the use of online resources in grief counseling, we suggest the book Dying, Death and Grief in an Online Universe (Sofka, Cupit, & Gilbert, 2012).

CONCLUSION

The field of bereavement research and practice has experienced a great surge of interest in the last 20 years, adding to our knowledge of grief, while also engendering controversies regarding how to incorporate these new understandings into the current practice of grief counseling. Counselors who work primarily with bereaved individuals need to be aware of the issues that are raised by new research in the field, and to stay abreast with clinical practice implications and recommendations from the research and literature in the field in order to provide support to their clients that is informed, relevant, and responsive.

Glossary

“Broken-heart phenomenon” – The view that when the death of a bereaved individual occurs after the loss of a signifi cant loved one, the individual “dies of a broken heart.” It is related to studies that demonstrate higher rates of morbidity and mortality in some bereaved individuals after the death of a loved one.

Congruence – An individual’s ability to experience and express his or her grief in a way that feels consistent with his or her personality, beliefs, culture, and experiences.

Resilience – The ability to recover quickly from illness, change, or misfortune; buoyancy. Not seen as a trait or characteristic in individuals, but an observation of their response to adversity.

Social media – Tools or applications that can be accessed through digital devices (smartphones, computers, tablets) that allow people to create, share, or exchange information, ideas, and pictures/videos in virtual communities and networks.

Stage theories of grief – The notion that a natural psychological response to loss involves an orderly progression through distinct stages of bereavement.

Questions for Reflection

  1. You are a grief counselor. List sources of information on practice and research in the field that you would regularly consult to stay current in the field. What might be the barriers to your being able to regularly access this information? What are possible ways that you could network and exchange information with other professionals in the field?
  2. What do you think should be the minimum level of education, training, and experience for individuals who assist bereaved individuals?
  3. One of the current controversies in grief counseling is the argument that the focus on professional intervention for grief implies that normal grief needs professional intervention, despite the fact that most people do not require the assistance of a professional to successfully navigate through their grief. When do you think people might need the assistance of a grief counselor? When might grief counseling be unnecessary, or even harmful?
  4. Complete a search of online resources for grieving individuals. Which ones might you find helpful in your work with clients? Which ones might be helpful for your clients?
  5. Discuss the pros and cons of offering online grief counseling to bereaved individuals.

 

 

 

Afterword

NEXT STEPS

Cassandra was a 43-year-old woman who called to set up an appointment for counseling after the sudden death of her husband 3 months earlier. When she came for the appointment, she discussed feeling paralyzed by the images of the paramedics working on her husband in their home just before he died. She also felt angry that she had been left alone to handle so many financial issues regarding his business, and she was greatly concerned for their three children, aged 5, 8, and 11, two of whom had witnessed the paramedics performing CPR on their dad. Cassandra used the ensuing sessions to sort through the traumatic imagery that centered on her husband’s death, and to prioritize her concerns about daily matters with the business, the family, and herself. She was very worried about her children, and she had placed each of them into grief counseling with a child therapist. However, they were resistant to attending the sessions, and they did not seem to be getting much out of them. She felt that they needed grief counseling because she knew that losing their father was so difficult for them, and she worried about their ability to cope with such a huge loss.

In one of her sessions, Cassandra asked for ideas about how to overcome her children’s resistance to their counseling sessions. It had never occurred to her that perhaps what her children needed most was her attention and presence and not attending counseling. Cassandra had been strongly influenced by the almost ubiquitous notion in North American society that grief is something that needs to be treated. When we reviewed possible signals that would indicate whether her children were coping well, it seemed that although each of them felt sad at times and would talk about missing their dad or feeling that his death was unfair, they were all managing to cope with his loss by relying on the supports they already had in place at the time. With some trepidation, Cassandra decided to cancel their grief counseling sessions and reported back that they seemed relieved to not feel pressured by her to attend them. We discussed potential signs in the children that might point to the need for intervention by a professional in the future, and we discussed the possible re-grief phenomenon that they all might experience as they got older, including special dates, occasions, and milestones, when their dad’s absence might be highly prominent to them. After this discussion, Cassandra felt more empowered to care for her children in the midst of their grief. She continued to attend sessions for a couple months more and then finished counseling after she began sleeping better and was ready to return to work.

Thinking back about what we have shared in this book, could you think about ways that you might have supported Cassandra in her loss? How about her concerns for her children? How would you have known what was most important to focus on in her sessions? We hope that after reading the content of this book, you would feel more confident in your support of a client like Cassandra, and that you would be able to assist her to build upon her innate strengths and resilience as she continues to rebuild her world.

In this book, we have discussed many aspects of grief counseling. We have delineated how grief counseling is unique from other forms of counseling because the normal grieving process is not something that needs to be treated, but rather allowed to unfold in its own healthy and adaptive way. Whether you are a clinician with many years’ experience or a novice to this field, hopefully you have gleaned a good, solid understanding of the grieving process and an appreciation for the importance of learning how to be fully present to the experiences of bereaved individuals, both as a professional and as a fellow traveler of life’s path. We also hope that you will more readily recognize that experiences of significant loss and change can be akin to the grief that occurs after the death of a loved one. There is no need for there to be a “body” per se in order to realize that a death of something intangible or symbolic has occurred.

Grief counseling is really about honoring losses that occur as part of normal lived human experience. The grief response is often socially stigmatized because it reveals our vulnerability in the midst of a society that places such a high value on productivity, efficiency, and rugged individualism. Human beings are social creatures, meant to form strong attachments to others as part of their existence and survival; however, the focus on highly individualistic and materialistic goals makes this relational side of our being seem like a detriment instead of a gift. What we have often found in counseling individuals whose worlds have been shattered by loss is that the time we feel broken and vulnerable can also be a time of great potential. In the painful process of having to rebuild your assumptions about the world after a significant loss, you might also begin to question priorities and goals that were previously taken for granted, or to see life in a way that you may never have seen it before.

After a period of time, it is common for our clients to begin to realize that they are much stronger and more resilient than they ever thought was possible. With this recognition, they find possibilities that they may never have been considered before. When you journey alongside bereaved clients for a while and begin to see this type of pattern emerging from the despair, you begin to trust the process more, and you find the work nurturing a sense of hope and meaning rather than being depressing and morbid. Halifax (2004) refers to this type of journey as the “fruitful darkness,” indicating that we often become more open to receiving and learning some of the most valuable lessons and insights about ourselves, others, and the world after we go through some of the darkest times in our lives.

We hope that as you embark in a practice with individuals who are grieving, you will also find these things to be true. You can learn more about your capacity to care and the depth of your ability to be fully present to others. You can also hold the hope for those who seek your assistance at this time, knowing that this painful journey has the potential to lead them to a place of greater compassion for themselves and others. But most of all, we hope you simply find a greater appreciation for life in all of its diversity and experiences, and embrace the deep resilience and strengths that each of us may have.

 

 

 

 

 

 

Appendix: Case Studies

We have included this section with sample case studies for you to consider in light of what you have now learned and can hopefully apply in real-life situations with grieving individuals. Please note that the sample case studies described here are fictitious and are not actual client stories from our practice.

In each of the following case studies, imagine that you are the counselor who is working with these individuals/families. In your role as the grief counselor, identify the following:

  1. What is/are the main loss(es) that are described in this situation (both death and nondeath)? Next, identify the aspects of the individuals’ assumptive world that could possibly have been affected by what has happened.
  2. Can you identify any potential factors that might predispose one of these individuals toward the development of complicated grief? Next, are there any signs of complicated grief in any of the individuals described here?
  3. Consider the social context of the people involved in the case study. How might social views and norms have an impact on this scenario and those involved?
  4. Are there any indications of special precautions or interventions that you might draw upon as you work with this case? Remember, your goal is not to “fix” things, but to provide the best supportive and compassionate presence that will allow your client to honor his or her grief in the best possible way. You may also wish to consider the material from the chapter that describes when grief goes “awry” and explore if any of these situations may be at risk for the complications of grief.

 

CASE STUDY 1: SUSAN

Susan and her sister grew up in a small town in the southeast United States. They lived with their mother and father. Susan was 12 and her sister Doris was 10 when their mother was diagnosed with breast cancer. The prognosis for Susan’s mom was not good. The cancer had metastasized from the breast to other organs in the body. Over the next year, Susan’s mom’s condition continued to deteriorate. She finally reached the point where she was no longer ambulatory and hospice was called in. Hospice care was provided for the family for approximately 6 months.

One Friday morning in October, Susan, who was now 13, woke up to find that her mother had died early that morning. Because hospice was present, they pronounced Susan’s mother dead at 3:45 a.m. Susan, Doris, and their dad spent some time in the room with their mother until the funeral home came to the house to pick up her mom’s body. The next day Susan’s father went to the funeral home and planned her mother’s funeral, which was scheduled after 2 days. On returning home, Susan’s father informed the girls that they were not allowed to attend the funeral. He also informed them that, from that day forward, their mother’s name was never to be mentioned in the house again. Their father followed that up by removing all the photos and other memorabilia that belonged to her mom. He remarried several months later.

Susan, now 43 years old, got married when she was in her late 20s. She and her husband had a loving relationship and had a daughter when Susan was 30. Susan’s daughter Diane grew up in a very healthy and stable environment. At some point during Diane’s 13th year, Susan found herself dealing with high levels of anxiety. She kept ruminating about what it would be like for Diane if something were to happen to her and she died. The anxiety persisted for a number of months. This seemed to be counter-intuitive because Susan was health conscious, an avid runner, and took exceptionally good care of herself. However, the anxiety continued to persist. When Susan realized that she could not get her anxiety under control, she decided that she would pursue counseling. She hoped that the counselor would be able to help her with whatever was going on with her.

CASE STUDY 2: JANICE

You are a grief counselor in a local counseling agency. Janice is a 42-year-old single woman who comes to speak with you regarding the loss of her mother 6 months earlier. Janice states that her mother, who was 67 years old, died after being admitted to the hospital with the flu. Until her hospitalization, Janice’s mother had been very active and enjoyed a good quality of life; she lived independently, and the two of them spent much time together. Janice became concerned when her mother’s condition began to deteriorate in the hospital after 2 days. Her mother became confused and seemed to be in pain, but could not verbalize exactly what was hurting or where. Her mother then developed a high fever and began to have difficulties breathing. Janice describes feeling frantic during this time, trying to get the attention of the doctors to do something to help her mother. She was told that “old people sometimes do this when they are in the hospital.” Janice finally was able to pin down a resident, who examined her mother and declared that she was in septic shock, and transferred her to the ICU and began antibiotic treatments. However, her mother died a day later. Janice tells you that she feels a great deal of anger toward the people at the hospital for ignoring both her mother and her. She also feels a great deal of loneliness, because she and her mother spent much time together, and she does not have a family of her own. She has been unable to concentrate and had to take a leave of absence from her job because she cannot function well in her work.

CASE STUDY 3: BARBARA AND JOHN

Barbara and John met in college and married shortly after graduation. They went to the Caribbean for their honeymoon. Their marriage was off to a wonderful start. Within months of getting married, however, John began getting headaches. He thought the headaches were secondary to eye strain, so he got a pair of reading glasses. This did not seem to help the headaches, so he went to see his primary care physician. After running a series of tests and deciding that an MRI was a good idea, John was diagnosed with a brain tumor. This diagnosis came approximately 8 months after they got married. John began a regimen of radiation and chemotherapy. The treatment seemed to be effective and the cancer went in to remission. This pattern of recurrence, treatment, and remission continued for a period of 10 years.

In the spring of the 10th year of their marriage, Barbara got pregnant. Nine months later Barbara gave birth to a beautiful and healthy girl. She and John were ecstatic. However, in the following spring during a regularly scheduled scan, the doctors noticed that, once again, the tumor had started growing. John’s oncologist informed them that, this time, the tumor seemed to be growing aggressively. Once again, a regimen of chemotherapy was begun. Unfortunately, this time it did not stop the growth of the tumor or the spread of the cancer. With the next MRI, a second brain tumor was discovered on the other side of John’s brain. John’s oncologist was not very hopeful; however, John’s parents, who had strong opinions as to what Barbara and John should do, convinced John to begin another round of radiation. The chemotherapy and the radiation seemed to have a negative effect on John’s body and, at this point, John had lost control of the right side of his body and he was no longer able to use his right arm or his right leg.

Barbara has seen John’s condition continuing to deteriorate and has pursued counseling to get some guidance as to how she should proceed. She wants to stop treatment and bring in hospice to provide palliative care. John’s parents want to continue aggressive treatment in spite of the fact John’s oncologist has informed them that he will not recover from the cancer. How would you guide Barbara through this difficult time and difficult family situation?

CASE STUDY 4: ANDY

Andy is a 30-year-old man whose wife died from an acute asthma attack 3 months ago. His wife, Sharon, had a history of asthma and she had several inhalers to control the symptoms when necessary. One night, Sharon woke up gasping for breath. Andy woke up and grabbed all of her inhalers and brought them to her, but the one she needed most was empty and she did not have another one to replace it. As he watched and tried to help her, Sharon went unconscious and began to convulse. Andy then called 911 and tried to help Sharon breathe until the paramedics arrived. When the paramedics arrived and saw the gravity of the situation, they informed Andy that the 911 attendant should have sent for a life support team, as they did not have the necessary supplies to open Sharon’s airway properly. Andy and their two young children watched in horror as the paramedics tried to help Sharon without a response from her. They then placed her into the ambulance and rushed her to the hospital, 20 minutes away. When Andy arrived at the hospital shortly after Sharon was brought in, he was taken into a small room and told that Sharon had died. Andy vented his anger freely at the medical team, and when he finished venting, he cried and stated that he felt responsible for what happened and how awful it was for him to watch her be unable to breathe and not be able to help her while his two young children watched what was happening. He states that he often drinks “a lot” after his children go to bed so that he can sleep and he feels isolated because his friends and family do not know what to say to him.

CASE STUDY 5: BETTY

Betty is a 37-year-old woman who grew up in the northeast United States. Betty is the youngest of three sisters. Betty’s family was close, and she and her sisters have a good relationship. One Sunday morning, Betty received a call from the younger of her two sisters. Her sister told her to sit down because she had some terrible news to share with her. Betty’s eldest sister had been found murdered in her home. Betty’s eldest sister was a very highprofile person in the Southern community in which she lived; therefore, the story of her death blanketed the news. Betty came down for the funeral. She was obviously overwhelmed by her sister’s murder. The day before the funeral, Betty realized that she needed to see her sister’s body. Although she knew “in her head” that her sister was dead, she kept thinking that somehow this must all be a mistake. She contacted the funeral home and asked to see her sister’s body at the funeral home so that she could be absolutely sure that it was her sister. The funeral home staff prepared Betty for what her sister would look like before the viewing and the process was difficult for her, but it did relieve her of the nagging doubts. A month later, Betty realized that she was often ruminating about how her sister died. She now wanted to see the police photos and speak with the detective who had been assigned to investigate her sister’s murder. She often envisioned what her sister’s last moments must have been like, and she worried that her sister had felt frightened and that she had died in a very horrific way.

CASE STUDY 6: MICHAEL

Michael sat at his desk and read the words he had carefully typed. He could no longer live his life as a lie, and as much as he cared about the well-being of the people in the Catholic parish where he was the priest, he could no longer be a representative of a religious tradition that he now found to be oppressive and rigid to many of the individuals he cared about deeply. The change had occurred over a long period of time. He had tried to ignore the inner discomfort at first, assuming that it was just a “phase” he was going through as he reached midlife.

Gradually, the discomfort turned into a painful loneliness and cynicism that robbed him of the very parts of himself that drew him to the church in the first place – compassion, a desire to serve, and a sense of divine purpose. Now, he just felt empty and tired. And he knew that the cure was to leave what was once a home to him, but which now felt like a prison. From the moment this letter of resignation left his hands, his life would be forever changed … or was he already changed, and the letter just a reflection of what he had now become?

He thought of his parents, and how hard this news would be for them. He wondered how he would survive financially, because a degree in theology did not offer much for job prospects in the secular world. Many people in his parish would feel that he betrayed them, and he would be unable to explain that he felt like he was betraying them by mouthing words that were now empty to his heart. This was not how he envisioned his life to be. None of his hopes and dreams when he was younger included the possibility of losing his faith, his community, and the support of his family and friends who were all firmly rooted in the church’s teachings. He wondered how God would weigh in on all of this … and yet, he was not even sure that he really even knew God at all now.

CASE STUDY 7: JANET

Janet, a 45-year-old woman, was referred to counseling by her family doctor. She had been seeing a gastroenterologist for severe stomach-related problems. After scheduling several tests and finding no definitive causes for her stomach problems, her doctor did a preliminary psychological assessment. During that assessment, the doctor uncovered the fact that she had experienced the death of her 9-year-old daughter 4 years earlier.

During the initial interview, Janet tells you that she has a strong religious faith. She states that she knows that her daughter was in heaven with God and, therefore, there was no reason to grieve. After you have seen Janet for a few sessions, you notice her adamant tone begins to waver when she talks about her daughter. At one point, she tells you that the “church people” admonish her to “be strong” and to “trust God.” However, this belief system seems contradictory to what she is feeling “deep down.” As she begins to explore her feelings, she starts to question the role her faith has played in her grieving. She is afraid of “causing problems” in her church community, so she tends to distract herself from her grief by staying very busy with volunteer activities at the church. She does notice, however, that certain days and times of the year she just feels “very bad.” In one of her counseling sessions with you, she mentions that both of her parents had been killed in a car crash a few years before her daughter’s death, and as would be expected, she did not allow herself to grieve her parent’s death because they were in heaven with God and there was nothing to be sad about.

CASE STUDY 8: ANGELA

Angela had skated all her life. When she was 8 years old, her coach told her parents that she had a great deal of potential and they enrolled her in a competitive figure skating program, where she flourished. Angela loved being on the ice. By the time she was 12, she had won many championships at both the provincial and national levels. At age 14, her coach introduced her to a senior women’s skating coach. This coach had been involved with many Olympic champions, and it was no secret that Angela was tracking for Olympic competition with her talent and abilities.

On Angela’s 16th birthday, her boyfriend (who was 17 years old), took her to a special dinner. On their way home, the car hit black ice and he lost control, with the car spinning off the road and hitting a tree head-on. The dashboard of the car was shoved into the passenger area, pinning Angela’s legs. When the emergency workers arrived, they had to use the Jaws of Life® to extricate Angela from the car. Angela’s right leg was broken in many places. She required extensive surgery to reset the broken bones. However, the bones in her ankle were shattered. The surgeons fused these bones to save her foot and to provide her with functionality in order to walk again.

Angela’s recovery was slow but steady. It took several months for her to be able to walk again. Over time, she painfully realized that she would perhaps skate again with a special boot to stabilize her foot, but she would never be able to skate competitively. Angela’s entire life had been devoted to skating and being on the ice. All of her time outside of school had been devoted to her life on the ice. Her future had been planned around skating. Her parents had spent thousands of dollars in her training and competition.

CASE STUDY 9: REBECCA

Rebecca, a 60-year-old woman, was born and reared in the northeastern part of the United States and had relocated with her husband Jack to the Southeast upon his finishing dental school. Living in the Southeast proved difficult for Rebecca; the people were different, the culture was different, and life was different.

Rebecca had been concerned about her husband. His behavior seemed to be erratic. According to Rebecca, he did not seem to be taking care of himself. She also thought that he was overusing prescribed narcotics. Rebecca had confronted Jack on numerous occasions about his overuse of codeine and oxycodone. She was also concerned when he requested money from her to help pay for the employee retirement account in his dental practice. Their relationship had been rocky for a number of years. At one point Rebecca believed that Jack was having an affair and went to see an attorney to find out how she could get him out of the house and begin divorce proceedings. Because Rebecca had no “hard” evidence, the attorney advised her that she had no grounds to have him removed from the house. Rebecca therefore decided to stay in their marriage of over 30 years, and tried to make it work. Although resolution of their problems was the intention, there always seemed to be a wall between the couple. On one occasion, Jack asked Rebecca if she loved him, and she could not respond back that she did. Although they continued to live together, their relationship was quite ambivalent.

As was stated previously, Rebecca was concerned about Jack’s health. She threatened to call his primary care physician to report her concern about his use of codeine products. However, she never followed up on that threat. During the Christmas holiday season, Jack, an avid hunter, went hunting with their son and two other friends in a rural area of the state in which they resided. Rebecca had a premonition that something terrible might happen. She even said, “Don’t leave me.” That was the last time that Rebecca saw Jack. While hunting, Jack had a massive heart attack. Because they were in a rural area of a small county, it took a long time for the EMTs to arrive. Although he was transported to the hospital, Jack died while in transit.

Rebecca has been devastated by Jack’s death. On some level she blames herself. “Why didn’t I call his doctor?” “Why didn’t I stop him from going hunting?” “Why didn’t I tell him I loved him”?

CASE STUDY 10: KAREN AND DOUG

Karen and Doug, a young couple in their late 20s, come to see you for counseling after the loss of their only child, Joey, 6 weeks earlier. The baby was 4 months old and died from SIDS (sudden infant death syndrome). Karen, who was home at the time of the death and who found Joey not breathing in his crib, states that she cannot stop crying, blames herself for what happened, and has great difficulty trying to sleep at night. Doug returned to work a week after the death of Joey, and confesses that he “hates to come home” now because the house feels empty when he walks in the door and he is distressed by seeing Karen’s pain. Most of their friends are married and have young children. Their parents have been telling them to “try again,” and that once they are able to have another child, they will feel better. Karen and Doug went through a great deal of trouble to have a lovely grave marker made for Joey. Karen goes to the cemetery regularly and places flowers and toys on the grave. She no longer feels that she can relate to her friends, saying that they do not know what to say to her and that she feels “different” from them. She also feels isolated from Doug because he is staying so busy with work and does not like to talk about what happened.

 

 

[1] Ethology is concerned with the adaptive, or survival, value of behavior and its evolutionary history. Ethology emphasizes the genetic and biological roots of development; thus, attachment is seen as an instinctual drive in humans and most mammals (Hinde, 1992).

[2] This exercise is used with permission from Brad Hunter.

[3] Ethology is concerned with the adaptive, or survival value of behavior and its evolutionary history. It emphasizes the genetic and biological roots of development and behaviors that are instinctually programmed into an animal’s normal repertoire of responses to given events.