Pearlman, Wortman, Feuer, Farber, Rando. Treating Traumatic Bereavement_ау2


TABLE 8.2. Considerations for Deciding Whether to Use This Treatment Approach with a Particular Client

  1. Very recent loss. That is, the loss occurred so recently that the survivor is still in a state of total shock, and his natural coping responses have not had time to launch.
  2. Problematic reality testing (e.g., a woman whose husband has died is unable to comprehend that her husband is not alive, that she and her children and other loved ones are not doomed to early deaths, and that your intention is to help her).
  3. Problematic or questionable judgment regarding safety of self or others (e.g., dependent children). For example, the survivor is leaving his young children unattended, or is engaging in risky behaviors such as very fast driving or excessive alcohol consumption.
  4. Difficulty maintaining continuity in life and between sessions, such that engaging in this treatment might overload the client rather than helping her manage her life challenges. For example, the client’s degree of disorganization makes it difficult for her to get her children to school, pay her bills, go to work, or to find someone to help her to do these essential life tasks).
  5. Persistent inability to recall what happened in the last session, despite your reminders.
  6. Anything that interferes with the person’s ability to participate actively in the treatment. Examples:
    1. Lack of physical or emotional safety, and inability at present to enter into a treatment in which the client could let down protective psychological barriers in order to yield to the demands of treatment.
    2. Limited memory of material related to the deceased or the loss. The treatment will require the client to engage in actively recalling the loss, as well as his relationship with the person who died.
    3. Psychosis, disabling depression, or other serious, uncontrolled mental health problems.
    4. Dissociation, active substance abuse, or self-injury that the person can’t control.
    5. Active suicidal ideation (although the treatment can address hopelessness and despair).
    6. Absence of adequate English language literacy (resulting in inability to use the handouts); however, you can read handouts to the client and/or share the currently relevant points in session to overcome this potential obstacle.
    7. Inability to come to appointments regularly (e.g., lack of child care, health issues, lack of transportation, ambivalence).
    8. Violent behavior.
    9. Financial problems that might prohibit the client from attending sessions or focusing on processing the loss.
    10. Genuine lack of time to do this work.
    11. Client’s self-described lack of interest in moving forward (e.g., the survivor has come to treatment only because someone else insisted he do so).
    12. Inability to participate and collaborate (e.g., the client wants you to “administer” the treatment).
    13. Other current life circumstances that would make focus on a specific traumatic death difficult (e.g., impending active military duty; active primary relationship distress [not related to the target loss]; job loss; or serious, ongoing physical health problems, such as diabetes or cancer).



Clinical integration

Donald looked down at his notes as he waited for Barbara to arrive. They had met once already, and in today’s session he wanted to discuss the appropriateness of this treatment approach for Barbara. Donald’s highest priority in moving forward with Barbara was to support her sobriety, and his concern was whether the tasks of the treatment might jeopardize it. He decided to present this concern to Barbara directly.

Once Barbara arrived, Donald introduced his thoughts and concerns. “I want to spend some time today discussing the appropriateness of this treatment approach for you. I know that you have sought support and therapeutic intervention in various ways over the past 4 years, and that you continue to experience symptoms of trauma, depression, acute grief, and a strong urge to drink. I think I can help you find further relief, and I think you are a good candidate for the specific treatment approach we’ve discussed. You’ve demonstrated psychological insight about your situation; an ability to draw on resources available to you, including AA; willingness and even determination to seek help; and the capacity to experience difficult feelings in here with me. As you know, this is a challenging treatment: It involves reviewing Janie’s death in detail, and engaging with your memories, feelings, and thoughts about her death and the car accident more generally – all in an active and planned way. Before we dive in, I want to explore my concern for your sobriety. You have done such a good job maintaining your sobriety, and…”

“I’ve relapsed twice,” Barbara interrupted with a tone of self- reproach.

“Yes, you did. And each and every other day of each and every other year since Janie’s death, you have maintained your sobriety. Relapse can be part of recovery, right? You sounded harsh toward yourself just now?”

Donald presented this as a question, which Barbara then attempted to answer. “I’ve been told that before, especially in relation to Janie’s death. My sister tells me that I expected myself to prevent her death, and that this was just not possible.”

“I agree with your sister, and the thoughts and expectations that you hold related to your role as a mother are one of the elements this treatment approach can address. I’m wondering if you judge yourself according to unrealistic standards and then criticize yourself accordingly. If so, this could be feeding into the depression you experience. A potential dilemma for us is this: In order to elicit these thoughts and expectations so that we can examine them, we need to engage with the details of the accident, details of Janie’s death, and details of your grief. I imagine that you’ll want to move – maybe even run – away from some of these details and feelings. In other words, it will be difficult to engage with this material. I will help you do so. This treatment is designed to help you do so. There are supports in place. I can talk more about these today and in the future, but before I do, I’d like to ask you: What do you think you’ll need throughout this treatment in order to assist you in maintaining your sobriety?”

“I know I’ll need to keep my schedule of at least three AA meetings per week, and I know I need to continue the recovery work I’ve been doing with my sponsor,” Barbara replied.

“Good. One of your strengths, which will help you in this therapy, is that you have a strong awareness of the support you need. Now let me ask you this: What do you

client assessment

know about your most recent relapse? When you look back on it, were there warning signs or steps that might have led to your decision to drink?”

“It was 5 days after Janie’s birthday, about 3 years after her death. The day was excruciatingly painful, but I got through it. I spent time at her gravesite, attended an AA meeting, and fought the urge to drink. The day was horrible, though, and even though I did everything I thought I should do, nothing felt better. In fact, the feelings of grief were worse than ever that day. I thought it was supposed to get easier with time. It wasn’t easier, and I felt as though I were being punished for not protecting

Janie and for not doing enough to somehow make myself better.” “I hear some harsh thoughts again,” Donald noted.

“Yeah. It’s easy for me to blame myself. One day at a time had been helping me up until then, but after Janie’s birthday that year, I began projecting into the future – thinking that it would never get easier, and that everything I was doing to stay sober and to grieve wasn’t helping. The symptoms I told you about were at their worst around that time, too. I wasn’t sleeping, and the flashbacks to the accident were more frequent.”

As Barbara spoke, Donald was making notes about a few things. He jotted down what he heard to be several problematic beliefs: Barbara’s beliefs that her pain was evidence of punishment; that somehow she was solely responsible for “making herself better,” as if this were purely a matter of will; and that she should have saved her daughter. He also noted what seemed to be her openness to examining these beliefs. Finally, Donald jotted down a note about Barbara’s knowledge of some specific strategies for maintaining her sobriety, as well as some potential warning signs of an increased vulnerability to drinking, which included worsening trauma symptoms. He wondered whether she had addressed her traumatic experience of the accident, apart from Janie’s death, and noted that as a question as well. He also made a mental note of his feeling that they were developing a rapport; Donald believed they could be direct with one another as concerns arose throughout their work together. Although Barbara’s history of alcoholism presented a concern for Donald, he believed that her strengths and resources, the tools offered by the treatment, and the therapeutic relationship could together offer the support needed to usher Barbara through the treatment while she maintained sobriety.

Concluding remarks

Within this chapter, we have offered a framework for assessing the appropriateness of this treatment approach for any given individual. This framework can act as a foundation that will support you as you make decisions and judgment calls based on your own clinical experience and knowledge. Donald’s assessment of Barbara offers one example of thinking through the appropriateness of the treatment for a particular client. In this example, the therapist honed in on a history of alcoholism as a potential risk factor for this client. In response to his concern, Donald assessed the resources Barbara had utilized successfully to aid her recovery to date; signs of increased vulnerability to drinking, based on past relapses; and what Barbara knew about what she would need to prevent a relapse. Donald also took note of those strengths and resources that made Barbara a good candidate for the treatment approach more generally, noting that her long-term experience in AA had probably contributed to the development of these strengths.

While assessing treatment fit, Donald also noted targets for intervention. He identified certain problematic beliefs that might be contributing to Barbara’s distress, and wondered about her experience of the accident apart from her daughter’s death. Barbara had also faced death that day, and he hadn’t heard her talk about this piece of the experience. Throughout the assessment, Donald was listening for strengths, vulnerabilities, places Barbara might be stuck, and targets for intervention. Together, these elements would help him to tailor the treatment approach to Barbara’s specific needs.

Thoughtful evaluation of a survivor’s vulnerabilities – including her trauma and loss history, as well as her resources and strengths – will help you to determine the appropriateness of this treatment approach for a particular client. A thorough assessment will also help you to assess where a client is in terms of the six “R” processes of mourning, where she may be stuck in processing the trauma, and where she may need added support for building resources. Such an assessment, in turn, will help you to craft a specific treatment plan and to assess the client’s progress along the way. Of course, the tasks of assessment and evaluation continue throughout the treatment, so that you and your client can make adjustments as needed.



Chapter 9. Implementation issues

Shantal sat at her kitchen table with a cup of coffee, wondering whether she would make it to her therapy appointment later in the day. She’d had a bad panic attack that morning and didn’t feel up to going. Shantal contemplated asking her friend, Jan, to drive her there if she were still feeling out of it by the afternoon. “I probably should go, and I probably shouldn’t be drinking coffee,” she thought to herself as she took the next sip.

Shantal was a self- described survivor. She grew up in a single- parent home, in poverty. She was raped at the age of 17. She suffered the loss of several family members, including her mother and a younger sibling. She divorced soon after she had her youngest son. But her faith had remained strong through all of her experiences of trauma and grief. This, along with good friends and children she loved, carried her through. Shantal was the kind of woman who knew how to put one foot in front of the other and did exactly that through a series of profoundly difficult experiences.

The loss of her youngest son was different. Nothing could have prepared her for the anguish she felt watching her 7-year-old son, Tyler, die from a bullet wound in their front yard. While playing ball with his older sister, he was caught in the crossfire of a gang shooting. The mental pictures of that day were as vivid for Shantal now as they were on the day of the shooting 2 years ago. Although the shock of her son’s tragic death had worn off, the pain was now more intense than it had been in the initial months after the shooting. In fact, Shantal sometimes wished for the shock and numbness that first characterized her grief and traumatic stress. The memories, panic, sleeplessness, emptiness, and pain that now lived in her heart seemed too much to bear.

In this chapter, we discuss both general psychotherapy issues (e.g., therapeutic relationship, therapy frame, and termination) as they apply to working with this population. We also discuss issues that are specific to this treatment approach (e.g., using independent activities and designing a treatment plan to meet each client’s needs).

general Psychotherapy issues

Therapeutic relationship

Clients must participate actively in this treatment approach: They must engage in resource- building activities both during and between sessions, as well as challenging their own thoughts, beliefs, and behaviors. From the beginning of the treatment, it is important to set the expectation for a collaborative relationship with the client. As in any psychotherapy relationship, the client is the expert on her own experience. Pearlman and Saakvitne (1995) have described the ideal therapeutic relationship with a trauma survivor client as one in which you as the therapist provide information about the common effects of traumatic events, help the client develop self-capacities, are genuine and present emotionally, focus on development of the therapeutic relationship, and openly invite the client to process transference. These principles apply equally to the relationship with a traumatically bereaved client, since such clients constitute a subset of the trauma survivor population.

A collaborative relationship empowers the client to face his fears and do the difficult work of processing the loss. Such a relationship is based on respect, information, connection, and hope, as described in Risking Connection (Saakvitne et al., 2000). As the therapist, you can provide respect by acknowledging the client’s experience as valid, attending closely to his needs and concerns about both the content and process of the treatment, offering a collaborative approach, participating in the treatment with honesty and integrity, and maintaining the treatment frame. You can provide information about sudden, traumatic death and traumatic bereavement, as well as about paths to adaptation to the new reality. The handouts in the Appendix and on this book’s website supplement ( materials) can be used for this purpose. Connection refers to the sense of partnership between you and the client; the connection the client will make with his own feeling states, his past relationship with the deceased, and his future without her; and with a supportive community that he will access or develop in this treatment. You can provide hope by encouraging the client to engage fully in the treatment process, giving feedback on progress and successes, guiding the client to create a meaningful future, and maintaining your own belief that the client can continue to move forward through the mourning process. These treatment relationship elements are central to any effective psychotherapy, and are essential for psychotherapy with a traumatically bereaved client.

Developing a therapeutic relationship with the client requires sensitivity to the nature of the client’s attachment to the deceased significant other. For example, it would be wrong to assume that a client will have few challenging issues to address because she was no longer married to her deceased ex-husband. Such an assumption will probably diminish the empathic connection to the client and result in missing important readjustment needs.

Sensitivity to the nature of the attachment includes considering how you will refer to the deceased. The issue of which term to use can be resolved by using the deceased’s name, by referring to the specific relationship (e.g., “child,” “spouse,” etc.), or simply by asking the client her preference. Referring to the person as “the deceased” may sound too formal to the client. In addition, the use of such an impersonal term may reinforce the client in avoiding the emotions related to the loss. Of course, you will need to use clinical judgment to adjust the tone of the therapy to suit the actual relationship between the client and the deceased.

Therapy frame

The chaos that sudden, traumatic death creates in people’s lives can leave them feeling disoriented and lost. Establishing the frame of therapy and maintaining boundaries help to create the sense of safety and support necessary for clients to engage in this treatment. You can begin setting the frame for the therapy in the first session by discussing the nature, goals, and process of therapy (Handouts 1, Sudden, Traumatic Death and Traumatic Bereavement, and 2, Orientation to the Treatment, can be useful for the client to take away, but will not replace a discussion of these issues with the client); the roles of, and expectations for, you and the client; meeting time; length and frequency of sessions; and appropriate types and frequency of contact. Additional important frame issues to discuss – such as financial responsibility for the therapy and the involvement, if any, of third parties (e.g., insurers, family members, collateral treaters, consultants to the treatment) – will be included in a standard written form that the client will sign if you are requesting consent to consult or include others in the treatment and also merit discussion. A collaborative, respectful decision- making process about the treatment frame helps a client to feel empowered, hopeful, and safe, and provides an open invitation to express feelings, concerns, and needs related to the therapy (Pearlman & Courtois, 2005; Pearlman & Saakvitne, 1995; Wilson, Friedman, & Lindy, 2002).

As the therapist, your role is to provide information, guidance, and skills. It is important to practice the techniques developed through independent activity assignments with clients until they can do them on their own. You may talk about theory and research during sessions because it is important that clients understand why they are doing what they are doing. Understanding the ideas behind the work increases the likelihood that clients will be able to apply their new skills in novel situations in the future. Moreover, for traumatically bereaved clients in particular, understanding the nature of the treatment helps to restore a lost sense of control.


It is important to manage boundaries in a way that conveys respect and security for both parties and creates a warm, supportive environment for the client. A sense of safety and warmth may seem difficult to maintain in a therapy that focuses on something as distressing as sudden, traumatic death. Survivors may be concerned that their thoughts, feelings, or accounts of their experiences will upset you. As described in Chapter 3, for example, survivors of deaths that were caused by others often experience rage toward the perpetrators, as well as fantasies about ways to make them suffer. Clients need to understand that they will not overwhelm you with their stories or their distress.

Clinical judgment must be your guide in countertransference disclosures. If you express shock, horror, or some other distress reactions (e.g., crying) in response to a client’s account of a death, the client may feel ashamed or may conclude that you are not strong enough to deal with the situation. Yet if you show no response to the account, the client may not feel understood or supported, or may experience you as cold or distant. Generally, a mild but warmly concerned verbal response is a good starting point (“I’m so sorry this happened to [your loved one]. How truly terrible”). You can gauge the appropriate intensity of your remarks by using the client’s language and responses as a guide. Part of the art of psychotherapy is to balance the expression of your authentic responses with what you deem best for the client at any moment.

You may struggle with the urge to overextend yourself in order to protect a client from further loss or to attempt to “make up for” the loss. You might feel compelled to provide sessions at times you don’t typically work because the client tends to experience more loneliness or distress at those times (e.g., evenings or weekends), or to have frequent or lengthy phone or e-mail contacts with clients between sessions. In order to maintain the necessary balance between strength and empathy, to protect the therapeutic relationship, to convey respect for and faith in the client’s ability to function, and to prevent burnout and minimize vicarious trauma, it is essential to establish and maintain good boundaries. These boundaries are guidelines that prevent a client from becoming excessively dependent on you as the therapist, and prevent you from doing more for the client than is therapeutic. These guidelines should be shared (and, as appropriate, developed) with the client in the first session of therapy, and later as the need arises. For example, during a difficult exposure period, one client began phoning her therapist regularly between sessions. The therapist talked with the client about her possible need for more support. Together, they agreed that the client could attempt to elicit support from family members and close friends, and that they would meet twice a week during the remainder of the exposure work. (More detailed information on frame and boundaries in psychotherapies with survivors of traumatic events can be found in Courtois, 2010; Pearlman & Saakvitne, 1995; and Saakvitne et al., 2000.)

documentation and informed Consent

Careful documentation of therapy is a legal requirement, a therapy tool, and an ethical issue. Traumatically bereaved clients often have legal involvements, and their therapists’ notes may be required in legal proceedings. These considerations necessitate careful note taking and documentation of attributions of guilt and blame, as well as the risk of harm to self or others. Depending on a client’s wishes and the possibility of legal involvement, you may choose to keep the copies of the Automatic Thought Record (Handout 13) the client completes, or allow the client to keep them. You should be aware of relevant statutes governing note taking, and ensure that your notes and records meet state/provincial and professional ethics guidelines. At the same time, you must take care not to misrepresent the client in the record. As described previously, many survivors of sudden, traumatic loss blame themselves for their loved ones’ deaths. It is important to note in the client’s record that self- blaming thoughts are distorted thoughts. Poorly worded or misrepresented descriptions of a client’s self-blame could be used against her in a court case. One resource for therapists whose clients may have court involvements is Barsky’s Clinicians in Court (2012).

Our approach focuses heavily on helping clients challenge their thoughts. Clients’ choices of words and specific phrasing often reveal their underlying distorted beliefs. Clients may not be far enough in moving through the six “R” processes to be ready to challenge their negative thoughts. You may wish to make verbatim notes of such clients’ words, in order to challenge later the thoughts they convey. Early in therapy, you may notice a distorted thought in a client’s independent activity writing, but choose not to address it because either another thought/issue takes precedence or the client does not yet have the skills to challenge it. Writing down and keeping a list of automatic thoughts, or saving independent activity assignments, will make it possible to go back to these at a later point in therapy. For example, you may address self-blame- related automatic thoughts before addressing thoughts about God or spirituality, but you will want to keep a record of these latter thoughts for later reference. You may also want to refer in sessions to past independent activities as a way of showing the progress the client has made.

Because this therapy is a collaborative relationship between you and the client, it may be helpful to explain to the client how you take notes, and to show the client the form or format you use. Clients may worry about what you are writing about them, or may feel intimidated by what they imagine is a process that only you understand. Making these methods transparent allows a client to feel more in control of the therapy – control that was absent at the time of the loss.

Clients may feel reassured by a discussion of your specific policy on note taking, as well as of the relevant law on confidentiality, which varies from state to state. Traumatized clients may feel safer knowing that you will not share any information about them without their consent unless they are in danger of hurting themselves or someone else, or unless they report child or elder abuse (in addition to whatever legal statutes specify in each state). This discussion is also a way to acknowledge to the client that traumatically bereaved clients do sometimes think of hurting or killing themselves and that you will try to help him with these issues.

independent Activities

Independent activities are a critically important component of our treatment approach. These activities are designed to be completed between sessions. We have developed them to expand the work performed during the sessions, and to facilitate resource building, trauma processing, and mourning. Independent activities give clients the opportunity to practice the desired behaviors on a regular basis.

Such activities have been a core feature of CBT since its inception. Although this approach is employed among practitioners of many theoretical orientations, the use of independent activities is highest among cognitive- behavioral therapists. In one study, it was reported that therapists using CBT approaches used homework in an average of 66% of their sessions (Kazantzis & Deane, 1999). In a second study focusing on 827 American Psychological Association members who practice CBT, 68% reported using homework (Kazantzis, Deane, Ronan, & L’Abate, 2005).

The most widely used term for independent activities is homework. Over time, an increasing number of practitioners have moved away from this label, arguing that for most people it has negative connotations. As Kazantzis and colleagues (2005) put it, this term “evokes a powerful dynamic in which patients are completing it for the therapists rather than for themselves” (p. 218). Consequently, a number of alternative terms have emerged in the treatment literature, such as home practice, personal practice, self-help assignments, between- session activities, and independent activities (Kazantzis et al., 2005; Tompkins, 2004). The last of these is the term we use in this book.

Independent activities have been studied more than any other process in CBT (see Kazantzis, Whittington, & Dattilio, 2010, for a review). A meta- analysis conducted by Kazantzis and colleagues (2010) provided empirical support for the use of such activities. The results, based on a review of 44 studies, provided clear evidence that independent activities enhance therapy outcomes. Their findings suggest that 62% of patients improve when receiving therapy with independent activities, whereas only 38% improve if receiving therapy without such activities. As these authors emphasize, their findings demonstrate that treatments that include such activities as a main component “produce superior treatment effects to those that do not” (p. 153).

There are numerous benefits to using independent activities (for an excellent discussion of this issue, see Tompkins, 2004, or Kazantzis et al., 2005). First, by providing clients with additional opportunities to practice specific skills, these activities can facilitate learning key components of the treatment and accelerate the pace of doing so. In a sense, these assignments provide the opportunity for clients to transfer the skills they have learned in therapy to everyday situations. Second, independent activities provide an opportunity for clients to test the validity of their underlying assumptions and beliefs. Third, these activities also enable clients “to collect information regarding their thoughts, moods, physiology and behaviors in different situations” (Kazantzis et al., 2005, p. 2). Fourth, since these between- session assignments are carried out in a variety of different settings, they can help clients generalize what they have learned. Fifth, using independent activities can help clients gain confidence in their ability to deal with their problems without the assistance of a therapist. Sixth, the handouts assigning independent activities (and other handouts associated with the treatment) constitute a permanent record of the issues that have been addressed, and can be utilized as a resource as needed in the future. Seventh, independent activities provide the opportunity for clients to work on issues that cannot be addressed fully in sessions. For example, a client whose child died in a motor vehicle crash may find that she is paralyzed by anxiety whenever she attempts to drive a car. This issue can best be addressed by exposure activities that involve driving. Such activities are particularly helpful in combating avoidance. Eighth, independent activities allow clients to take responsibility for their treatment gains, which can be empowering. Finally, as Kazantzis and colleagues (2005) have noted, independent activities provide a structure and rhythm across sessions that is beneficial to many clients.

Some practitioners regard independent activities as a way of extending the treatment beyond the end of therapy. As Kazantzis and Deane (1999) have indicated, the pressures of managed care have often resulted in fewer sessions being reimbursed. Independent activities enable a client to obtain maximal benefit from the sessions available. Tompkins (2004) asserts that independent activities allow a client to practice skills that would take many months to learn if she could only practice once per week in her therapy session. Experts agree that independent activities constitute a cornerstone of CBT. These activities should therefore not be regarded as “add-on” or adjunctive procedures, but rather as a crucial aspect of the treatment (Kazantzis et al., 2005).


Typically, clients who engage in this treatment will not have had an opportunity to say goodbye to their deceased loved ones. This can result in a fear that others will leave or die before they have been able to say goodbye. Even clients who previously had the ability to end relationships constructively may face challenges in doing so after a sudden death. As a result, they may end relationships abruptly in order to feel a sense of control over endings, or may avoid intimate connections in order to try to protect themselves from the pain of endings. It is valuable to help each client realize that while all relationships eventually end, they need not all end traumatically. We strongly recommend that you begin processing the client’s feelings about the ending of this therapy during the early sessions, and that you revisit the topic frequently. This is especially important for a survivor of sudden, traumatic death, who may experience the termination of treatment as another abandonment. Although the focus on the ending may feel unfamiliar, it provides an opportunity for the client to acclimate to the fact that this treatment will end. It also gives both parties an opportunity to reflect on progress.

The two of you can approach the termination of therapy as an example of an anticipated, planned, and mutual end to a relationship instead of another wrenching loss. Since the therapy is designed to foster the client’s increasing confidence in his own resources, including his social support network, his reliance on you as the therapist should decrease over time. The main goal of discussions about termination should be to process the client’s feelings about the losses inherent in finishing therapy, as well as the different experiences of planned or expected versus unexpected losses. A planned loss (such as the ending of a therapy relationship or sending a child off to college) or an expected loss (such as losing a loved one after a lengthy illness) offers the opportunity to conclude unfinished conversations, to reflect on the relationship, and to say goodbye.

None of these important processes can take place when the death of a loved one is sudden.

In initial termination discussions, you can educate the client about common reactions to ending therapy. (You can also give Handout S2, Ending Therapy, to the client.[7]) You may discuss the difference between the end of this relationship and the end of the relationship with the deceased, focusing on the planned nature of this ending. Later termination discussions may include talking about the feelings that the prospect of ending raises for the client. You can also prepare the client for using the new skills learned in therapy to cope with potentially distressing experiences in the future, such as anniversaries related to the death. In addition, it will be useful to discuss signs indicating that the client might need to return to therapy (with you or another therapist) in the future.

The ending of treatment need not signal the end of the client’s internalized relationship with the lost loved one. In other words, we all hold our relationships in our hearts and minds, and they can remain important and sustaining even when we no longer have contact with the other party. Yet a client may hold this fear, implicitly or explicitly, and may need to discuss it with you. For example, the client may fear that this therapy is the only relationship in which she is able to talk about the deceased, her memories of him, and her feelings about him and about the death. If you encounter strong reluctance in the client to ending the treatment, this may be a dimension to explore.

Of course, not every client will decide to complete the treatment. In some cases, the treatment may begin to feel too challenging to the client. Alternatively, the client may feel that he is making inadequate progress, or that the treatment model or your therapeutic style is simply not a good fit with his personal style and/or needs. Another possibility is that the client will leave treatment soon after he begins to feel better. What is a “premature” termination in this treatment model? If the client leaves the treatment without starting or resuming movement along the six “R” processes of mourning, we consider this a premature ending. If the client announces his intention to leave the treatment before it is complete, you should discuss the client’s reasons for leaving. First, you will want to ascertain whether the client has made the decision to leave, or whether this is only the client’s way of expressing some dissatisfaction with the treatment or with your therapeutic style. If the latter, you can discuss ways of addressing the client’s concerns. If the former, you should address the ending as a potential loss (even leaving a relationship one is ready to end represents a change with inherent loss).

Of course, it is possible that a client will decide her needs have been met before you consider the treatment to be finished, and yet the termination is not “premature.” The client may, for example, have strengthened her resources enough to address the trauma and may now feel that she is on a clear path to move through the remaining mourning processes. She may feel prepared to do that work on her own. She may feel that her work is complete and she is no longer feeling stuck or plagued by problems related to trauma and grief. In any of these instances, it is your job to enter into a positive ending process with her, as described below, unless you feel she is avoiding work that remains to be done. Even if you disagree with the client’s decision, a positive ending is important so that the client does not take away a sense of failure, but rather leaves with an understanding of what she has gained and what may remain to be done.

Once the client has announced a decision to leave and you have accepted this decision, the client’s focus may shift to positive or valued aspects of the treatment relationship. In any case, this ending will be planned, and thus different from the loss of the deceased. The client is choosing when and how to end, and there is an opportunity to reflect on the relationship and to say goodbye, even if it must be done in that session. In the course of this discussion, additional reasons for ending (such as the client’s wanting to be in control of this ending process) may emerge, and these can provide opportunities for reflection and reconsideration.

If you are moving toward ending the treatment for any reason, we strongly recommend a planned ending. This means that you discuss ending, the feelings the ending raises for the client, the advantages and disadvantages of ending at this point, and the value of not ending abruptly in light of the client’s previous sudden loss of a loved one. Ideally, you will discuss in one or more subsequent sessions what the client has gained from the treatment, what expectations were not met, what remains to be addressed, and the client’s need for further treatment (related to this loss or not) with referrals to other therapists (if either you or the client feels that it would not be optimal to continue together and that further treatment is warranted). You can also invite a mutual expression of positive feelings for each other (e.g., you can express appreciations of each other’s strengths and contributions to the treatment process, and talk about ways you will remember each other), as well as a discussion of possible signs that the client might want to seek therapy in the future, if she is not doing so at this time. We discuss possible countertransference responses to therapy termination in Chapter 14.

designing The Treatment Plan

Together, you will develop a treatment plan. This plan will be based on the client’s unique manifestation of traumatic bereavement, as well as his resources (e.g., his adaptations, needs, goals, and strengths) and your clinical knowledge and judgment. Together, you will also develop the content of specific sessions. This is where the art of therapy takes place, reflecting some combination of spontaneity and careful planning. The 25- session sample treatment plan offered on this book’s website supplement ( materials) outlines a framework within which you and the client can design your approach. You can use the sample treatment plan as a foundation, drawing from, tweaking, and building upon it. It is based on a pilot study that provided information about how the elements of the treatment approach can be integrated to serve the goals of the therapy.

Ideally, you will sketch out a clear vision for the treatment in the first few weeks of meeting with the client, and develop working plan after the third or fourth session. For example, a client with a history of self- injurious behavior may need more sessions devoted to building self-capacities and coping resources in the beginning of therapy. Someone with little social support may need a greater emphasis on building and accessing a social network. People with few problems in a specific area may be able to skip many of the independent activities in that area and focus their efforts elsewhere. The assessment process will reveal much about a client’s strengths (self-capacities, coping skills, social support) and challenges (including distressing beliefs and other signs of trauma and grief). Of course, you can and should revisit and revise this plan as needed along the way. This preparation can be time- consuming, but will require less time as you become familiar with the treatment elements and the process of matching them to clients’ needs. Appropriate planning and preparation will facilitate the smooth development of individual sessions, as well as the whole of the treatment. We strongly recommend that you read the handouts presented in the Appendix and on the website supplement as you begin treatment with each new client. It may be useful to review this material again along the way to remind yourself of available resources.

Maintaining a structured approach facilitates the completion of many activities within a moderate time frame. Again, you may want to use the sample treatment plan mentioned above. This is a plan for moving through all three of the core treatment components (resource building, trauma processing, and facilitating mourning). If so, you will have to stay on task in order to finish each session in 45 minutes and to finish the entire treatment in 25 sessions. Although it will be challenging at times, the structure offers many other advantages. It can provide a level of confidence for both you and the client. As a result of your or the client’s preferences or the client’s resources (e.g., time; child care; or financial constraints, including limitations in the number of visits covered by the insurance plan), you may choose to modify the treatment, selecting and prioritizing those elements that best address the client’s needs.

Whether or not you use the structured treatment plan, the use of handouts gives the client a sense of active participation in the treatment and concrete tools to use outside treatment sessions. The use of Handout 13, the Automatic Thought Record, for exploring cognitions ensures that each belief receives detailed attention. The structure also helps to manage potential avoidance.

Alternatively, you can use the session topics and subtopics listed in Table 1.2 to help design a treatment plan for a particular client. You should review this plan frequently to adapt the treatment plan to the client’s evolving needs. Once you identify the topics and subtopics you plan to address with your client, you can refer to Table 9.1 to identify the relevant handouts to use.

It is only over the course of working with a particular client that you will gain a clearer understanding of how much material you can cover in a session and what the client is able to do between sessions. In addition, a client’s capacities, resources, and needs may become more apparent after the initial assessment, as you begin working together. Thus one aspect of treatment planning that may need adjusting over time involves the amount of work that can be accomplished in a given session, as well as its intensity. This should be regulated to keep the client within the therapeutic window (Briere, 1996a, 2002), which, as noted in Chapter 8, is the place where there is enough challenge for growth and enough comfort to be able to engage in the work. You must remain aware of the tension between overwhelming the client (which would indicate the need to build more resources or reduce the amount of material in, between, or across sessions) and collaborating in (often unconscious) avoidance of trauma material. When in doubt, it makes sense to invite the client to reflect on this dynamic tension along with you, in order to build the working alliance and include the client in modifying the plan to meet her goals.

While a thorough assessment is important at the outset of any psychotherapy relationship, it is crucial when only a few sessions are available. For clients who are struggling with acute trauma symptoms, sessions should focus on (1) building coping skills; (2) providing psychoeducation about other resource- building activities (particularly developing social support), even if trauma and mourning work cannot take place in this round of treatment; and (3) providing resources that the client can draw upon during and after the treatment. Many clients will present for treatment with coping skills that are more than adequate to allow them to move forward with the trauma and mourning work. Often 9 – 12 sessions are adequate to pursue trauma and mourning work if the client has strong coping skills. Many survivors of sudden, traumatic losses have spent years honing their coping skills and building resources (including social support), but have never had the opportunity to speak candidly about their losses. Thus, no clients can complete trauma work in a relatively short period of time. In addition, you should help the client to think creatively about how to finance therapy, offering solutions such as 9 – 12 weekly sessions followed by bimonthly sessions.


Table 9.1. handouts by Treatment element

Sudden, traumatic death
Handout 1 Sudden, Traumatic Death and Traumatic Bereavement
Handout 27 Guilt, Regret, and Sudden, Traumatic Death
Handout 28 Anger and Sudden, Traumatic Death


Handout 8 Feelings Skills
Handout 27 Guilt, Regret, and Sudden, Traumatic Death
Handout 28 Anger and Sudden, Traumatic Death Coping strategies
Handout 7 Breathing Retraining
Handout 18 The Importance of Enhancing Social Support
Handout 19 Building Social Support

Social support

Handout 18 The Importance of Enhancing Social Support
Handout 19 Building Social Support

Bereavement-specific issues

Handout S5 Bereavement-Specific Issues
Handout S6 Getting through the Holidays: Advice from the Bereaved

Meaning and spirituality

Handout 31 Spirituality

Values and goals

Handout 21 Values
Handout S1 Personal Goal Setting

Cognitive processing

Handout 5 Exploring the Impact of the Death
Handout 8 Feelings Skills
Handout 9 A Model for Change
Handout 10 What Are Automatic Thoughts?
Handout 11 Identifying Automatic Thoughts Worksheet
Handout 12 Sample Automatic Thought Record
Handout 13 Automatic Thought Record
Handout 14 Challenging Questions Worksheet
Handout 26 Account of Your Relationship with Your Significant Othera
Handout 29 Letter to Your Significant Othera
Handout 30 Exploring the Meaning of the Lossa
Handout S8 Continuing Your Relationship with Your Significant Othera
Handout 32 Final Impact Statement

Imaginal exposure

Handout 7 Breathing Retraining (for use before or after the exposure only)
Handout 16 First Account of the Death
Handout 20 Second Account of the Death
Handout 22 Third Account of the Death
In vivo exposure
Handout 13 Automatic Thought Record
Handout 25 Fear and Avoidance Hierarchy Form Mourning
Handout 5 Exploring the Impact of the Death
Handout 6 The Six “R” Processes of Mourning
Handout 17 Secondary Losses
Handout 24 Positive and Negative Aspects of Your Relationship with Your Significant Other
Handout S4 Review of Your Relationship
Handout S7 Your Assumptive World
Handout 30 Exploring the Meaning of the Lossa
Handout S8 Continuing Your Relationship with Your Significant Othera

These handouts also include an emotional processing aspect.



The handouts in the Appendix and on the website supplement can be valuable resources, although it is important not to overwhelm the client with too much information. It can be useful to review the list of all handouts at the beginning of the Appendix with the client and together identify a small number that you and the client believe might be useful. Alternatively, you may choose to make this selection yourself, based on the treatment plan. However, it is best to offer clients exposure exercise handouts, such as Handouts 5 (Exploring the Impact of the Death), 15 (Processing the Loss), and 16 (First Account of the Death), during a period when they are scheduled to attend at least weekly sessions. These handouts invite them to engage in exposure work that raises strong feelings. During this process, they may benefit from reassurance, encouragement, and support from you. The activities we describe in a full treatment plan can be used in a shorter treatment, with the caveat that exposure work requires adequate support and self-capacities for the client. If you have not addressed support activities during an abbreviated treatment, it may be worthwhile to provide the psychoeducational handouts related to resource building, such as Handouts 4 (Self-Care), 6 (The Six “R” Processes of Mourning), and 8 (Feelings Skills).

If the client can only attend a small number of sessions and chooses to schedule the individual sessions at 2- or 3-week intervals, it may be feasible to assign more independent activities, thereby increasing the benefit of treatment. However, we do not recommend this less frequent session scheduling if the client’s symptoms are acute or if you are doing exposure work. Another option would be to meet for a block of sessions (perhaps 5 or 10), take a break for an interval to be decided by the two of you together, and then meet for another block of sessions. The client can use the interval to practice using her resources to manage challenging situations, and can bring back to the treatment her observations about what went well and where she needs further work.

If your assessment suggests that the client’s self-capacities and resources are strong, and if you are well versed in CBT and exposure techniques, you may be able to complete exposure work within 10 sessions. Clients will benefit most if they are committed to attending sessions at least once a week and to doing both self-capacities work and exposure exercises between sessions.

Therapy will usually include planned breaks, such as vacations or other absences. It may also include unplanned breaks, such as those related to illness or family emergencies, that interfere with the regular schedule. Such breaks can be difficult for any distressed client, and more so for those who are mourning traumatic losses. Ideally, you will notify your client of any planned absence several weeks in advance, and explore the client’s feelings about the absence both beforehand and afterwards. Even client absences can create distress for a traumatically bereaved client because of the vulnerability that separation elicits. Anticipating such reactions, normalizing them, and planning for them with the client can assist her in managing them effectively. These breaks provide important opportunities to practice coping skills and build self-capacities.

structured session format

Table 9.2 presents the format of a typical structured session. Each session begins with introductory activities: setting the session frame (an introduction to the work that lies ahead), as well as a discussion of any treatment frame issues (such as appointment scheduling or payment).



Table 9.2. format of a Typical session

  1. Introduction
  1. Session frame: Focus, topics, rationale. The therapist briefly describes the focus of this session, lists the topics to be addressed (see Table 1.2 and/or the sample treatment plan on this book’s website supplement), and discusses how these topics contribute to healthy accommodation of traumatic death (the rationale). (All sessions)
  2. Treatment frame issues. This is the opportunity to discuss issues such as scheduling, payment, and

(toward the middle of treatment and in later sessions) termination. (Most sessions)

  1. Brief review of independent activities. Here the therapist checks in to see whether the client has completed the independent activities from the previous session. If not, the dyad explores the obstacles to completing the activities and what support the client may need in order to complete them. The dyad may complete in session any activities not completed in advance, using the framework below. (All sessions)
  2. Psychoeducation. This is a place to provide information about the topics and tasks of today’s session. Material in the handouts can be useful to this process. (Most sessions)
  3. Core treatment components
    1. Resource building. Here the dyad may discuss the client’s progress in building self-capacities, social support, and coping skills, as well as in addressing bereavement-specific issues, values and goals, and meaning and spirituality. (All sessions)
    2. Processing the traumatic death. This is the place to process exposure activity assignments, as well as to engage in exposure activities in session as indicated. (Most sessions)
    3. Mourning. This is the place in the session to discuss the “R” process that is the current focus. (Most sessions)
  • Wrap-up
    1. Integration. Here the dyad looks at big-picture issues, such as how the elements of the treatment fit together and how the death and secondary losses have affected the client’s worldview, values, or other broad beliefs. (Most sessions)
    2. Independent activities for next time. Here the therapist proposes activities for the client to engage in between sessions, ideally one or more from each of the following two categories, and explains them to the client. (Most sessions)
      1. Resource building, trauma processing, and mourning activities
      2. Other activities (e.g., cognitive restructuring)
    3. Handouts. The therapist will give the client the handouts at the end of the sessions that include them. (Most sessions)

Note. The categories that should be included in all or most sessions are followed by “(All sessions)” or “(Most sessions),” respectively.



We suggest that you then conduct a brief review of the independent activities assigned during the previous session. Some of these activities entail very brief reviews; others will require more time and will essentially amount to separate interventions within the session. Whether you review the more time- intensive activities at this initial stage of the session or later on is a judgment call; it depends on which other topics are planned for that session, as well as considerations described below. In either case, follow the activities check-in with psychoeducation related to the topic of the session. Attention then moves to some combination of the core treatment components: resource building, trauma processing, and facilitating mourning. The specific treatment interventions are described in Chapter 10 for resource building, Chapter 11 for trauma processing (both exposure and cognitive processing), and Chapter 12 for facilitating mourning. Earlier sessions within the treatment are likely to involve more resource building, whereas later sessions will involve a heavier emphasis on exposure and cognitive processing. Most sessions require some combination of both, and these interventions will take up the bulk of the session. The session focus can then shift to the wrap-up, which includes big- picture or integration issues such as the relation among the three core treatment components discussed below. Sessions end with the assignment of new independent activities, and distribution of relevant handouts.

A client’s particular manifestation of traumatic bereavement, her unique needs, and your clinical judgment will all contribute to the way the intervention elements fit together in a given session. Within the template, we leave the specific content blank; you and the client will “fill in” this content. The list of session topics in Table 1.2, the list of handouts by treatment element in Table 9.1, and the detailed sample 25-session treatment plan described earlier and presented on the book’s website supplement provide further information about what sort of content fills in the template, based on the needs of the client.


Session Frame: Focus, Rationale, Overview, and Topics. An overview at the beginning of each session helps to structure the session and reduces the possibility that the client and you might unconsciously collude in avoiding difficult topics or otherwise get off track. We refer to this as the session frame. As an example, you might introduce a session as follows: “Today we will focus on how traumatic bereavement has two components: trauma and loss. This might give you a way of understanding your experience that will help.” In just a few sentences, you introduce the focus of the session, along with the rationale for that focus. An overview of the session tasks and topics further frames the session: “Today we will review the independent activities from the last session, discuss traumatic bereavement, help you to begin to process your loss, and end with discussing assignments for next time.” This is also the place to identify any planned in- session activities such as breathing retraining. Preparing for each session by planning a session overview will result in a smoother flow, as well as the opportunity to cover more territory.

Treatment Frame Issues. Treatment frame issues will be most salient at the outset and ending of treatment, although some, such as payment of fees and regular attendance at sessions, and process issues, such as the client’s feelings about the therapy and your therapeutic style, may arise at any time along the way. At the beginning of treatment, you and the client will typically discuss the goals and topics the treatment will address, the importance of both parties’ active participation, the value of independent activities, and so on. This is also the time to discuss both the inevitability of termination and any associated feelings. At times, either you or the client may see value in increasing the frequency or length of sessions. For example, it is often helpful to meet twice a week when the client is engaged in exposure work, and to plan for longer sessions when in- session exposure work is scheduled. Such issues form the content for this part of the session.

Brief Review of Independent Activities. After addressing any treatment frame issues, you should review the independent activities assigned in the previous session. Asking the client about the assignments reinforces the understanding that they constitute a valuable aspect of the therapy. If the activity relates to today’s topic, you can review it with the client later in the session. If it represents a completion of the previous session’s work or is part of the ongoing work of resource building, you can discuss it at the outset of the session. Briefly covering each activity that was assigned in the previous session before focusing on any specific activity can keep you from getting bogged down. Otherwise, you may become involved in a detailed discussion of some activities, and run out of time before discussing other activities or issues planned for the session. In-depth discussions of one assigned activity may also indicate that the client is avoiding other therapy material. The amount of time spent processing each type of assignment will depend on where the client is in the treatment.

If the client has not completed independent activities, you should learn why, and then address relevant issues. Clients often benefit from exploring their avoidance of independent activities in session. Many of the skills you teach and assign to your clients as independent activities can be used for processing avoidance of the assignments themselves. For example, you might ask a client to label and discuss emotions that arise when he is contemplating assignments. Clients might also benefit from completing Handout 13, the Automatic Thought Record, on a thought related to independent activities (e.g., “I will fail at this assignment and disappoint my therapist,” or “This assignment will make me so anxious that I’ll make a mistake at work and my boss will reprimand me”).

Many clients require concrete plans for engaging in avoided activities. If a client is avoiding independent activities, you might look together at the client’s schedule and decide when and how the activity could be done. (The client could try it again under different conditions, such as with the participation of a support person, or the two of you could do the task together in session.) If the client is avoiding cognitive restructuring activities or exposure assignments, you should help her to complete these activities within the session. These two types of activities are the most challenging for many clients because they often prompt strong emotions.

Clients sometimes avoid independent activities because they are too painful. If this is the case, you should make sure that you are not choosing an activity that is too difficult for a client at this point in treatment. Clients sometimes underestimate the difficulty of an activity or exposure assignment. They may need to choose an easier assignment or modify the activity to make it more likely that they will succeed. However, if the avoided activity is appropriate, remind the client of the exposure rationale (we present a summary of it here for your use; further details are available in Handout 15, Processing the Loss), and encourage the client to engage in all of the activities as fully as possible.

“One of the most important goals of this treatment is to help you react to your significant other’s death in a way that fits who you are and that is acceptable to you. Once you have identified, felt, and accepted your thoughts, feelings, and memories, you will be able to respond to them with more choice and freedom, and your emotions will become more manageable. We avoid feelings and thoughts about loss because they are painful. Unfortunately, the pain usually finds its way into our lives in one way or another, as flashbacks, intrusive thoughts, intense distress, or nightmares. Avoidance just prolongs this pain. This treatment will help you to experience emotions in a safe environment, with a lot of support.”

Psychoeducation. Providing information by using the handouts in the Appendix and on the book’s website supplement will be an important part of addressing the day’s topics and core components (see below). In sharing information, you should create opportunities for the client to ask questions and clarify points of confusion. Of course, such discussions can become another means of avoiding difficult feelings, so you must continually assess the potential value of further explanation and discussion.

core Treatment components

Building Resources. This work focuses on developing self-capacities, building social support and coping skills, addressing bereavement- specific issues, and working on values and meaning. We discuss these resource- building processes in Chapter 10.

Processing the Traumatic Death. This is the place in the session for exposure work and related emotional and cognitive processing. Processing the traumatic death begins once the client has some feelings skills in place. This processing should remain a focus of most sessions after the first few. A client (and sometimes you as the therapist) may be tempted to avoid this crucial element of treatment because of the feelings it raises. See Chapter 11 for specific information on trauma processing.

Mourning. Here, you and the client will address each “R” process as it becomes the current focus of the work. Independent activities, including those used for resource building and trauma processing, can help the client continue her movement through the six “Rs.” Chapter 12 provides detailed information about this aspect of the treatment.


Integration. This is a place to discuss worldview, assumptive world, values, and other broad beliefs that shape the client’s response to the loss and subsequent adaptation. It is also a good place to discuss the relation among the resource- building activities, processing the traumatic loss, and moving through the six “R” processes. For example, at this point in a session that has included exposure work, you might reinforce the client for the work he has done. Remind him that by confronting the painful aspects of the death, he is making it possible to move to the next “R” process; this will help him to understand the connection between trauma processing and mourning.

Independent Activities. In this final segment of the session, you will introduce the independent activities for next time. These include (1) resource- building activities such as building and using social support, coping skills, and self-care; (2) trauma- processing activities, such as cognitive restructuring,[8] exposure, and writing assignments; (3) mourning- related activities, such as recollecting the deceased or reflecting upon his positive and negative qualities; and/ or (4) other activities that relate to the treatment more generally, such as reading informational handouts about sudden, traumatic death (Handout 1, Sudden, Traumatic Death and Traumatic Bereavement) or treatment termination (Handout S2, Ending Therapy).

Independent activities between sessions are essential to the success of this treatment. You should select assignments that will further the work in which the client is currently engaged and that will balance support and challenge. It is essential that the client understand each assignment, and that you review the previous session’s assignments with the client as part of each session. You should familiarize yourself with the resources in this book (especially those described in Chapters 10, 11, and 12 and in the Appendix), in order to be prepared to draw upon them as needed during sessions. Once you are familiar with the various types of independent activities, you can tailor them to address particular issues the client is facing.

When deciding whether and how to assign additional independent activities, consider the time and effort involved, so as not to assign too many activities at once. Encourage the client to use supportive activities (such as breathing retraining, self-care activities, and other coping behaviors) after, but not while, engaging in a challenging activity (such as an imaginal or in vivo exposure). This process will reinforce the client in using the activities on his own between sessions. You may decide to leave certain issues to the client to address using newly learned skills once the major work of therapy has ended. For example, one man lost his sister in a helicopter crash. About a year after her death, he lost his job. Although he found a new job, this second loss had affected his self-esteem, identity, and sense of purpose. Because there were so many pressing issues to address with regard to his sister’s death, the therapist and client decided that he would use tools from the treatment to work on issues related to the job loss after his work with the therapist had ended. You may want to encourage clients to revisit particular independent activity assignments on their own once treatment has ended.

It is often useful to refer back to and elaborate on particular handouts. Several of these are designed to be referred to repeatedly. For example, the client’s list of secondary losses (see Handout 17, Secondary Losses) and the fear and avoidance hierarchy (see Handout 25, Fear and Avoidance Hierarchy Form) provide techniques and resources that can promote recovery. If you perceive a client to be struggling with an issue that you have addressed in the past, you may choose to revisit previous assignments. The session would end with giving the client the relevant handouts. It is a good idea to photocopy the blank handouts that are used frequently (such as Handout 13, the Automatic Thought Record) so that you have multiple copies to provide to the client. This will allow you to work on challenging automatic thoughts easily within sessions. Keep an extra packet of handouts available for each client, so that if the client forgets to bring in an independent activity assignment, loses a handout, or needs an extra copy, it is readily available.

The handouts provide crucial opportunities for the client to apply the principles that are introduced in the sessions. After selecting relevant handouts, you may want to identify additional handouts that guide the client to work with and apply that information to her situation. Some of the handouts are information sheets (such as Handouts 1, Sudden, Traumatic Death and Traumatic Bereavement; 2, Orientation to the Treatment; 3, Treatment Goals and Tools; and 4, Self-Care). Others are assignments (such as Handout 5, Exploring the Impact of the Death). Still others (e.g., Handouts 11, Identifying Automatic Thoughts Worksheet, and 14, Challenging Questions Worksheet) are worksheets to be used in sessions or as part of independent activities. Some handouts cover topics relevant to the major theoretical and conceptual underpinnings of the treatment (e.g., Handout 1, Sudden, Traumatic Death and Traumatic Bereavement; Handout 6, The Six “R” Processes of Mourning; Handout 19, Building Social Support) and the core treatment components (e.g., Handout 15, Processing the Loss). Effective use of the handouts requires a ninth-grade level of English language literacy. For clients without that skill level, or for those who are too distressed to concentrate, it may be useful to read handouts together or to extract the points that are essential to the client at this time and review those with the client in session.

Several practitioners have suggested ways to increase the likelihood that clients will complete independent activities successfully (see, e.g., Kazantzis & Deane, 1999; Najavits, 2005; Tompkins, 2004). From the beginning, it should be emphasized that these activities constitute a fundamentally important part of the treatment, and that they are integral to its success. It may be helpful to mention that studies show clearly that cognitive and behavioral therapy is more likely to result in a positive outcome if independent activities are used (Kazantzis et al., 2010). It is important to provide a rationale to the client for independent activities. Continue talking with the client about the benefits listed above – for example, that these activities help to build skills more quickly and also help clients gain confidence in their abilities.

Tompkins (2004) suggests that in introducing a particular independent activity, you should clarify the relevance of the activity to what a client has worked on in that session, as well as to the client’s treatment goals. Najavits (2005) recommends creating a higher meaning for the activities (which she terms commitments) that you ask the client to perform. For example, an independent activity might encourage the client to schedule a medical appointment. According to Najavits, the higher meaning might be the awareness that the client is taking care of her body, or that she is showing respect for her children (who depend on her), as well as for her own future.

Moreover, independent activities should be appropriate to the client’s sociocultural context. Tompkins (2004) provides an example of an unemployed, single mother of four, suffering from depression, who was assigned the task of going to a movie with a friend. In the next session, the woman tearfully indicated that she was not able to complete the assignment because she could not afford to pay for child care and a movie.

Ideally, the therapist should make the independent activity collaborative and provide some degree of choice regarding the assignment. Tompkins (2004) suggests that making a simple statement like “Would you be willing to try this?” can enhance a client’s motivation to engage in the activity.

Finally, the activity should be set up to minimize the likelihood that the client will fail. Tompkins (2004) provides several excellent suggestions for how to make independent activities what he calls a “no-lose proposition.” For example, he suggests saying, “There is no such thing as an unsuccessful homework assignment because we learn something every time a homework assignment is tried… If you have trouble completing the homework assignment, that’s okay.

We can figure out what got in the way so that you can complete it next time” (p. 29).



integrating This Approach into An ongoing Treatment

In the context of an ongoing treatment relationship, the two of you may realize that the client needs to work on a specific sudden, traumatic death. Alternatively, such a loss may occur while the client is in treatment for other reasons. You then may want to conduct an assessment as described in Chapter 8. This is especially true if certain areas have received little or no attention to date in your work together. The best approach is to draw on your evaluation of the client to determine what she needs at this time, and then to review the resources in Chapters 10, 11, and 12 and the Appendix and on the website supplement for possible relevance to your client’s situation. This treatment approach will be most effective when it targets one specific loss; when you maintain the flow and order of sessions and topics described in Table 1.2 (even if you are using only a subset); and when the client has adequate resources to process the traumatic memories in order to move through the six “Rs.”

In the midst of an ongoing treatment other than this one, you may decide to use the resource- building elements of the treatment when you hit a rough patch. For example, Bill, who had served in the military in Bosnia, came to therapy to address his PTSD related to that experience. It quickly became evident that he could benefit from work on self-capacities, coping skills, and values. His therapist used the material in Chapter 10, as well as the relevant handouts in the Appendix and on the website supplement, to facilitate this work. As another example, Dr. Sullivan had been working with Yani to address a worsening of trauma symptoms, triggered by the death of an uncle who had sexually abused her as a child. At the 1-year anniversary of her uncle’s death, a memorial service was held, and Yani became increasingly distressed. Dr. Sullivan, who was familiar with this treatment approach, practiced the technique of breathing retraining with Yani. She also collaborated with Yani to create a list of self-care activities within the session, and then asked Yani to engage with at least one of these activities per day in between their sessions.

When you are integrating this approach into a therapy that will continue after the traumatic bereavement work is complete (as opposed to using it as the whole treatment with a particular client), you may choose to reserve the termination material until you are ending the therapy. In this case, we strongly recommend weaving discussion of the ending of the treatment into the therapy along the way and providing adequate time to say goodbye, since this is such an important process for survivors of traumatic death.

Clinical integration

Anticipating her session with Shantal later that afternoon, Patricia felt anxious. She acknowledged a very strong desire to help alleviate her client’s suffering; Patricia found that she was easily able to empathize with Shantal whose son was killed 2 years earlier. In today’s session, which was their third, she intended to lay out a treatment plan in more detail. She hoped that orienting Shantal to a specific plan for the treatment as a whole would be organizing for Shantal, thereby reducing her anxiety about the therapy. Because Shantal’s life had been so chaotic for the past 2 years, Patricia wanted the treatment to serve as an antidote.

Her notes, written for a case consultation, read as follows:


Resources: Strong faith; experiences surviving and moving through past trauma and grief (though trauma history could also be a vulnerability); ability to tolerate strong affect; social support from friends & family; desire to be a good mother to her remaining children.

Mourning process: Traumatic imagery seems to prevent Shantal from remembering her son, Tyler, before the accident. Can’t remember realistically. Shantal can’t find comfort in celebrating Tyler’s life – it’s almost as though she can’t access information and memories of his life prior to the death. She can only picture him with a bullet wound. Seems to believe that if pain diminishes, she will lose an attachment to Tyler.

Trauma processing: Has Shantal begun to process her own experience of the gruesome accident apart from Tyler’s death? Her daughter watched it happen. Shantal heard the gunshot. She reports many trauma symptoms, including flashbacks and acute anxiety. Solid resources available to help get through exposure work while remaining grounded; however, anxiety and panic are very high at times. Explore Shantal’s experience of anger.

Problematic beliefs: “I should have protected Tyler; I’ve failed as a mother; trauma follows me everywhere.” All point to self-blame.


Patricia’s notes continued on the next few pages. Many of her observations and questions would prove to be relevant over the next several months. She understood that what was important at this stage of therapy was a flexible treatment plan that took into account the particular ways in which Shantal was stuck along the path of mourning her son’s death and processing her traumatic experience. Patricia picked up her pen and began to sketch out the following plan:


  1. With possibility of criminal case, discuss note taking and potential limits to confidentiality with Shantal again – hard to take in everything first time around.
  2. Work to maintain and solidify Shantal’s current resources. Assign a resource- building activity for each week, with an emphasis on breathing retraining. Check in about coping – particularly self-care – at beginning of each session, keeping coping explicit and front & center. Spend next three sessions (Sessions 3 – 6) focused on self-care and social support.
  3. Listen for problematic beliefs. Provide Shantal with psychoeducation about maladaptive beliefs and automatic thoughts. Ask her to keep a running list of automatic thoughts that arise between sessions, and do so with her within sessions. Use handouts for identifying and challenging beliefs. Introduce in about Session 6.
  4. Explore Shantal’s expectations of herself as a mother, both before and after the accident. Explore her thoughts and feelings about her trauma history. Session 6 or 7 – with intro to automatic thoughts.
  5. Provide some psychoeducation about exposure work and rationale for this. Given Shantal’s level of anxiety, start small and work up to more anxiety- provoking situations. Keep ratings of anxiety levels while doing any kind of exposure. Discuss the idea of a therapeutic window and stay within that. Introduce exposure in Session 7 or 8 (later than in the sample treatment; need to strengthen resources first), assuming Shantal demonstrates an ability to utilize resources, and as long as anxiety does not further intensify.
  6. As exposure activities progress, assess where Shantal is with each of the “R” processes. As of now, seems to be struggling to remember Tyler prior to his death – Recollect and re-experience the deceased and the relationship. Explore “Rs” as suggested in sample treatment plan.
  7. As treatment progresses, ask Shantal to consider places in her life where she might reinvest some energy. Could build on values and goals work later in the therapy.
  8. Throughout, be explicit about our relationship/connection and eventual termination; a part of Shantal is very sensitive to perceived abandonment, though it’s difficult for her to acknowledge this.


Patricia’s plan was to use these notes as a starting point. She included more specific information for the next several sessions, with a plan to fill in more specific details for later sessions as they approached. She planned to invite Shantal to consider this plan with her, tweak it as necessary, and continue to assess how Shantal was adapting along the way.

Concluding remarks

This chapter presents considerations for implementing this treatment approach for traumatic bereavement. Shantal’s therapy offers an example of the ways in which assessment of strengths and vulnerabilities, clinical judgment, general psychotherapy issues, and attention to the various elements of our treatment approach can be woven together to assist those suffering from traumatic bereavement. Shantal’s therapist, Patricia, ascertained that she had the resources available to engage effectively in exposure work, but she was also aware of the potential for Shantal’s anxiety to be very high. The therapist therefore took her time with a thorough assessment in the first few therapy sessions and developed a working plan that would emphasize breathing retraining, self-care, social support, and other resource- building activities. Given what she had learned about Shantal thus far, Patricia also took note of specific considerations with regard to the implementation of other aspects of the treatment – addressing problematic beliefs and working with the “R” processes, for example. Given Shantal’s trauma symptoms, Patricia was willing to slow down the therapy if needed, in order to ensure that Shantal’s level of agitation stayed within the therapeutic window.

In addition to discussing specific considerations pertaining to implementation of the treatment approach, such as informed consent and termination, we have offered an overview of possible ways to structure the treatment. You will need to attend to the overall structure of the treatment, as well as to the structure of a given session. The sample treatment plan on the website supplement, and Table 9.2, aid in these respective tasks. It is our hope that the nuts and bolts provided here help you to visualize how these pieces might fit together within a given individual treatment. You may wish to come back to this chapter after digesting the information presented in the remainder of the text.



Chapter 10. Building resources

Phyllis, in her mid-50s, first sought therapy about 18 months after losing her fiancé, who died only days after experiencing the first symptoms of meningitis. She had reconciled herself to living as a single woman until the day she met Alex, who changed her life. Their whirlwind courtship and eventual engagement were an unexpected delight for her. Then, one day shortly after their engagement, Alex developed a terrible headache and photosensitivity. When, at Phyllis’s insistence, he phoned his primary care doctor, the on-call doctor told Alex it was “probably just the flu” and to call in a few days if he wasn’t feeling better. Three days later, Alex was dead, from bacterial meningitis. At that point, Phyllis, in her own words, “lost it.” Prior to Alex’s death, Phyllis had usually been able to hold things together. A survivor of childhood abuse, she was already acquainted with the ramifications of trauma. Although she continued to experience some trauma symptoms as an adult, she worked hard to manage them in order to function effectively as a secretary at a social services agency. With the death of her fiancé, Phyllis’s life seemed out of control. She felt as though she were going crazy, was unable to trust anyone, and reported an almost complete inability to manage her day-to-day affairs. She no longer went to the office. She spent most of her days in bed, withdrew from social activities, and visibly shook when she did interact with others. During her frequent crying bouts, Phyllis’s sobs turned into gasps as she struggled to take in air. She experienced physical pain throughout her body and was unable to find relief through the many remedies suggested to her. Her grief, rage, and sense of betrayal consumed her. She almost never took advantage of the emotional or practical support her friends offered; she felt angry with everyone, including herself. She found little or no comfort in distractions such as reading, movies, or physical exercise on the rare occasions when she was able to attempt them.

This chapter provides guidance for doing resource- building work with clients.


Self-capacities (also referred to as feelings skills) are inner abilities that help people regulate internal states. Their presence or absence reflects the individual’s attachment experiences (Bowlby, 1969). Over time, self-capacities provide the foundation for managing strong feelings,


maintaining a fundamental sense of worthiness, and allowing for an internalized connection to loving others.

People who have early traumatic experiences (including, e.g., abuse, neglect, and chronic exposure to violence) may not develop adequate self-capacities to function comfortably in a complex world. And even those with well- developed self-capacities may find them challenged by a sudden, traumatic loss. Because traumatic death can evoke strong emotions, feelings skills are a foundational part of this treatment. In order to confront the trauma and approach what they may have been avoiding, survivors need adequately developed (or restored) capacities for regulating their emotions and maintaining a positive sense of self. Specific skills to deal with strong, intense, and potentially overwhelming emotions will help these clients to experience their feelings more fully, with less discomfort, less fear, and lower risk of destabilization.

Three self-capacities are essential to this internal stability: inner connection (which helps people to stay connected to positive images and memories of loved ones), self-worth (which helps people to maintain a generally positive and stable sense of their own value), and affect management skills (which help people to handle their strong feelings) (Pearlman, 1998; Saakvitne et al., 2000). We describe each of these abilities and discuss ways to build them below.

developing self-capacities

It is important to assess a client’s self-capacities as a way of gauging how to pace the exposure work, how much additional support the client will need, and where the client can seek respite through means other than avoidance. (See Chapter 8 and Brock and colleagues [2006] for information about assessing self-capacities.) The approach to developing self-capacities is the same for clients with and without attachment challenges. The difference is that the process is likely to take longer and include setbacks as an attachment- challenged client builds self-capacities, uses them in difficult situations, and refines them over time. The Risking Connection trauma training curriculum (Saakvitne et al., 2000) highlights the development of self-capacities in adults with childhood trauma histories.

Cultivating self-capacities takes place in the context of the therapeutic relationship. The therapist – client relationship is both the container within which these capacities germinate and the major tool for growing them. The feelings skills exercises the client engages in between sessions (see Handout 8, Feelings Skills) guide her in connecting with her inner experience and reflecting on the results of that connection. For each feelings skill, the handout describes the skill area, discusses its importance, and offers exercises for its development. In this context, connecting with inner experience means, for example, that the client will allow herself to feel grief, guilt, anger, curiosity, surprise, and happiness, even if momentarily, and then notice (with your support as the therapist) that she endured these feelings. Your confidence, respect, and guidance reinforce the client’s self-worth, inner connection with loving others, and affect management.

Engaging in the emotional processing work of this treatment (described in Chapter 11) is another way that self-capacities develop. Clients learn by doing. Their experience may be “I was afraid of facing my feelings, but I was able to manage this strong feeling, and I did not get overwhelmed.” Successfully completing exposure activities reinforces and enhances the client’s self-capacities (self-worth, in this case). The self-capacities (either the existence of affect management, or perhaps at first just an understanding of it) can help him to approach and tackle exposure. In turn, successes with exposure activities (initially talking about the deceased and

Building Resources

the loss, then eventually going into the world to confront what the client has avoided) build self-capacities (affect management and self-worth), all within the support of the therapy relationship. The client’s awareness of your compassion for the experience of traumatic bereavement and for his attempts to strengthen coping behaviors and social support helps him to create an internalized representation of the therapist (a “benign other”) that he can draw on in challenging times. This internalization process takes place over time, through forming a therapeutic alliance in which you convey respect and hope, reflect the client’s value, and reinforce his efforts to grow.

In addition to the exercises in Handout 8, we offer some specific suggestions for developing each self-capacity in the following sections. You can select those exercises that seem best suited to each client’s needs.

Inner Connection

As noted above, inner connection allows people to carry positive images and memories of their loved ones, even in the loved ones’ absence. Inner connection is the internal representation of loving relationships, rather than the interpersonal connection people may receive through social support. It can be thought of as a dimension of object constancy – the ability to maintain a stable internal representation of self and other (Mahler, 1975). The ability to imagine words of love, comfort, or support from a compassionate relative, friend, or other figure reflects a strong sense of inner connection with loving others. This resource can help people through difficult times, guiding and supporting them to feel less lonely and afraid.

Developing Inner Connection. Encouraging survivors to be creative in thinking about who their “loving others” are can help them develop a sense of inner connection. A “loving other” may be a friend or family member, a former teacher or clergyperson, a pet or imaginary figure, a historical figure, or a fictional character with whom a client has developed a special internal relationship. The person doesn’t have to be alive. Some clients will choose to use you, the therapist, as the important “other.” Whoever the “loving other” may be, encourage the client to imagine the “other” in times of pain or struggle – for example, “Can you imagine what your grandmother would say?” One survivor found it soothing to draw pictures of her beloved cat, which she then looked at when she was feeling lonely and distraught while at work.

If thinking of the loved one whose death is the focus of this treatment does not cause too much distress, the client may use the deceased as the internalized loving other. When clients find that thinking about their loved ones brings up a lot of sadness, support them in allowing themselves to feel the sadness. Remind them that they can keep this person’s love with them by recalling special moments and connections they shared. This is also good practice in increasing affect management and in addressing avoidance.


Feeling worthy or deserving of life and good fortune, even under difficult circumstances, is a sign of positive self-worth. It arises from a secure base in childhood, which develops when adults consistently treat children with love, compassion, and respect. Ideally, over time, people internalize that positive regard and come to feel “good enough” about themselves. You can say to a client:

“Adequate self-worth doesn’t mean never feeling bad about yourself, but it does mean that even when you feel bad, you know or can recall that you are still a reasonably good human being. When you do something you know is wrong, you may feel guilty about what you did, which is different from feeling as though you are a bad person.”

Developing or maintaining self-worth can be challenging for people whose childhood experiences have included unsupportive or harsh interactions with caregivers; bullying by peers; or other experiences of neglect, abuse, or humiliation. It is common for these individuals to shift into self-blame or feelings of worthlessness when they encounter stressful life experiences. Such clients are likely to require additional resource building in this treatment, and they will also benefit from the cognitive work on automatic thoughts (described in Chapter 11).

Developing Self-Worth. Traumatically bereaved clients who struggle with feelings of worthlessness should be encouraged to associate with people who treat them with respect and bring out the best in them. Self-worth can be increased by activities designed to help survivors learn to treat themselves with respect and engage in actions that are consistent with their dignity. Such activities might include spending time (even in small amounts at first) doing things they are good at, such as baking, arranging flowers, or repairing a bicycle. As clients begin to reengage with others, they may experience increased self-worth through your calling their attention to their helpful, respectful, or compassionate behaviors. Helping to care for a young child and offering to pick up groceries for a neighbor are examples of time- limited strategies that can build or rebuild a client’s sense of worth. Helping others is also a way of reengaging with the world and beginning to resume a life that includes something beyond grief and mourning. Some survivor clients are tremendously relieved when they realize they still have something to give to others.

affect management

Affect management (or feelings management) refers to the ways people experience and handle particularly challenging emotions. A person who has trouble experiencing anger, for example, may try not to feel it or may pretend it’s not there. Some people become so skilled at burying strong emotions – both negative and positive – that they are not even aware that they are experiencing them. Without awareness of emotions, such individuals lack essential information for understanding themselves and others and for maintaining relationships.

Emotions – even strong ones – help people to stay connected to themselves, to others, and to the world. They provide the feedback that assists clients in navigating the interpersonal world. For example, consider a person who becomes angry with a friend who is unsupportive after a sudden, traumatic death. This anger can be a signal that the relationship isn’t meeting his needs and that he should consider what is happening to determine how to handle the situation. People who are not connected to their emotions will miss the information these emotions convey.

There are four steps involved in feelings management, each of which is important throughout this treatment and beyond. The four steps are recognizing, tolerating, modulating, and integrating feelings.

Recognizing feelings means being able to sense an emotion as it arises in one’s body, and to label or name it. A client may find this step to be easy, difficult, or somewhere in between.



She may also find that she is able to recognize some feelings or connect some bodily states to emotions more readily than others. It may be easy to recognize sadness, and more difficult to recognize anger (or vice versa), for example.

Tolerating feelings means being able to accept emotions as they arise. It entails being open to experiencing one’s feelings as opposed to avoiding them. It also involves responding to emotions nonjudgmentally rather than trying to block, denigrate, or change them. Tolerating feelings can be difficult for those who have learned (usually early in life) that some emotions are “bad” or “wrong” and that they should be avoided. For some children, showing certain feelings may have resulted in negative consequences such as reprimands, punishment, or abuse from caregivers. Tolerating feelings may also be difficult if a client is afraid that emotions will take over, causing him to lose control or to harm himself or someone else. For example, feeling fatigue, confusion, or panic instead of rage may be a familiar way of operating. Addressing this issue in treatment can help the survivor to accept and process his rage. Finally, people who are accustomed to having a great deal of control over their emotions and who value a “rational” or unemotional stance in life may find it hard to accept or tolerate the full range of often powerful and fluctuating feelings that can accompany traumatic bereavement.

Modulating feelings entails being able to control the intensity of the emotion. It does not mean “not feeling.” Rather, it means regulating emotions so one can accept, learn from, and move toward integrating them. The ability to modulate feelings results in a decrease in the fear and distress related to experiencing them. An additional benefit is the knowledge that one can influence the intensity of emotions rather than feeling controlled by them, which itself is empowering.

Clients need encouragement to sit with their feelings long enough to practice modulating them. The idea that people can modulate their emotions may surprise clients who have learned that emotions control people, rather than the other way around. Modulating feelings is a learned skill, and thus clients need to be provided with the necessary information and tools.

Once clients can recognize, tolerate, and modulate feelings, they can begin to learn from them and integrate them. Integrating feelings means interweaving emotions with their context. This means that an individual can become aware of a feeling state and link it to a bodily sensation, the events and experiences that preceded or gave rise to the feeling this time, past experiences of this feeling, and ways she has responded to it in the past. Integrating feelings also means incorporating them into the narrative or story of one’s life, so that one can make sense of them within a broader framework of self- understanding. For example, a person may come to realize that when she is with someone who does not respect her, she gets a stomachache. Through reflection, she may understand that the stomachache is a sign of feelings of worthlessness. She may further link this to her childhood experiences of an older sibling diminishing her. Having a stomachache was a way to end the taunting because her mother would suggest she lie down in her room for a while to rest.

Developing Affect Management. Traumatically bereaved clients may feel that painful, unfamiliar emotions arise suddenly, without apparent context. It can be useful to invite such a client to develop a “thinking – feeling – doing” continuum. When the client reports being unable to understand the source of his feelings, you can suggest that the next time he is surprised (or overwhelmed) by a feeling state, he should write down what he remembers thinking, feeling, and doing just before he became aware of the emotion. Filling out this timeline backward (e.g., right before the feeling came up, the hour before, that morning, the night before) until the client reaches a possible point of origin for the feeling can provide a context for it. This demystification of emotions may help to reduce hypervigilance, because it helps clients feel greater control over their emotional states and thus better able to tolerate strong feelings when they arise.

The Risking Connection trauma training curriculum (Saakvitne et al., 2000) offers another type of feelings continuum: The therapist invites the client to develop a variety of names for related feelings states. This exercise helps the client differentiate feelings and their intensity; rather than simply “sad,” the client might start at one end of the continuum with “desolate” and move through “despondent,” “melancholy,” “unhappy,” and “blue” to ”down.” The significant connotation of each word is the client’s; the order of intensity or level of distress implied by each word is less important than the client’s observation that she can feel bad without being at the most intense end of her own continuum for that feeling state.

More generally, some research has suggested that resilience- building behaviors can increase affect management capacity by increasing hippocampal volume, decreasing amygdala activity and size, increasing serotonin and endorphin production, and activating the prefrontal cortex (Southwick, Litz, Charney, & Friedman, 2011). Relevant resilience- building behaviors include physical exercise and adequate sleep (McEwen & Gianaros, 2011; Pietrzak, Morgan, & Southwick, 2010), developing role competence and confidence (Johnson et al., 2011), practicing gratitude (e.g., Emmons & Mishra, 2011), and other activities discussed elsewhere in this chapter (e.g., meaning making, cognitive appraisal, and social support).

Developing role competence means enhancing one’s ability to fulfill such roles as worker, parent, or student. Guiding clients to resources for learning needed skills can help with this. Confidence comes about in part through the therapist’s attention to and reinforcement of what the client is doing well and questioning self- deprecation where appropriate (e.g., through the use of Handout 13, the Automatic Thought Record, as described in Chapter 11). Clients also gain confidence through successfully navigating tasks, including the tasks of the treatment.

Coping Skills

In this treatment approach, we view coping skills as activities and strategies that comfort, calm, soothe, or support an individual. Augmenting these skills contributes to the development of self-capacities; the client learns to recognize that she has strategies for managing strong feelings, and this recognition in turn increases both her affect management and her sense of self-worth. We have identified a number of coping strategies we believe are particularly useful for clients with traumatic bereavement. We recommend engaging in self-care and pleasant activities (see Handout 4, Self-Care); breathing retraining (described in Handout 7, Breathing Retraining); using social support (see Handout 18, The Importance of Enhancing Social Support); and addressing automatic thoughts (see Handouts 10, What Are Automatic Thoughts?, and 11, Identifying Automatic Thoughts Worksheet). We offer multiple strategies because different clients prefer different strategies. We recommend that clients choose the coping strategies they prefer, as long as those strategies address the issues each client is facing.

In this section, we discuss two important aspects of helping clients to develop their coping skills: integrating coping skills into this treatment, and addressing obstacles to coping behavior. Again, the therapeutic relationship is the crucible for the client to practice, refine, and broaden his repertoire of coping skills. Your therapeutic encouragement and consistency in discussing coping skills will support this growth; in turn, this will promote the client’s ability to do the challenging work of confronting the loss, thereby facilitating movement through the six “R” processes of mourning.

Most practitioners would agree that ultimately, survivors must relinquish the avoidance that enables them to evade distressing thoughts and feelings associated with the death (Shear, 2010). In treating survivors of traumatic bereavement, therapists sometimes try to break down clients’ avoidance by forcing them to do something before they are ready. Part of the art of this treatment is guiding a client and supporting him through challenging experiences without colluding in problematic avoidance or coercing him. With practice, the use of a fear and avoidance hierarchy (see Handout 25, the Fear and Avoidance Hierarchy Form), and feedback from the client, you will develop the ability to tune in to each client’s needs and to present exposure assignments that will help the client move forward through the “R” processes.

integrating Coping skills into the Treatment

We recommend assigning coping activities in every session. These activities support the client in his recovery process and help him develop both strategies and the habit of using them outside the therapy room. The best way to do this is by emphasizing the importance of coping skills at the outset of treatment, inviting the client to create a list of current strategies, and working on expanding the list together over time. Toward the end of each session, ask the client which coping strategy he would like to engage in, experiment with, or practice over the week ahead. As noted above, some therapists may be inclined to introduce coping strategies that focus exclusively on dealing with the loss. However, it is also important to introduce restoration-oriented coping strategies, such as doing new things, and meeting new people. You can introduce these strategies as part of the work with the client on values and goals, described in more detail below. At the beginning of each session, it is important to inquire about the coping behaviors the client has used since last time, to ask how things went, and to address any problems.

Addressing obstacles to Coping Behavior

Clients may be reluctant to engage in certain coping activities, particularly self-care and pleasant activities. It can be helpful to acknowledge that such activities are important, even though they may require a client to push herself. Positive coping activities can create guilt about focusing attention on oneself or feeling good in the context of a significant other’s death. The client (or her culture) may have explicit or implicit strictures about laughing, celebrating, or displaying positive emotions. In one case, a mother who lost an infant organized a birthday party for her 10-year-old. She felt hurt by the criticism she received that having a party was inappropriate during a period of mourning.

The client may believe (and it may be true) that others will disapprove if she attends to her own needs. In fact, many clients report that they had difficulty attending to their own needs even before the loss. These individuals may need to start with small attempts at self-care and pleasant activities. The therapy should explore beliefs related to self-care, coping, and pleasant activities, and use the cognitive processing techniques described in Chapter 11 to address them. For example, you and a client may agree that reaching out for social support by asking a friend to go to the gym with her would be a good thing to do. You may ask the client what thoughts come up for her as she thinks about doing this. The client might report something like “People at the gym will think I’ve forgotten my husband.” You could ask, “What would that say about you as a person?” The client might say something like “I’m selfish.” You and the client can then explore this belief – a possible instance of an automatic thought – by using Handout 13, the Automatic Thought Record.

Pain can be a way of staying connected to the deceased. The client may fear that enjoying life would be a betrayal of her deceased loved one or that she would lose touch with him. Again, automatic thoughts may come into play here, and you and your client can use the Automatic Thought Record to explore them as appropriate.

Social Support

Social support is one of the most frequently studied coping resources. It is usually defined as the emotional and physical comfort that people receive from those in their social network, including family members, friends, co- workers, and neighbors. Effective social support helps people to feel loved, cared for, valued, and understood. Social support reduces the impact of major life events or chronic strains on health and well-being (Thoits, 1995). Based on this knowledge, interventions designed to enhance social support have been developed for those experiencing a wide variety of stressful life events, including the sudden, traumatic loss of a loved one (e.g., Murphy, Lohan, Dimond, & Fan, 1998).

Empirical studies have provided mixed support for the idea that social support protects the bereaved from the deleterious effects of loss (W. Stroebe, Zech, Stroebe, & Abakoumkin, 2005). However, few studies have examined the effects of social support on survivors of sudden, traumatic death. In one of the few studies to assess social support in this context, Murphy, Johnson, Chung, and Beaton (2003) followed parents for 5 years after their child’s death by accident, suicide, or homicide. Perceived social support was one of only two variables studied that predicted a decrease in PTSD symptoms over time. In a more recent review of risk factors for poor outcome following the violent death of a loved one, Hibberd and colleagues (2010) also concluded that social support protects survivors from the development of PTSD.

  1. Stroebe, Stroebe, Abakoumkin, and Schut (2005) have found that a variable called emotional loneliness is critically important in understanding spousal loss. These authors indicate that, contrary to popular belief, social support does not influence emotional loneliness. Widows and widowers report that even when they are with other people, they still feel deeply lonely because they miss their spouses. These results are troubling because bereaved individuals usually exhibit high levels of emotional loneliness for years (van Baarsen et al., 1999). Consequently, attention should be focused specifically on emotional loneliness and its ramifications for a widowed client.

We believe that survivors of sudden, traumatic death will benefit from a full consideration of issues surrounding support. We provide specific strategies for improving support below.

Developing Social Support

Initially, it is important to provide a rationale to the client for increasing useful social support and staying connected to others. At this point, we recommend giving the client Handout 18, The Importance of Enhancing Social Support, which provides a list of reasons for strengthening a personal support network as discussed above. It can be useful to ask the client specifically whether he has found himself withdrawing from others. If so, you can go through the list of reasons for social withdrawal (see Handout 19, Building Social Support) and ask the client whether these are true in his case. It is important to validate the client’s desire to withdraw from others who make hurtful comments, while also exploring how the client can deal with such comments when they occur.

Next, you should ask the client about his current support network. Handout 19 can serve as a guide in eliciting information from the client, as a reference for the client to help him to assess his support network, or both. You and the client should establish who is in the network, which network members provide effective support, which members were in the network prior to the loss but have backed away, and so forth. If the mourner has difficulty providing such information, you can mention broad categories of people and ask whether specific people in that category have been supportive or unsupportive. Such categories might include parents, siblings, friends, co- workers, neighbors, and members of the client’s faith community.

Drawing from this conversation, the next step is to guide the client in making a list of the types of support that she needs now. Some clients may need tangible assistance. For example, a widow may need help with household projects such as shoveling snow. Although the mourner may be reluctant to request such help, you might mention than many people find it valuable and meaningful to be in a helping role. Another client may be in need of a good listener – a person who allows the mourner to express his thoughts and feelings, and who accepts these feelings without judgment. Still another client may benefit most from being around friends who convey their love and concern, or who are willing to invite the mourner to share their daily lives without needing to focus on the loss. Once the client generates the list, you should assist him in going through it to identify people who would be particularly appropriate for providing specific kinds of support. Next, you can work with the client to generate small goals that involve relating to others (e.g., the client might call an old friend to see a movie or go for a walk). You may want to identify one or two of these goals together to schedule as independent activities, perhaps as part of the values and goals work described below.

Alternatively, you and your client may plan exposure activities (discussed in more detail in Chapter 11). This approach suggests establishing a hierarchy for the list of goals involving social support, and then addressing them from the easiest to the more difficult. The client may have to create social events that fit into his hierarchy, rather than waiting for social opportunities to arise.

In generating the list of social support goals, both you and the client should try to identify barriers to seeking support. If the client is unable to carry out the goals you agreed upon during the previous session, a discussion of potential barriers may prove fruitful. For example, a woman may decide not to attend a social gathering because she believes that others don’t really want to see her. If you so desire, you can add this situation to the client’s hierarchy, then structure one or more exposure tasks to fit into the treatment at the appropriate juncture. You can also use Handout 11, the Identifying Automatic Thoughts Worksheet, to address underlying beliefs that impede the client’s ability to seek social support.

You can use Handout 19, Building Social Support, to explore the kinds of social responses that others have made to the client and the feelings they elicited. You should validate the client’s anger and frustration with those who provide unhelpful support. One mother who lost her child had difficulty spending time with her sister, who cried the entire time they were together. “I felt that I had to take care of her,” said the mother. In such situations, it may be beneficial to encourage the client to minimize contact with unhelpful people.

You can help the client to educate potential supporters about traumatic bereavement and about the types of responses that she finds helpful. Shear has developed an innovative approach to creating more effective support (see, e.g., Shear, Boelen, & Neimeyer, 2011). The client is encouraged to invite a family member or friend to a session. The therapist discusses issues pertinent to support provision and also provides psychoeducation.

For clients who are particularly troubled by the insensitive comments of others, it is important to help them understand why others make such comments. It may be worthwhile to encourage clients gently to consider the situation from the potential supporters’ point of view. You may wish to initiate a discussion about why others behave the way they do. Of course, most potential supporters have never experienced a loss of this sort, so they are simply not able to comprehend the human suffering that is unleashed. Moreover, for people who have not experienced a traumatic death, interacting with someone who has can evoke discomfort, anxiety, or fear. Such feelings may lead potential supporters to blurt out inept comments that inadvertently hurt the survivor. Others’ painful remarks usually result from lack of information or social discomfort, and not simply callousness. In fact, some mourners have stated that prior to their loss, they would not have understood what survivors are dealing with, and that they would have been just as insensitive to survivors of traumatic loss as their supporters are to them (Dyregrov, 2003 – 2004).

Mourners also find it helpful to tell others what they believe to be important elements of their loved one’s death. For example, one couple lost a son as a result of a motor vehicle crash. Following the crash, he was rushed to the hospital, but he had extensive brain damage. This couple wanted their closest friends to understand the difficulties they had in removing their son from life support. Sharing such information provides common ground, enhancing the likelihood that support attempts will be on target.

Overall, survivors stress the importance of relating to others with openness and honesty. Many advocate giving clear signals to others regarding the kinds of support that are useful and appreciated. As Dyregrov (2005 – 2006) has noted, “thereby the ineptitude of social support networks could be diminished, and well- intentioned initiatives that result in unhelpful or even harmful support could be avoided” (p. 356). Dyregrov’s (2003 – 2004) respondents indicated that social network members who had themselves experienced sudden, traumatic deaths provided the most helpful responses (see also Lehman et al., 1987). These findings suggest that it may be worthwhile to ask a survivor whether anyone in his social network has experienced traumatic loss. Interactions with such an individual can be extremely effective in validating the client’s concerns and providing assurance that his feelings and behaviors are normal. In our experience, even someone on the periphery of the network – for example, a colleague at work whom the survivor does not know very well – may be an excellent source of support if he has experienced a similar loss.

Some clients may benefit from attending a support group for individuals who have experienced similar losses. Such groups may be particularly valuable for those who have few social relationships. However, there are considerable differences in how such groups are run, and whether there is any involvement by knowledgeable professionals. Some groups base interventions on grief models that lack empirical support, such as stage models. We strongly advocate making referrals only to groups with which you are familiar.

In addition to the direct benefits that stem from effective support, supportive ties also provide a context for work on other important issues. A survivor who has been avoiding a certain activity, such as going to temple or church, has a better chance of addressing the problem if she has a network of friends who encourage her to go and offer to accompany her. Supportive relationships can also help survivors begin investing in the future by exposing them to new people, ideas, and activities.

internet support resources

An increasingly important source of support for the bereaved is the Internet. As Stroebe, van der Houwen, and Schut (2008) have noted, there has been an explosion in the number and types of Internet resources that offer support for bereaved individuals. Many clients seek information or support over the Internet before coming to treatment. (For informative reviews of bereavement support services on the Internet, see Dominick et al., 2009 – 2010, and Sofka, Cupit, & Gilbert, 2012.) Sofka and colleagues (2012) argue that modern communication technology has had a profound influence on how we think about grief and how we attempt to come to terms with it.

There are two broad categories of Internet resources that, in our judgment, can provide support for bereaved individuals: sites providing information about grief or online support groups, and sites serving primarily to memorialize or pay tribute to the deceased. Because each of these categories has the potential to provide unique sources of support, we describe them separately below.

information and internet Support groups

Most websites designed to deal with grief and loss provide information about the mourning process, message boards, books about grief and mourning, and chat rooms, which afford opportunities for online interaction with others who have experienced similar losses. Gilbert and Horsley (2011) offer a cogent discussion of the appeal of such websites: They are available around the clock; they offer anonymity; and they offer support that may, for a variety of reasons, be difficult for a survivor to find elsewhere. Gilbert and Horsley maintain that interactions over the Internet are particularly valuable for mourners who do not feel comfortable in social situations. They give the example of a person whose loved one committed suicide. As described earlier, such individuals often feel that others blame them for what happened or are unsympathetic. The Internet can serve as a refuge for such people, who say that for once they are welcomed and encouraged to share their feelings.

In our experience, online communication can also be especially valuable to a survivor who, because of the type of loss that occurred, will have few opportunities to interact with similar others. Certain types of losses may raise unique issues that are best supported by those whose losses are similar. For example, parents who lost their only child may find it more beneficial to interact with similarly bereaved parents, as some of their concerns are not the same as those of parents who have surviving children. In addition, mourners who are disenfranchised, such as some gays or lesbians who lose life partners, or people who have been divorced, may find support online that is not readily available elsewhere. The website GriefNet ( has over 50 different bereavement support groups. Many of these are quite narrowly focused, such as death resulting from medical errors, from a murder – suicide scenario, or from a drug overdose (Lynn & Rath, 2012).

As is the case for support groups, however, online chat rooms are often unmoderated. Most sites do their best to remove posts that seem likely to cause distress. Nonetheless, a survivor may encounter members who are highly critical of how he is coping with the loss, which could undermine his motivation to continue to seek support. It is important to explore the client’s use of these types of support, in much the same way as you inquire about support from network members. This practice will allow you to assist the client in evaluating the positive and negative dimensions of all these resources. You should also monitor whether Internet use contributes to a client’s isolation by decreasing face-to-face contacts (Stroebe, van der Houwen, & Schut, 2008).


internet memorialization

The Internet is also increasingly used to commemorate the deceased and to create memorials (Gilbert & Horsley, 2011). People contribute narratives about their relationship, as well as poems, artwork, photographs, music, or videos. An advantage of such memorials is that they allow the bereaved to “honor their dead in their own way and at their own time” (p. 368). A major trend in how people handle their grief today is the use of social networking sites, such as Facebook, MySpace, and Friendster. Given the role of these sites in facilitating social connection, it is perhaps not surprising that they play an increasingly influential role in coming to terms with the loss of a loved one. As Fearon (2012) has indicated, these sites provide a vehicle for survivors to connect with other mourners. This vehicle is particularly popular with young people, who have grown up with Internet use and are very comfortable with it.

By far the most influential of the social networking bereavement sites are the Memorial Groups established by Facebook. These groups are typically created by a friend of the deceased. In a qualitative study of Facebook Memorial Groups, Fearon (2011) has identified a variety of purposes that such a group can serve. The first is that members feel that they are part of a group – a group linked together by their connection to the deceased. This is particularly important for mourners who are isolated (socially, geographically, or both) and have little opportunity to interact with other mourners. As one member expressed it, “By visiting the site, I could see that I was not alone.” Second, these groups provide an outlet for those who wish to memorialize the deceased and create a lasting testament to his life and identity. Heartfelt comments from friends can console survivors and demonstrate that the loved one had an impact on the lives of others. As one bereaved parent expressed it, “It was not until we read the comments on Facebook that we saw how many lives our son had touched.”

A Facebook Memorial Group also creates a community where mourners can give and receive support. Nearly 90% of Fearon’s (2012) respondents acknowledged that they used such a group to initiate or maintain a connection with other mourners. The group provides validation for the magnitude of the loss and for the distress resulting from it. In many cases, it appears that writing about one’s feelings on a website has advantages over discussing them with people. As one group member indicated, “It is a way to share how much I am hurting without directly making someone feel uncomfortable” (quoted in Fearon, 2012, p. 67). Stroebe, van der Houwen, and Schut (2008) maintain that Internet memorialization may be particularly beneficial for disenfranchised grievers – that is, people who experience a loss that is not openly acknowledged or validated. For example, a woman may be confronted with the death of a man with whom she was having an extramarital affair. She may feel uncomfortable discussing this loss with anyone.

An important feature of these groups is their continuity over time. Mourners can continue to use a Memorial Group as long as they wish. As one mother indicated approximately a year after her daughter’s death, “Every so often I go on the site so that I can reminisce about her life, and see if there are any new posts from her friends.” Survivors can also use the site to share information about new events to honor the loved one, such as a candlelight vigil to be held on her birthday.

An intriguing feature of these Memorial Groups is that in many cases, mourners leave messages directed toward the deceased (Williams & Merten, 2009). In reviewing posts from the members of several groups, Fearon (2011) found that about half of the participants he studied regarded one or more posts as a direct communication to the deceased. Some participants remarked that they found it healing to talk to the deceased. One person stated, “When I post something on [his] wall it makes me feel like I’m actually connecting with him even though I know I’m not” (quoted in Fearon, 2011, p. 63). Others believed there was a chance that their remarks would be read by the person who died. As one Memorial Group member stated, “Who knows? Maybe there is a Facebook in Heaven that she is reading, and seeing everything we say” (quoted in Fearon, 2011, p. 78). Available evidence suggests that these messages are motivated by the wish to maintain a continued connection with the deceased. Stroebe, van der Houwen, and Schut (2008) have emphasized that despite the widespread use of memorial sites, it is unclear whether memorializing the deceased “helps people work through their grief and toward accepting that the loved one is gone, or whether it… causes people to get stuck in or fixate on grieving” (p. 560).

To maximize the benefits that can accrue to your clients and to minimize the risks, it is important to touch base with them about the use of Internet resources such as Memorial Groups. Clients will benefit from your openness to their seeking information and support on the Internet, and your willingness to consider and examine these resources collaboratively. Equally important is your exploration of how clients are perceiving and processing this information and support.

Bereavement-specific issues

As mourners attempt to move forward in dealing with the loss, it is common for them to encounter bereavement- specific issues. These are situations, events, or experiences that evoke powerful (and often unanticipated) feelings of acute grief. Bereavement- specific issues reawaken intense grief and trauma responses that may have diminished to some extent. In this section, we describe bereavement- specific issues and discuss ways to address and manage clients’ reactions to them.

Rando (1993) has termed such an acute grief response a subsequent temporary upsurge of grief (STUG) reaction. Rando’s term emphasizes the secondary and temporary nature of such a reaction; that is, it occurs after the initial period of intense grief has subsided and in response to a specific trigger. The term STUG indicates that the reaction represents an upsurge of something that had decreased in intensity or become dormant when the person encountered the triggering event. Some therapists use terms like waves or spurts of grief.

In the case of traumatic bereavement, bereavement- specific issues can evoke grief or trauma responses that were not anticipated. Fortunately, with treatment, these responses are likely to be less intense than, not to last as long as, and to come less frequently than the mourner’s earlier (pretreatment) trauma responses to the same triggers.

The power of bereavement- specific issues lies in their ability to underscore the absence of the deceased, and often, to do so when one least expects it. Such bereavement- specific issues may occur long after a death. For example, Jane, whose husband had died 10 years earlier, experienced acute grief when her son received a prestigious award and her husband was not there to see it. Renaldo, whose wife had died on their honeymoon years earlier, had a nightmare of her death the night after he proposed marriage to another woman.

At times, the situation that precipitated an intense grief reaction is itself unexpected, as was the case when Sabrina ran into her deceased daughter’s best friend at the hairdresser. On other occasions, the intensity of the grief or traumatic stress may be what is surprising. This was the case for Emmett, a widower who experienced panic attacks while at a conference with colleagues. Emmett had anticipated that the conference might be difficult for him, since many of his colleagues brought their partners along, but he never expected his responses to feel overwhelming and incapacitating.

It is common for these reactions to occur in social settings. For example, a woman whose son was killed may be approached by an acquaintance unaware of the death, who asks how her son is doing at college. In most cases, both parties may experience such encounters as awkward. The survivor is typically caught off guard and feels confused about how to respond. Following the encounter, she may experience feelings of humiliation because she believes she responded inappropriately. The intensity of the survivor’s distress can lead her to question whether she has made any progress in dealing with the loss.

It is important for therapists and clients alike to know that strong responses to bereavement- specific issues are a normal part of the mourning process. As a clinician, you will be better able to assist clients if you recognize the types of situations that can trigger STUG and traumatic stress reactions along the path of mourning. In fact, a STUG or traumatic stress reaction after a period of relative calm may be the reason a client seeks treatment.

Rando’s (1993) three-part categorization of triggers of STUG reactions can help both you and your clients to anticipate such situations. The first category includes cyclic events, such as anniversaries, holidays, seasonal changes, and repetitive rituals (e.g., an annual family vacation to the beach). Many survivors experience these occasions as relentless and brutal. Regarding her deceased child’s birthday, one mother asked, “How could I observe the day this child entered the world without completely falling to pieces? Yet how could I not observe it?” (Mehren, 1997, p. 89). Another mother, who lost her 10-year-old son, stated, “Last year I took Johnny and his friends to a theme park for his birthday. This year, I spent his birthday at the cemetery.” As another survivor indicated when discussing family occasions, “When we’re all together, we’re not all together” (Wolterstorff, 1987, p. 14). Mourners may also have difficulty with innocent questions from others about their holiday plans, such as “Will the family all be home for the holidays?”

Rando’s (1993) second STUG category is linear events, which are events that occur as a function of reaching a particular age, time, or state. Unlike cyclic events, these are one-time occurrences. A major one occurs when the mourner reaches the age of the person who died, in cases in which that person was older than the mourner at the time of the death. In other cases, these events are associated with particular occasions, such as graduations and weddings. Such events can be agonizing for parents who have lost children before they have achieved this milestone. A single mother who had lost her teenage daughter was invited to the wedding of her niece. Since she and her niece were close, she decided to attend. She became so distraught at the ceremony that she quietly slipped out the back door so as not to call attention to herself. Before she could drive away, two members of the congregation came after her and tried to comfort her. This only made her feel worse. “I felt terrible about leaving in the middle of the service,” she said, “but I had to get out of there.”

Some linear events are associated with particular stages in life. For example, Amy and Joan were life partners who had planned to retire when they both turned 65. After Amy’s death, Joan experienced intense distress when she turned 65 and had to face retirement alone. Another type of linear event is related to life crises, such as losing one’s job or being diagnosed with a life- threatening illness. At such times, it is common for the mourner to experience intense yearning for the security and comfort the loved one would have provided.

Rando’s (1993) third category is stimulus- cued precipitants, which are reactions to stimuli unrelated by time. Some of these are memory- based, as when a bereaved husband encounters a woman who is wearing the same cologne that his wife used to wear. In other cases, the event may serve as a powerful reminder of the person who died, as when “Daddy’s Little Girl” is played at weddings.

In some cases, someone may ask the survivor a question that evokes thoughts of the person who died. For bereaved parents, some of the most excruciating precipitants of STUG reactions are questions about how many children they have. Should a parent mention that he had three children but that one has died, and endure a painful and awkward scene? Or should he simply answer by giving the number of children who are alive now? Mourners typically experience this as a no-win situation. As one woman who opted for the second approach explained, “In one cold syllable, that response invalidates your child’s existence.” Other questions pertaining to their children are also likely to be quite painful for bereaved parents. For example, an acquaintance who is unaware of the death may ask, “What are your children doing now?”

Stimulus- cued precipitants may have a higher likelihood of evoking trauma responses because of their unexpected nature. For example, a father who had lost his youngest son took his two surviving sons on a camping trip. He was pulling them up a hill in a wagon when a passer- by commented, “Aren’t you glad you don’t have three?”

Typical responses to traumatic death include feeling helpless and out of control. As a woman who lost a child expressed this feeling, “I’m not in charge and I know it” (quoted in Finkbeiner, 1996, p. 187). No matter where they go or what they do, survivors of traumatic bereavement never know when they will encounter painful reminders of their loss. STUG and reawakened traumatic stress reactions such as those described above contribute to these feelings. Furthermore, each successive experience of lack of control can reinforce a sense of helplessness, impeding trauma recovery.

The fear of encountering triggers of STUG reactions often discourages the traumatically bereaved from being actively engaged in the world. This fear reinforces the tendency to withdraw from others, which can keep the survivors stuck in their grief and can interfere with healing. Finally, as described previously, available studies suggest that survivors of sudden, traumatic death are less likely to receive effective support from family members and friends than those whose loved ones died from natural causes under circumstances that were not traumatic. Thus survivors of traumatic death are likely to experience STUG reactions against the backdrop of others’ disapproval and insensitivity. In many cases, STUG reactions may fuel others’ insensitivity. This is particularly the case when survivors show signs of distress in a public setting. Recall the example in Chapter 4 of Peggy, who had lost her infant son and was attending her sister’s baby shower. She had reservations about going to the shower because she knew it would evoke feelings of sadness regarding her loss. Because she and her sister were very close, she decided to go. She was determined to keep her emotions under control, but she did become tearful from time to time. After the shower, she overheard her mother criticize her to a friend, stating that she was so focused on her own tragedy that she could not be happy for anyone else. Peggy felt angry at her mother and hurt by her comment. She also questioned whether she should have stayed home to protect herself and others from her obvious distress. Later, she wondered whether her pain was simply too much for her mother to bear.

Addressing Bereavement-specific issues

How should therapy address STUG reactions such as those described above? First, it is important to help clients normalize what is typically a painful and bewildering experience. Second, clients will benefit from understanding the types of situations that are most likely to trigger trauma or STUG reactions. Third, you can assist clients in developing strategies for dealing with their fear that a bereavement- specific issue may arise. Finally, you and your clients can discuss ways they can respond when they encounter such situations, including how to manage trauma or STUG responses.

In many cases, bereavement- specific issues may appear to be small and inconsequential. For example, a man whose wife has died may become distraught when someone phones the house asking for his wife. In addition, clients regard their reactions as diagnostic of how well they are coping. Clients may infer that they are not making “progress” in dealing with the death if they continue to be caught off guard by sudden, intense rushes of overwhelming sadness or anxiety. Such experiences may lead them to believe that the treatment is not working. Consequently, clients may lose interest or confidence in employing strategies to deal with their loss. If you can normalize these responses, clients may become less self- critical and willing to invest in the treatment. In addition to helping the client understand that these reactions are normal, it may be useful to remind him that healing from trauma and accommodating grief are not linear processes. In other words, the natural progression in treatment may include rough patches – days when the grief and trauma symptoms are stronger than they were days, weeks, or even months earlier.

Clients may not raise the issue of trauma or STUG reactions because they may feel ashamed that they are still experiencing such intense feelings, believe that their reactions reflect badly on their coping abilities, or worry that they are letting you down. Knowledge of each client’s unique situation, as well as of possible bereavement- specific issues that most survivors face, will facilitate the process of eliciting and discussing the client’s reactions (Handouts S5, Bereavement- Specific Issues, and S6, Getting through the Holidays: Advice from the Bereaved, available on the book’s website supplement, will also be helpful in this regard.) Gentle probing about how the client felt during a recent potentially evocative event, such as a wedding or a funeral, may be productive. It is helpful for the therapist to be aware of situations that may increase the likelihood that a STUG reaction will occur. For example, people are likely to ask a pregnant woman whether she has other children (e.g., “Is this your first?”). This question may prompt a STUG reaction from a woman who has previously lost a child.

It is important to assess how the client’s feelings about past STUG reactions or her fears that future ones may occur have affected her coping strategies. For example, is this issue reinforcing the survivor’s tendency to withdraw from social encounters? Together, you and the client can work to develop coping strategies that will reduce the likelihood of the client experiencing future trauma or STUG reactions in a particular setting. For example, the two of you may decide together that the client would benefit from using breathing techniques to regulate emotional distress if she has such a reaction.

Drawing from your understanding of bereavement- specific issues, you can also assist clients in developing coping strategies to reduce the likelihood that a trauma or STUG reaction will occur. Because holidays raise a host of bereavement- specific issues, it can be useful to address them in advance. As noted above, a handout on this book’s website supplement (Handout S6, Getting through the Holidays: Advice from the Bereaved) describes the dilemmas that clients typically face during holidays, as well as possible coping strategies. Similarly, you can work with clients to strategize how they can approach other potentially challenging upcoming events, including anniversaries, funerals, and commemorations of the anniversary of their loved one’s death within their faith communities. Survivors will benefit from an open exploration of whether they should attend such events or not. For example, in helping a Jewish mourner decide whether to attend a commemoration of his loved one’s death at the temple, it is important to explore ways to balance his natural wish to avoid painful reminders with the potential value of including himself in his community’s commemoration practices. If he decides to participate, you can discuss ways he can proceed that will give him some sense of control. Such participation can provide an opportunity for growth when it is used as an exposure activity, as described in Chapter 11.

In some cases, clients experience a STUG or trauma reaction in a situation that they are likely to encounter again. This is the case for parents who have lost a child. As discussed previously, it is common for parents to be asked how many children they have, and this question typically evokes great distress. Clients’ tendency to be critical of the way they responded can increase their distress. Many clients then live in fear that they will be asked this question again. These fears are exacerbated in situations where they will be meeting people for the first time, such as a luncheon for new parents at a surviving child’s school.

Such a client may fear that the question will require an explanation about her child’s death, or that she will cry while providing such an explanation. The client may have the automatic thought that crying in front of someone else at this point in the mourning process may make her look out of control. You and the client can explore this thought, examining how likely it is that someone would label crying while in such a situation as “out of control.” If someone reacts negatively to a survivor in such a situation, you and the client can use Handout 13, the Automatic Thought Record, to address the issue of whether this is more of a reflection on the client or a possible indication of discomfort of the person who reacted to her crying. Alternatively or in addition, you may choose to deal with the same situation behaviorally. The intensity of STUG reactions may be driven in part by the client’s concerns about how she appears to others. Responding naturally in social situations that tend to prompt STUG reactions will be more difficult at first, but will gradually become easier with practice. In this way, the client can use the idea of exposure to lessen her anxiety gradually about appearing distraught when she encounters traumatic stimuli. Reducing the anxiety related to how others perceive the survivor may help to decrease the impact of situations that provoke STUG reactions and trauma responses.

You and the client may choose to design role-play or exposure activities (described in Chapter 11) in which the client practices disclosing information about the loss to you, in order to prepare for this type of question. This type of exposure may also be pursued with the help of a supportive friend or family member. Preparation may require a joint session with the client and the support person in which you help the client to explain his concerns (e.g., “I’m afraid that people will be horrified if I cry when they ask me about what my children are doing now”). You may then coach the client and support person through a discussion or role play to help overcome this fear.

In addition to providing validation for the client’s distress about bereavement- related challenges, you should praise attempts to deal with these issues even if they are not entirely successful. Clients may tend to focus only on how they behaved and felt in a situation, and may fail to acknowledge the role of the other people involved. At times it may be useful to validate a lack of social skills on the part of others, and to help clients process whether others’ behavior is the norm. Such acknowledgments may give clients hope about pursuing future social situations and avoiding maladaptive coping strategies, such as spending most of their time at home to avoid trauma and STUG reactions.

In sharing their thoughts and feelings about bereavement- specific issues, mourners can both anticipate and decide how to respond to them, restoring an element of control. Through these processes, they may be able to develop principles to guide their behavior when they encounter new bereavement- specific issues. For example, a survivor may decide to respond to any threat to his composure by taking several deep breaths and then asking himself, “How do I want to respond to this situation?”

meaning and spirituality

Following the traumatic deaths of loved ones, many survivors become engaged in an intense and prolonged struggle to make sense of what has happened. Beliefs that they have held for their entire lives – such as “God is loving and protects us from harm,” or “If we lead a good life, we will be rewarded” – are typically shattered by such losses. Survivors are likely to feel confused, betrayed, and uncertain about their connection to God or their spirituality.

In recent years, there has been increasing interest in understanding the conditions under which people seek meaning and the ramifications of not being able to find it (Gamino & Sewell, 2004). Both researchers and clinicians have maintained that one of the most significant new developments in the field of bereavement is the recognition that grief is essentially a process of reconstructing a world of meaning and purpose – a world that has been called into question by the loss (Neimeyer & Sands, 2011; Stroebe & Schut, 2001a).

Over the past decade, studies have emerged that provide support for the importance of finding meaning. In one study, Currier and colleagues (2006) focused on a large sample of college students who had experienced the violent deaths of loved ones through accident, homicide, or suicide. They found that participants’ ability to make sense of what happened accounted almost entirely for the relationship between the violence associated with the death and complicated grieving. According to these authors, “failure to find meaning in a loss is… a crucial pathway to complicated grief” (p. 403). Keesee, Currier, and Neimeyer (2008) obtained similar findings in a study of parents who lost a child. Parents who reported having made little or no sense out of their children’s deaths experienced more intense grief.

Regardless of the benefits that it might confer, research has shown that finding meaning may be an unrealistic goal for many people who have experienced the sudden, traumatic death of loved ones. As we have described in Chapter 3, this was the case for survivors who experienced the traumatic loss of a spouse or child (Davis et al., 2000; Lehman et al., 1987; Murphy, Johnson, & Lohan, 2003b). Most mourners indicated that they searched for meaning, but relatively few were able to find it. When asked how they felt about this, most survivors reported that it was painful that they could not make sense of what happened. A significant minority of respondents indicated that they never searched for meaning. Some of these people had found meaning, but others had not. Those who were not preoccupied with the issue of meaning showed the best adjustment.

As discussed previously, there are many different ways of finding meaning in a loss. Lichtenthal, Currier, Neimeyer, and Keesee (2010) conducted a study designed to identify specific themes of meaning or sense making among parents who had lost children. The most common response, made by 44.9% of the parents, was that no sense could be made of these deaths. Other responses included viewing it as God’s plan, or assuming that God knows what is best (17.9%); believing that a deceased child is safe in heaven and will be reunited with the parent (16%); and believing that suffering and death are inevitable (10.9%). Other ways of finding meaning included working to help others who had experienced similar losses; developing new goals or

Building Resources

a new purpose; placing the loss in a spiritual context; or finding benefit or redeeming features in the deaths. Most experts believe that the search for meaning requires a certain amount of reflection on a mourner’s part. However, many survivors of traumatic bereavement report that it is difficult to reflect on the meaning of their losses. Doing so evokes disturbing thoughts about the loved one and his death.

Many mourners report that those in their social environment are uncomfortable with discussions about meaning. As one woman expressed it, “I was outraged that God took my beautiful and brilliant daughter, who had dedicated her life to serving others, instead of one of the rapists, murderers, or thugs who populate society. But no one wants to listen to an incensed mother who is raging at the fates.” People may be more likely to make progress in dealing with issues of meaning with the aid of a therapist than on their own. It is also important to avoid assuming that a client is struggling with issues related to meaning, or to push her to do so.

Addressing Meaning and Spirituality

As a therapist, what can you do to help? We recommend taking a nuanced approach, listening for indications that the client is struggling with issues of meaning, and validating his feelings. Clients may find Handout 31, Spirituality, useful to this work.

Robert Neimeyer and his associates (Neimeyer, 2000a, 2001, 2012; Neimeyer, Burke, Mackay, & van Dyke Stringer, 2010) have suggested that therapists can facilitate meaning making by assisting clients in a process they call narrative repair. They maintain that if life is viewed as a story or narrative, tragic loss can be regarded as disrupting the coherence and continuity of the narrative. According to Neimeyer, such a loss “can occasion profound shifts in our sense of who we are as whole facets of our past that were shared with the deceased slip away from us forever” (1998, p. 90). Disruption of the narrative requires a survivor to envision major changes in the plot so that her story can move forward. It is also important for her to envision changes in her own identity – ideally, ones that capitalize on her strengths and encourage contemplation of moving forward without her loved one. In this narrative repair approach to treatment, a therapist’s role is to guide survivors of sudden, traumatic loss through a process of accepting and processing the loss and challenging and refining their beliefs about the loss and its meaning. Neimeyer, Harris, Winokuer, and Thornton (2011) recommend employing such means as clinically guided journaling, poetic writing, and graphic recounting to help survivors arrive at an account or “repaired” narrative of the loss that renders their lives, their loved ones’ lives, and the deaths meaningful. Neimeyer and Sands (2011) list several resources that describe these methods in more detail.

Another approach is to assist clients gently in widening their perspective on finding meaning. For example, you might ask your client to indicate what the death of the loved one means to her (Gamino, Hogan, & Sewell, 2002). In most cases, broad and general questions of this sort are more likely to result in a productive discussion of these issues than asking clients directly whether they have been able to find meaning in the loved one’s death.

It can be beneficial for a client to shift from searching for meaning in the loss to searching for meaning in his life. We agree with Neimeyer (1998) that in most cases, it is helpful to focus on how the loss has affected the bereaved person’s identity. It is important to recognize that such meanings do not have to be cosmic or spiritual. Neimeyer cites the case of one bereaved mother, a social activist, who came to believe that the world was imperfect and that everyone had pain in his life. However, she believed that her task was to ameliorate this pain whenever possible through involvement and advocacy. Clients may wish to honor their loved ones by carrying on their charity work, setting up a memorial scholarship, or working to prevent the types of events that caused the death. Validating clients’ desire to be involved in such activities can facilitate the healing process (Lewis & Hoy, 2011).

Ancillary treatments may help clients deal with issues pertaining to meaning. Murphy, Johnson, and Lohan (2003b) studied the predictors of finding meaning 5 years after the death of a child by accident, suicide, or homicide. They found that parents who attended a support group were four times more likely to find meaning than parents who did not. It is not clear how support group attendance facilitates parents’ search for meaning. Perhaps parents benefit from exposure to people who have dealt with the issue of meaning in different ways. Spiritual beliefs also facilitated finding meaning. Murphy and colleagues found spirituality to be the second most important factor predicting who would find meaning.

In an excellent discussion of this topic, Tedeschi and Calhoun (2006) have recommended encouraging the exploration of spiritual issues:

Bereaved clients can find it to be a great relief when clinicians are open to all kinds of ideas and experiences in relation to the death of a loved one, and the spiritual and religious concerns this raises. For example: Is there an afterlife? If so, is it like the traditional versions of it that I might have been taught about? Is my deceased loved one aware of my thoughts, feelings, and actions now? Can we communicate with each other? Will I recognize them in the afterlife? Did God plan their death? Is their death God’s punishment for me? If they weren’t baptized, are they in heaven? Could they be reincarnated? (p. 112)

Tedeschi and Calhoun suggest that instead of offering answers to such questions, “[therapists should] regard themselves as companions on the journey through grief’s unfamiliar territory. On this journey, it is useful for clinicians to assist clients in developing beliefs that provide some comfort in the midst of the distress that is death” (2006, p. 112). Such beliefs may include the notion that the deceased is at peace.

You and your client can also discuss spirituality as a potential resource. A client’s spiritual beliefs are a significant aspect of his assumptive world, which is related to the search for meaning. The term spirituality refers to those aspects of a person’s life in which he connects with something beyond himself and beyond interpersonal relationships. This may include a connection with God, nature, history, humanity, beauty, awe, wonder, and so forth. A sense of spirituality can be a source of sustenance in difficult times, and traumatic loss often disrupts it (McCann & Pearlman, 1990b). Addressing spiritual disruptions can help the survivor to articulate the effects of the death on his spiritual beliefs (which may or may not include a belief in God). It can also normalize spiritual disruption following a sudden, traumatic death. Finally, this work can introduce the idea of redirected, renewed, or newly developed spirituality as a potential resource.

You may invite a client to express current feelings about spiritual connection. Some of these may be healing (i.e., the belief that the loved one is no longer suffering), while others may be deeply disturbing (i.e., the belief that God is no longer worthy of the mourner’s faith). You may wish to explore the disruption to these connections as a potential secondary loss. If a client has strong negative responses to talking about spirituality or does not connect with the concept of spirituality, then it is appropriate to discuss his worldview more generally. For example, clients may find it easier to talk about what gives their lives meaning or what they do to restore themselves when they feel depleted. Of course, it may also be important to explore the client’s reluctance to discuss spirituality. In addition, it may be useful to make a distinction between

Building resources

spirituality and religion. A person can have an active spiritual life that sustains him without any connection to organized religion.

In virtually all of the studies that have focused on finding meaning in traumatic death, a subset of respondents concluded that the search for meaning was fruitless. As one mourner expressed it, “The meaning is that there is no meaning. Some things that happen just don’t make sense.” A clinician who believes that finding meaning is central to the mourning process may suggest possible meanings to a client, or impose his own desire to create meaning onto a client who sees her experience as meaningless. Such a dynamic can create an empathic disconnection (McCann & Pearlman, 1990b), set the client up for failure, decrease the client’s motivation to collaborate in the treatment, and dishonor the client’s experience. As clinicians, we all need to respect bereaved survivors’ existential crises, searches for meaning, recognition of meaninglessness, and the places they inhabit as they move through these experiences. Although it is important to normalize the difficulties of the search, we should not impose our preconceptions about the necessity of finding meaning or what constitutes recovery. Some clients may not wish or need to engage in such a quest for meaning.

values and Personal goal setting

We use the word values to refer to people’s fundamental principles or standards, or what they want their lives to stand for (Hayes, 2004). Goals are steps that people take in the direction of their values. Sudden, traumatic death often brings about a profound change in a mourner’s values and wreaks havoc with goals for the future. As one father expressed it,

I will never be the same person as before the loss of my child. Then a new era started. What was of great importance before does not matter now. At work, I am listening to what my colleagues define as problems in their private lives, but it is nothing. Therefore, I rather choose to withdraw or to leave the room. My scale of values is turned upside down. (quoted in Dyregrov et al., 2003, p. 158)

Values and goals both reflect and provide a sense of purpose and meaning. People’s values also convey how they define themselves and how they relate to others. As the quotation above illustrates, traumatic events often derail the fundamental goals that guide a person’s behavior.

Disruption of survivors’ goal- seeking behavior can occur for many reasons. The sudden, traumatic death of a loved one provides incontrovertible evidence that everything can change in an instant. Many people feel that in such a capricious world, there is no point in working toward long-term goals. When asked about goals, a traumatically bereaved survivor’s typical response is something like this: “At this point, I don’t have long-term goals. My only goal is to get through the day.”

Survivors may abandon the pursuit of goals because their goals and those of the deceased were intertwined. As one woman explained after the death of her spouse, “We had bought a recreational vehicle, and our dream was to visit every state in the country. Every night we pored over maps to plan our trip. When my husband died, this dream died along with him.”

The purpose of values work with traumatically bereaved clients is to help them regain a sense of purpose and direction in their lives by identifying what matters to them most at this point. Values work helps people choose to move forward in a meaningful direction and become engaged in activities they view as worthwhile. It can also propel forward movement in a client who seems to be stuck in the mourning process. For all of these reasons, values work can be extremely useful for survivors of traumatic death.

This book’s approach to values and goals is drawn from acceptance and commitment therapy (ACT), which was pioneered by Steven Hayes in the mid-1990s (see Hayes, 2004). This evidence- based intervention uses strategies based on acceptance of one’s difficulties, mindfulness, commitment, and behavioral change. This approach is part of the “third wave” of interventions within CBT (Hayes, 2004; Zettle, 2007). Those working within an ACT framework have applied ideas on goals and values to a wide variety of problems, including depression, anxiety, addictions, and chronic pain. Although we are not aware of any ACT work focusing on grief, the approach has been used effectively with individuals who have PTSD (Walser & Westrup, 2007).

A major tenet of ACT is commitment to and action toward living a life consistent with one’s values (Eifert & Forsyth, 2005). Within the ACT framework, values are chosen life directions. As Hayes (2005) describes them, “values are vitalizing, uplifting and empowering. They are not another… measurement to fail against” (p. 155). The therapist helps survivors of traumatic experiences to “embrace living in ways that are meaningful and value driven” (Walser & Westrup, 2007, p. 3). The goal is for clients to stop living in reaction to negative experiences and to start living according to what is important to them.

Our integrated treatment approach also draws from the work of Katherine Shear and her colleagues (Shear & Frank, 2006; Shear et al., 2005). These investigators have used work on personal goals as part of their treatment program for complicated grief, described in Chapter 7. Therapists ask clients to identify things they would like to do if they were no longer grieving. The therapists then work with the clients to come up with specific steps the clients can take to reach these goals, and monitor progress toward the goals. According to Shear and Frank (2006), “We were surprised to find that many people with complicated grief do harbor such goals. Even in earlier sessions, an individual’s affect becomes noticeably more positive as he or she focuses full attention on the discussion of personal goals” (p. 297). In addition, Shear and Frank emphasize that such work conveys to a client that the therapist has confidence in his ability to recover. It also conveys that it is perfectly acceptable – in fact, desirable – for the client to be experiencing less grief. Finally, it illustrates that the therapist considers the life of the mourner to be important apart from his grief and loss.

Addressing values and goals

It is important to provide a rationale for working on values and goals. We recommend discussing how the traumatic death of a loved one can drain a survivor’s life of purpose, meaning, and vitality, and how focusing on goals and values will help the client to move forward in the mourning process. For clients who are not yet ready to engage in this work, activity scheduling, described in Chapter 11, is a good alternative.

To facilitate this focus, we have drawn from the work of Hayes (2005) to develop two handouts. The first is Handout 21, Values, which is located in the Appendix. The second, Handout S1, Personal Goal Setting, is on the book’s website ( materials). Both handouts are designed to help clients clarify and prioritize their values. Both guide the client through the process of developing goals that are consonant with their values, and identifying action steps that will help them reach their goals. Handout 21 provides a more comprehensive analysis of how to develop goals and action plans. It also addresses how to overcome barriers that may keep us from reaching our goals.

After providing a rationale for this work, it may be beneficial for you and your client to review Handout 21 in session. Drawing from this material, you should help a client understand the difference between values and goals. “Maintaining good health” is an example of a value, whereas “exercising three times per week” and “not eating fast food” are goals. Next, you and your client can explore what value she would like to work on at this time. Then she develops one or more goals that will move her in the direction of the value she has identified. The next task is for the client to identify specific steps or actions that she will need to complete in order to reach her goal. If her goal is “making new friends,” an action plan might include “invite a colleague out for coffee” or “accept the dinner invitation that I received from my neighbors.” You can explain that the main reason many people don’t reach their goals is that they do not have an action plan. Such a plan will help the client to move forward step by step. We encourage you to assign Handout 21 to your client as homework. This will help her consolidate the information reviewed in session.

Focusing clients’ attention on what matters most now can also facilitate the process of goal and activity selection. In her work with homicide survivors, Armour (2003) has used this approach extensively. She has maintained that if survivors can engage in activities reflecting what is important to them now, they are more likely to find meaning in the loved one’s death. In working with traumatically bereaved clients, we have found this approach to be very effective. One woman who had lost her older son decided that what mattered now was to be the best possible mother to her surviving son. “I arranged a sleepover for my son, and cooked him his favorite dinner. It made me feel good,” she said. A woman whose partner had died decided that what was now most important was staying healthy so that she could raise their children. “I had canceled my two previously scheduled mammograms, but this time I kept my appointment,” she said. “I was proud of myself.”

Keep in mind that clients may not feel ready to pursue their own goals. They may feel that their most important goals were shattered with the loved one’s death. They may also feel that pursuing something that would be positive for them is disloyal to the lost loved one. In these cases, it can be helpful to frame the values and goal- setting work as a way of minimizing the encroachment of trauma and grief into their lives. Clients may also be unable to move forward with their goals because of avoidance. You should address these barriers to making progress on goals on a regular basis. Both cognitive processing and the exposure approach described in Chapter 11 can be applied usefully to this realm as well. Finally, as Armour (2006) has indicated, it is important to help survivors celebrate their movement forward “by recognizing the myriad of small but important decisions they make daily to prevail rather than despair” (p. 83).

It is common for a client to make an action plan but be unable to carry it out. If this occurs, it can be useful to discuss barriers that may have interfered with the client’s successful completion of the tasks he identified. For example, the client’s fear that someone may ask him how he is doing may keep him from reaching his goal of getting together with others.

Values and goals work may confer two additional benefits. First, there is often an increase in positive affect. As discussed earlier, positive emotions can play an important role in the coping process. They can also provide a psychological break or respite from grief, allowing mourners to replenish their resources; they are also reinforcing in and of themselves. Both these factors in turn promote more effective coping and problem solving. Second, focusing on goals and values often helps to alleviate a client’s struggles with finding meaning in the loss. It is not clear whether such work facilitates finding meaning or whether it renders the search less important; this may differ from one person to the next. It appears that positive feelings and less distress about meaning are by- products of working on values and goals. The more the client engages in work with values and goals, the more these processes will come into play, and this in turn will facilitate additional work on these issues. Taken together, these processes can result in an upward spiral of well-being, and can help the client to begin living a more vital and purposeful life.

Clinical integration

Phyllis sought therapy on the advice of her sister. She wanted to feel better, and she had to return to work, but she didn’t know how to help herself. Upon meeting Phyllis, Dr. Santiago Gonzales immediately observed how overwhelmed she seemed. Phyllis tried to be open and to stay in control of her emotions as she spoke with Dr. Gonzales, but she could barely get her words out. She spent most of the first session shaking and sobbing. At the end of the first session, she told Dr. Gonzales that she was afraid that he, too, would let her down, as Alex’s doctor had.

Dr. Gonzales knew they would need to strengthen and rebuild Phyllis’s self-capacities as well as her social support – two resources that had been easier for her to access before Alex’s death. He knew, too, that they would eventually have to address Phyllis’s disrupted trust schemas. He thought he would introduce the Automatic Thought Record and Challenging Questions Worksheet once they had shored up her emotional regulation and social support a bit. He reasoned that if this early work went well, Phyllis might have more confidence in him – and herself – for the trauma processing ahead.

When they met for their fourth session, Dr. Gonzales asked, “So how did you do with your breathing retraining and social support activities since our last session?”

“It went OK,” answered Phyllis. “I asked my friend Mary to go to the attorney’s office with me last week. I’ve been so consumed with the decision of whether to pursue a lawsuit against the doctor that exercises almost fell off my radar. But then I thought to myself, ‘Why not use them for support when I meet the attorney to discuss the case?’ And this is what I did. I called Mary and asked her to come, and I practiced the breathing retraining on my way there while Mary drove.”

“And how did it go?”

“It was strange for me to ask Mary for support. Part of me thought that she would not follow through. Still, it was mostly OK.”

“That’s good to hear, Phyllis. You said it was ‘mostly OK.’ Can you say more about what ‘mostly OK’ means to you?” Dr. Gonzales wanted Phyllis to reflect on how she was doing and to articulate this for herself.

“Well, first of all, Mary showed up, which meant a lot to me. Also, I was able to get through the meeting without breaking down. In general, I’m doing better than I was when I first came here. I’m going through my day without feeling so overwhelmed. It’s as though I’m beginning to trust myself again. I feel less suffocated by my anger. I think the breathing retraining activity is helping with this. I’ve been practicing this exercise every morning. I’m learning to breathe through my tears. I used to cry and lose my breath as I was crying. Now when I cry, I’m aware of also breathing. It makes me feel like I’m beginning to have some control over my feelings.

“Also, when Mary and I went for coffee afterward, I was able to acknowledge that I’m still angry, I still can’t trust people, and I’m still struggling but I’m not getting stuck there. I could say those things, and then also ask her how she was doing and be genuinely interested in that. I could sort of leave my own pain for a while, which I wasn’t able to do before. Mary really understands; she doesn’t pressure me to not be angry or to depend on her too much, you know what I mean?” Dr. Gonzales nodded. “Because she lets me be angry, I can also then calm down. It sounds weird, but I’m learning that the less I fight my feelings, the more I’m able to handle them. Mary seemed to help me with that just by being her supportive, accepting self.”

“I’m curious about what made you decide to call upon Mary in particular for support with your legal consultation,” said Dr. Gonzales.

“I actually spent time thinking about several people I could ask to come with me. Mary has been so consistent and reliable in the face of my grief and anger during the past year and a half. As I thought about this, I realized that part of what keeps me from socializing and asking for support is a fear of being disappointed. I think I’m afraid of trusting too much, being let down, then going into a rage. When I thought about Mary, this fear wasn’t as strong.”

“That’s a very important awareness, Phyllis,” said Dr. Gonzales. Phyllis had just expressed many important things; he was taking his time to sort through them, deciding where to move next. “You’ve just expressed many significant developments and insights,” he began. “First, I want to point out how you knew what you needed with regard to social support. Somewhere within yourself, you knew that Mary could be a support to you. It sounds as though you felt that support, maybe a bit of calmness, even as you brought her to mind – before the two of you actually met. That’s an example of the feelings skill we talked about: drawing on internalized, positive others. And the breathing practice seems to be helping you to tolerate and manage your strongest feelings – another skill we’ve discussed. I think you’ve had those skills and abilities for a long time, but you forgot how to use them or something got in the way of using them. My hope and my guess is that the more you practice using these skills, the easier they’ll be for you to use, and that you’ll then feel more comfortable going out and accepting support from others. Can you see how all of these elements that we’ve been discussing fit together?” Phyllis nodded.

“You mentioned a fear of being disappointed. And of losing control. This is a good place to introduce another element of the treatment approach we’ve been using. It’s the element of maladaptive beliefs and automatic thoughts. The thought ‘Others will disappoint me, and then I’ll lose control of my anger’ is a good example of a thought that may get in the way of your mourning. Are you ready to shift to a discussion of automatic thoughts?” asked Dr. Gonzales.

“As ready as I’ll ever be,” said Phyllis.

Concluding remarks

Building and solidifying resources are crucial aspects of this overall treatment approach. Phyllis is a good example of an overwhelmed survivor in need of a lot of attention to resource building. As a childhood trauma survivor, Phyllis was vulnerable to the disruption of self-capacities that her fiancé’s death evoked. Fortunately, Dr. Gonzales recognized this and prioritized this aspect of the treatment, front- loading the treatment with resource building. As their work progressed and he introduced other elements, resource building remained central and was integrated throughout the treatment. This heavy emphasis won’t always be the case, as some clients will need less of this, but all clients ought to receive some attention to solidifying resources.

The example of Phyllis and Dr. Gonzales also demonstrates the importance of the treatment alliance as a container for building self-capacities, trust of others (and therefore ability to use social support), and other resources such as breathing retraining and coping skills. Notice Dr. Gonzales’s tone as he spoke to Phyllis; it was encouraging, respectful, and collaborative. Finally, Phyllis showed us how the ability to access various resources increased her self-confidence, which positively affected her self-worth and enhanced her capacity to continue with the work of moving through traumatic bereavement. Supportive resources are particularly important in challenging times and situations, such as when there is legal involvement. As Phyllis’s ability to utilize various resources grew, she and Dr. Gonzales might wish to focus on setting some goals for her future – yet another resource- building strategy discussed within this chapter.



Chapter 11. Processing Trauma

Larry grew up in a working- class family on the outskirts of the city. His family struggled financially throughout much of his childhood. As the oldest of six children, Larry often felt a sense of parental responsibility toward his younger siblings. He was especially protective of his two youngest brothers. By the time they were of middle school age, gang violence had become more widespread in and around their neighborhood. Larry somehow felt responsible for making sure they would “make it” – for ensuring that neither brother would become another sad statistic, and instead that both would have careers and start families of their own. Motivated by his desire to support his siblings, Larry worked hard to establish a career. He also married his high school sweetheart and had two daughters.

Lawrence senior was an alcoholic who became verbally abusive toward his sons when he drank, and Larry junior seemed to get the worst of it. His father often told him that he was “good for nothing” and wouldn’t “amount to anything.” Larry used this as motivation to do just the opposite in order to prove his father wrong: to be successful, and to do so within his father’s field of work. Lawrence was an ironworker, and his son followed in his footsteps, proving his own skill, work ethic, and eventual managerial skills. At the time Larry married, he landed a high- paying job as a construction manager. Twenty years later, he was still with this company. He had remained married and had one teenage daughter. His older daughter had died 5 years earlier while on vacation in the Bahamas. Her unexpected death crushed Larry’s spirit. He did everything possible to meet the responsibilities of his job and his family. But he could not shake the feeling that life as he knew it was over.

Trauma processing is one of the three core treatment components (resource building, trauma processing, and mourning) of this approach. Trauma processing occurs on both a cognitive and an emotional level. Clients learn different techniques for both types of processing, which can be very useful when applied together. In this chapter, we discuss the application of trauma processing to traumatic bereavement.

Cognitive and behavioral theories for alleviating traumatic bereavement inform our treatment approach.[9] Challenging depressive and anxiety- provoking automatic thoughts, and pursuing behavioral activities that expose clients to avoided stimuli, can help in several ways. These processes can help survivors to stop negative cycles of thoughts, moods, and behaviors; process traumatic memories; break anxiety- provoking behavioral associations; fight against the apathy and isolation that were triggered by the death; create meaning from traumatic death; and reengage in their lives.

Behavioral techniques, in the form of exposure to feared stimuli or the behavioral experiments of activity scheduling, allow traumatically bereaved survivors to experience their feelings and to gain corrective information from the world. Clients are often too afraid of their feelings to do the processing necessary to move forward. Avoiding powerful emotions can consume all of their time and energy, and can keep the survivors stuck in their mourning process. Facing anxiety- provoking situations reduces fear and engenders feelings of pride and hope that things can change. Allowing themselves to experience the feelings stirred up by facing reminders of traumatic death helps survivors to habituate to their emotions – that is, to tolerate the affect until it decreases. Purposely delving into their emotions, by confronting feared situations or by describing their memories in detail, allows clients to reengage in life.

The cognitive element of cognitive- behavioral theory posits that people can learn to monitor their own thought processes and identify related negative emotions and behaviors. They can then learn to challenge the damaging automatic thoughts they identify, thereby lessening the impact of these thoughts on mood, behavior, and physical reactions. A sudden, traumatic death will generally prompt painful thoughts about oneself, the loved one, the relationship, and the world. This therapy approach teaches clients methods for recognizing, challenging, and restructuring the thoughts that cause them distress. Therapists work with clients to identify, challenge, and then modify the thoughts, beliefs, and interpretations that may have become habitual and that may inhibit the process of mourning the loss. Repeatedly challenging negative automatic thoughts gradually decreases their frequency and reduces the power of the beliefs at their root. For example, using the tools described later in this chapter, a traumatically bereaved survivor may be able to identify the belief that he doesn’t deserve to live because he “allowed” his sister to kill herself. The work on challenging this automatic thought will help him to understand the links among this thought, his depressed mood, and his social avoidance. It will provide him with the opportunity to assess realistically his role in the suicide and the opportunities he had to intervene.

In this treatment approach, as is the case in CBT more generally, cognitive and behavioral techniques work together. When clients become aware of the distressing schemas underlying their automatic thoughts, strong emotions can surface because of the close link between thoughts and feelings. Being aware of the thought that “Loved ones always abandon me,” for example, may evoke emotions associated with a previous abandonment, as well as the vulnerability associated with the need to trust in others. This kind of situation then allows you and the client to address the overgeneralized thought, the need for trust, and the associated emotions. Likewise, facing a feared situation such as cleaning out the closet of a deceased child is likely to evoke strong feelings of grief and may elicit maladaptive schemas as well: “I should have bought her that dress she really wanted,” or “I should have never let him drive that night.” In other words, thoughts, emotions, and behaviors relate to each other in a complex matrix, and addressing one aspect of the matrix is likely to bring the others into focus as well. This integrated treatment approach intervenes in all three facets of this matrix – thoughts, emotions, and behaviors – with the awareness that each aspect relates to the others.

As described in Chapter 7, several different versions of CBT have demonstrated effectiveness in the treatment of PTSD (Blanchard et al., 1996; Foa & Rothbaum, 1998; Resick & Schnicke, 1993). PE, both alone and with the addition of cognitive techniques such as CPT, is a highly effective treatment for PTSD (Foa et al., 2005, 2009; Hollon, Stewart, & Strunk, 2006; Rauch et al., 2009). Moreover, Shear and colleagues (2005) recently demonstrated the effectiveness of CBT for complicated grief as assessed by the Prolonged Grief Disorder Scale (Prigerson, Maciejewski, et al., 1995).

In this chapter, we describe cognitive processing interventions, emotional processing interventions, and behavioral interventions. As stated above, these techniques are intended to be utilized in ways that complement one another. The art of implementing this treatment approach requires an awareness of these interrelationships. In utilizing the techniques for processing sudden, traumatic death on both the cognitive and emotional levels, you can help survivors to reengage with life and once again seek fulfillment of their needs, even in the absence of their deceased loved ones.

Cognitive Processing interventions

Cognitive work is very helpful in reducing distress. Learning to identify automatic thoughts or problematic beliefs is the first step toward decreasing their power over moods and behavior. Once a client learns to identify the thoughts, his goal is to consider them carefully and decide whether they really make sense. Like exposure, cognitive work requires patience, courage, and concentration. If clients understand the rationale for the cognitive techniques, they will be more likely to put in the necessary effort. We therefore recommend reviewing Handout 9, A Model for Change, with each client, as it describes the rationale for the cognitive work. Clients begin by identifying their distressing thoughts related to the death by using the Identifying Automatic Thoughts exercise (described in Handout 10, What Are Automatic Thoughts?, and Handout 11, the Identifying Automatic Thoughts Worksheet). They then learn to challenge these thoughts and to reframe or replace them as appropriate. We detail the process of identifying and challenging distressing automatic thoughts below.

identifying Automatic Thoughts

Identifying distressing automatic thoughts takes practice because they are so “second nature” that many people don’t realize they have them. Problematic automatic thoughts tend to be extreme and are often quite harsh. They often contain thinking errors such as all-or- nothing thinking, discounting the positive, catastrophizing (predicting a negative future), and overgeneralizations. “I’m a failure as a parent,” “People always abandon me,” and “God never loved me” are examples. People tend to believe them because they have repeated them in their minds so often. Such automatic thoughts often express problematic schemas about the self, others, and the world that were developed early in life and that are then reinforced in the wake of a traumatic experience. To help clients recognize automatic thoughts, we suggest reviewing Handout 10, What Are Automatic Thoughts?, before moving into the exercises described below.

Once a client understands what an automatic thought is, introduce Handout 11, the Identifying Automatic Thoughts Worksheet, as a way for him to begin to identify his automatic thoughts. It may be helpful to let the client know that during the next session, he will learn how to challenge these automatic thoughts so they do not have such a powerful impact on his moods and behavior, and that challenging such thoughts requires identifying them first. You can explain to the client that although tracking the automatic thoughts may not make him feel better initially, it is a necessary precursor to challenging the thoughts effectively. In other words, this is the first step in a process.

Handout 11 consists of three columns that the client fills in: the situation, his mood, and the related automatic thoughts. Tracking these is the first step toward decreasing the frequency of distressing thoughts. As you review this handout with the client, explain that he may fill out the columns in any order (i.e., starting with a mood, a situation, or a thought, whichever is most apparent to him). We recommend that you practice filling out at least one copy of this handout with the client in preparation for asking him to complete it between sessions. Although it is preferable to choose a thought associated with the loss, any example will do.

Some clients will have difficulty naming moods or feelings. The “Recognizing Feelings” section of Handout 8, Feelings Skills, may be helpful to clients who have difficulty filling out the “Moods” column on the Identifying Automatic Thoughts Worksheet. Another potential difficulty is that clients may list a thought in the mood column, typically by prefacing it with “I feel…” For example, the client may list “I feel like I will always be alone” as a mood when it is actually an automatic thought. A simple guideline for distinguishing between thoughts and feelings on the worksheet is that feelings or moods can usually be described in one word. An example of a belief might be “I’m a terrible person,” while the accompanying feeling could be “shame.” Practicing together in session will help the client feel more confident when completing this exercise independently.

After you and the client have practiced completing an Identifying Automatic Thoughts Worksheet, you can then give examples of possible situations, thoughts, and feelings (based on previous conversations with the client) that the client can use to complete some additional copies of this handout on his own. Writing down the beginnings of an example together in session is an effective way of encouraging the client to continue this practice as an independent activity.

Challenging Automatic Thoughts

Once a client has some experience in recognizing automatic thoughts, you should introduce and practice techniques for challenging the distressing thoughts. To learn the technique of challenging automatic thoughts, she will use Handout 13, the Automatic Thought Record. This is essentially an expanded version of Handout 11. Clients use Handout 14, the Challenging Questions Worksheet, in tandem with Handout 13 to challenge distressing thoughts. The first three columns of the Automatic Thought Record are similar to those on the Identifying Automatic Thoughts Worksheet. The additional three columns are “Evidence That Supports the Automatic Thought,” “Evidence Against the Automatic Thought,” and “Alternative, Balanced Thoughts.” During the session in which you introduce the technique of challenging automatic thoughts, you should complete an Automatic Thought Record together, which may require most of a session. It is often easiest for a client if you keep a blank copy of Handout 13 at hand and fill out the columns as the client generates the information. In other words, you can play the role of note taker during session to help the client practice completing an Automatic Thought Record before she tries it on her own.

When completing a practice Automatic Thought Record, you can copy the first three columns (“Situation,” “Moods,” and “Automatic Thoughts/Images”) from the Identifying Automatic Thoughts Worksheet the client completed between sessions, or you can assist the client in generating new information for the first three columns of the Automatic Thought Record. If the client has generated more than one automatic thought, you might encourage her to choose the most distressing thought from her Identifying Automatic Thoughts Worksheet to work on in session. You can then use this worksheet in conjunction with the Challenging Questions Worksheet to explore and challenge the chosen thought. Handout 12 provides a Sample Automatic Thought Record. Many clients find it helpful to see a completed worksheet to gain a better understanding of the entire process of challenging automatic thoughts.

Choosing an automatic thought to question can itself be a challenge. The specific expression of the thought is important. Clinical judgment will play an important role as you assist the client in choosing the exact expression of the thought that you will challenge together. It is often useful to demonstrate the downward arrow technique to help the client arrive at an automatic thought she can challenge effectively.

Downward Arrow Technique

This technique is a method for questioning a client so that she arrives at the essence of the automatic thought. For example, the client might state that her deceased partner was perfect for her. This statement would be written at the top of the “Automatic Thoughts/Images” column of Handout 11 or 13. Employing the downward arrow technique, you would then ask what it means that her loved one was perfect for her. The client might reply, “He was my soul mate.” You would draw an arrow pointing down from the initial thought, and write, “He was my soul mate” beneath it. If you then ask, “What does that mean for your future?”, the client might say, “I’ll never love anyone like that again.” This could be the final thought under a downward arrow, or, if this is pursued further (“And what does that mean for your future?”), the final thought might be “I’ll be alone forever.” The downward arrow technique thus helps the two of you arrive at the essence of the thought – at what it ultimately means for the client.

The downward arrow technique often helps you and the client to discover the schema or core belief underlying the automatic thought. These schemas vary greatly from one client to another, but they often represent one of the five need areas listed in Table 2.2: safety, trust, esteem, intimacy, and control. These five areas can be referenced in order to help clients identify themes in their thinking. You should understand and use the need categories as a tool for identifying the schemas or core beliefs that drive automatic thoughts. Clients are often overwhelmed by the number of automatic thoughts they notice when they first start keeping track. Helping them to identify the underlying needs can be reassuring, especially when they are just beginning to learn how to identify and challenge automatic thoughts. Working on one automatic thought related to a particular need facilitates work on other thoughts related to that need.

Automatic thoughts are often severe or overstated and should match the emotions or moods the client has listed. Again, if there is more than one thought, circle the thought the client identifies as the most powerful or distressing. This is the thought she will address on the Automatic Thought Record.

The two of you then proceed to complete the next two columns of the Automatic Thought Record. Beginning with the “Evidence That Supports…” column, ask the client to tell you all the reasons she believes this thought to be true. Then record these reasons and ask questions to help the client to generate more reasons if applicable. When the client has listed all of the evidence she can for the automatic thought, direct her to Handout 14, the Challenging Questions Worksheet. This worksheet lists questions designed to help clients generate evidence against the automatic thought. This can be very difficult because people typically don’t challenge their automatic thoughts. Automatic thoughts are habitual, are often long- standing, and may feel like the truth to the client. Ask the client to start by looking at the automatic thought she chose to circle on her Automatic Thought Record and questioning whether she has any general evidence against the thought. Once the client has generated as much evidence as possible, ask her to use the Challenging Questions Worksheet to try to generate more evidence against the automatic thought.

This is likely to be the aspect of the Automatic Thought Record with which clients will need the most assistance. People have often spent years believing their habitual automatic thoughts and actually generating evidence to support them, particularly when they are distressed. Although this may not appear rational, it is easier for them to continue to believe what they have always known and comfort themselves with evidence than to accommodate to new information that would alter habitual beliefs, even those that are negative. Although it may seem counterintuitive, people sometimes feel affirmed by “evidence” that they are correct, even in beliefs such as “I’m alone,” because their worldview is confirmed.

The next step is to ask the client to go through each statement of evidence for the automatic thought and to ask herself whether it proves that the automatic thought is true. Together, you can use this process to generate more evidence against the automatic thought. In some cases, this can be as simple as rewording evidence that is overstated. For example, the “evidence” for “I’m a terrible person” might start as “I never do anything right” and evolve, upon examination, into “I sometimes do things correctly and sometimes make mistakes.” As stated above, this process is often the most challenging part of completing the Automatic Thought Record. The accommodation of new information (i.e., evidence against an automatic thought) requires reexamining a network of interrelated assumptions about oneself, others, and the world (the assumptive world). This is a task most people do not take on unnecessarily, as it challenges their identities, their worldviews, and the foundation of their relationships. Because this aspect of the task can feel overwhelming or even terrifying, you may be tempted to offer contrary evidence yourself. However, it is especially important to strike the delicate balance between the roles of note taker and teacher in this part of the exercise. Whereas you can and should ask questions to help a client arrive at evidence for and against the automatic thought (Socratic questioning), you should try to avoid generating evidence yourself. Doing so usually invites the client to disagree, which is counterproductive.

The final step in completing the Automatic Thought Record is to create a balanced thought. The balanced thought is a statement that summarizes the information in the “Evidence That Supports…” and “Evidence Against…” columns. It is important for the client to understand that she doesn’t have to convince herself of anything she doesn’t believe. Challenging automatic thoughts is not the same as the “power of positive thinking.” A client may still be convinced of her initial automatic thought by the end of the process. More often, however, the client is at least able to modify the thought so that it becomes slightly less harsh, if not to discount it. Even a slight modification in a habitual automatic thought can make a tremendous difference in mood. For example, when a traumatically bereaved client moves from believing that she is a bad person because she does not react to her sister’s death the way her friends expect her to react, to believing that her way of reacting may not be typical but that it is not wrong, the “I’m bad” automatic thought may shift to “I’m different.” Increased confidence and, eventually, increased self-worth may accompany this changed belief.

Clients may find that thoughts they have successfully challenged recur. Automatic thoughts are usually habitual, and clients will typically need to challenge them each time they surface.

Over time, the distressing automatic thoughts will lose their power.


Clients may find it hard to challenge long- standing automatic thoughts or beliefs because they have difficulty dealing with the emotions the thoughts provoke. In this way, the cognitive processing technique overlaps with that of exposure. For example, a client may state that he should have checked his voice mail during his camping trip so he would have known that his father had died while he was out of town. When you prompt him to examine the thought more closely, the client may arrive at a simple and extremely distressing thought, such as “I never was a good enough son,” and intense emotion may accompany this thought. The client may need some time habituating to this emotion alongside the need to process the thought cognitively.

Clients may also resist examining automatic thoughts because they relate to an important aspect of their lives, such as their upbringing or religion. For example, a Christian client may believe that if his faith were stronger, he would be able to accept the loss and would not be suffering. Challenging this thought may help the client to view all of his emotional reactions, including suffering after a loss, as part of a normal human response. Thus he might move from believing “I’m not a good Christian,” to “God is with me in good times as well as when I’m struggling.” Both skill and patience on your part will help clients to proceed with this process of challenging, even in the face of impediments.

You should try to complete at least one copy of the Automatic Thought Record with the client (and more as needed) in session to teach him the process. As noted above, you may find that you need to devote an entire session to this task. If you are short on time, the two of you may find it necessary to generate a few statements of evidence for the thought and then move on to the “Evidence against…” column rather than creating a comprehensive list for each column. The learning process typically continues for several sessions, as you both review in session the Automatic Thought Records the client generates at home.

It is important to repeat the rationale for cognitive work (Handout 9, A Model for Change) to your clients during the initial stages of teaching these skills. Completing the first few Automatic Thought Records is demanding and time- consuming. You can remind clients that they are trying to break a habit of thought they may have been engaging in regularly since childhood. It is important for them to practice this skill on paper until they are entirely comfortable with it. Ideally, they will begin to notice they are challenging their automatic thoughts when they have them during the course of their day. In this way, they will begin to replace old, damaging habits of thought with new, more balanced thinking habits.

Automatic thoughts tend to follow patterns. Identifying and challenging one thought will generalize to other, related thoughts. Understanding this may help clients feel less overwhelmed at the number of automatic thoughts they notice. For example, some clients tend to minimize the importance of anything positive that happens to them. Others engage in all-or- nothing thinking and tend to view things in extremes. Clients may benefit from having you help them identify such patterns in their negative thinking.

You can also use cognitive processing more broadly in this treatment approach. For example, you can use the techniques described above to challenge automatic thoughts concerning specific coping activities or social support. Some clients may find it helpful to work through their fears about exposure by using the Automatic Thought Record. You might ask a client, “What do you fear will happen if you allow yourself to feel your emotions?” If the client expresses fear, encourage her to give a vivid description of what would happen. Then explore the likelihood of the event, and/or the actual consequences of the event. Many clients say things like “I would never be able to stop crying,” or “My family would have me put in an institution.” Explore how likely the consequences are. For more realistic consequences (“I’d cry for several days and need help caring for my kids”), encourage the client to engage in problem solving and to weigh these potential costs against the long-term benefits. We invite you to think creatively about the use of the Automatic Thought Record and the Challenging Questions Worksheet.

Several handouts included in the Appendix or on the book’s website supplement can technically be considered cognitive processing exercises, but have a definite emotional processing component as well. These include Handout 26, Account of Your Relationship with Your Significant Other; Handout 29, Letter to Your Significant Other; Handout 30, Exploring the Meaning of the Loss; and Handout S8, Continuing Your Relationship with Your Significant Other. These are often useful for a client who has progressed through most of the treatment. They offer opportunities to remember the deceased and the client’s relationship with her, while both considering what she means to him and experiencing his emotions about the relationship and the loss. This can be especially helpful for clients who tend to avoid their emotions by intellectualizing the loss.

emotional Processing interventions

The emotional processing element of the integrated treatment approach is based on supported exposure to the thoughts, memories, and situations that trigger strong emotions. Put simply, supported exposure is a carefully paced, guided approach to facing fears that not only decreases avoidance and anxiety, but helps survivors to experience their full range of emotions. Its success depends on trust within the therapeutic alliance, and on a client having the resources with which she entered therapy or that were created or restored in the resource- building aspects of this treatment.

Cognitive- behavioral theory and available evidence suggest that guiding people to approach benign but feared stimuli slowly, beginning with the least feared and working toward the most, will help them learn to tolerate distress until it dissipates. This process also builds clients’ confidence that they can handle these situations and emotions.

Such exposure activities are experiments in which a person tests his theories about what is actually dangerous in the world. The feared stimuli can be in the real world (e.g., airplanes) or in the client’s memory or imagination (e.g., the memory of the phone call informing a man of his partner’s death). In this treatment, you will employ different methods, depending on what the client is avoiding. There are two general categories of exposure activities: imaginal and in vivo.

Presenting the exposure rationale

Some clients have an intuitive understanding that facing their fears will be beneficial to them. These clients are often motivated to try imaginal and in vivo exposure. Other clients may be more fearful and hence more reluctant to engage in exposure activities, saying things like “I just want to put that behind me,” or “I just need to move on.” In these situations, it may be helpful to describe the importance of fully experiencing emotions in a safe environment without avoiding them. Earlier in this chapter, we have described the common fear that experiencing emotions about the loss will result in an inability to stop crying or to go on with life. Your reassurance, calm demeanor, and faith in the process are enormously helpful to clients at this stage of the therapy. The survivors’ motivation to feel relief from intense suffering, combined with trust in you as the therapist, allows them to move forward into exposure. It is important to acknowledge that exposure can engender painful feelings. You should normalize clients’ concerns about exposure, emphasize its effectiveness in decreasing long-term distress, reassure clients that they are capable of experiencing intense emotion without being disabled by it, and explain that the exposure element of this approach takes place within a broadly supportive treatment context. In other words, there are many strategies and supports in place that will allow clients to feel supported through this process.

You can explain that it is natural for people to want to avoid any person, place, activity, thought, feeling, or memory associated with negative emotions. Clients should understand that avoidance of feared thoughts and situations may help them feel better in the moment, but hurts them in the end. People avoid feelings and thoughts about loss because they are painful, but most clients will acknowledge that avoiding things that trigger emotions has not made the pain go away so far. In fact, it is likely that the clients have sought therapy because avoidance didn’t work. Purposely facing their emotions allows mourners to regain control over them, and this control allows them to reinvest in life and to remember their lost loved ones in a fuller, healthier way. This is the exposure rationale.

In our sample treatment plan (provided on this book’s website supplement), the rationale for exposure activities is presented in Session 6, about one- quarter of the way through the treatment. At this point, a client will have approached feared and avoided memories related to the loved one’s death while completing activities such as the initial impact statement (Handout 5, Exploring the Impact of the Death) and looking at photographs of the deceased. The client must also overcome significant fear and anxiety to identify and challenge automatic thoughts about the loved one’s death. Although these writing activities in previous sessions were not presented as exposures per se, they can be viewed as examples of situations in which the client was able to face fears. Even making the decision to seek therapy and come to the first session requires many clients to overcome their anxiety. You can remind the client of past success with these “exposures” to thoughts about the death, to put in vivo exposure into a more familiar context. In addition, many clients have already conducted informal in vivo exposures in their therapy work. Social activities and goals work often bring clients into contact with situations they have been avoiding, and typically prompt significant anxiety. Most clients will have conquered a number of these challenges by this point in therapy. Reminding clients of these successes may also reduce their fear about in vivo exposure.

Exposure is difficult work, but sticking with it alleviates pain. When clients create a safe environment and allow themselves to confront the painful thoughts, memories, and emotions, the pain will gradually lessen. If a traumatically bereaved client pushes himself to stay at a previously avoided restaurant for 45 minutes even though he may remain afraid, his anxiety will gradually fall (i.e., he will habituate to it), and he will experience less anxiety with each subsequent visit to the restaurant. Clients are often reassured by the idea of working their way gradually up the hierarchy with support, so that it doesn’t feel overwhelming. The pain does not diminish as quickly as it does when they escape it by avoiding (e.g., leaving places that remind them of their significant other or working long hours to keep the focus off their grief), but the relief is more likely to be permanent through exposure activities. Escape and avoidance alleviate discomfort in the moment, but when clients escape by avoiding, the painful emotions come back full force the next time they confront those situations, memories, or thoughts. When clients purposely and repeatedly engage with what they have been avoiding, they will find that the painful emotions diminish, enabling them to move forward again.

Clients may avoid important aspects of life after a traumatic death because they serve as reminders of the loss. Behavioral exposure can help clients gradually approach an avoided person, place, or activity until they begin to feel comfortable again.

imaginal exposure

Much of the distress that traumatically bereaved clients report stems from thoughts and memories of the loss that they work hard to avoid. In imaginal exposure, the therapist asks the client to recount traumatic events in detail in the first person and the present tense, in either written or oral form. The client writes or tells this narrative repeatedly, with increasing sensory detail. This process evokes emotions that a survivor typically avoids. With repetition, the client experiences her emotions and learns that she can tolerate them. The more the client evokes the traumatic memory and finds that she is able to tolerate it, the less overwhelming the emotion becomes. At this point, the client can more easily process and begin to come to terms with the traumatic death. Imaginal exposure is used to help the client habituate to the anxiety caused by memories or other fear- provoking thoughts. Imaginal exposure is particularly useful in cases when in vivo exposure would be dangerous or impractical. The integrated treatment approach includes such exposure activities in the form of writing assignments.

Many of the writing assignments we recommend are imaginal exposure assignments. Those that are not specifically designed as imaginal exposure assignments contain elements of exposure, such as writing about the impact of the death (see Handout 5, Exploring the Impact of the Death). You may want to use the writing assignments in the order in which they appear in the Appendix, as this order represents the approach we used in pilot- testing the treatment. However, if you are comfortable with CBT or know your clients’ needs, you may choose to use some or all of these activities in a different order.

The main written exposure assignments that ask the client to describe the “story” or account of the death or of finding out about it form the core of the emotional processing aspect of our therapy approach. Over the course of the 25-session sample treatment plan, a client is asked to write an account of the death three times (following Sessions 6, 7, and 8), and to read the account daily (see Handouts 16, First Account of the Death; 20, Second Account of the Death; and 22, Third Account of the Death). If you and the client are both able to do so, it can be helpful to schedule longer sessions (up to 90 minutes) for exposure work, and to try to schedule exposure sessions so that the client does not have to return to work, care for children or engage in other potentially demanding activities immediately after the session. A client who finds exposure work particularly challenging may want to schedule more frequent sessions during this process (e.g., twice weekly) for added support.

choosing the event to Describe

People experience the traumatic death of a loved one in individual ways, so a client should choose the event or the aspect of the event that caused the most distress. Some clients choose to recount receiving the phone call or hearing the knock on the door; others report finding their loved one’s body; and some might classify identifying the loved one’s body at the morgue as the most distressing event. Some clients were present when their loved one died, and may choose to recount that moment. Each client should also choose where to begin and end the “story,” or the account of the death. Clients often feel that the events of the days prior to or after the loss are significant, and you should encourage them to include these. By attending carefully to the information each client chooses to include, you may identify obstacles to the client’s mourning.

guidelines for Writing assignments

Encourage clients to write when they have ample time and no distractions. Advise them to begin at their own pace, giving only as many sensory and emotional details as they feel they can handle. Exposure should be challenging but not overwhelming, and most clients choose to report few details at first. The basic guideline for these writing assignments is that a client should write in such a way that she experiences her emotions as fully as possible without overwhelming herself. It is important for the client to feel a sense of control over this process, as an antidote to the loss of control that is the hallmark of a traumatic death.

Clients may use self- soothing skills such as breathing retraining before or after, but not during, a writing assignment because doing so would reinforce avoidance of the emotional experience. Exposure, particularly PE (see Chapter 7), is effective because it allows a client enough time to habituate to the emotion. If the client takes frequent breaks to calm down, she will not receive the full benefit of the activity.

Ask clients to write these assignments by hand. They should not type, edit, or rewrite the assignments. If clients are concerned that what they have written is not good enough, inaccurate, or in some other way “not right,” it may help to assure them that they will be writing their accounts again in future sessions. You will also ask clients to write continuously. If they need to stop, they should draw a line indicating where they stopped and resume writing as soon as possible. These lines will help you to identify aspects of the account that may have been most distressing to each client. These assignments are repeated, and clients should be encouraged to include more and more sensory and emotional details in their accounts. The inclusion of such details tends to prompt the release and processing of emotions about the loss.

Focusing on a “Hot Spot”

If a client is having difficulty elaborating on or expressing feelings about a specific aspect of the account, it may help to use the “hot spot” technique. A “hot spot” is the specific aspect of the account that the client finds particularly distressing. This approach involves asking the client to write about only that segment of the account with as much detail as possible, and to read it repeatedly during the next session. The client can write the “hot spot” account at home, but she should read it multiple times in session because these accounts tend to be brief and it may require repetition before the client begins to feel less distress. If the client is unable to write the “hot spot” at home, you can ask the client to write it in session, and then read it repeatedly in session.

reading the account in the next Session

When you have assigned a writing activity to be done between sessions, ask the client to read aloud what she wrote at the beginning of the next session. You can of course discuss and address any discomfort the client feels about reading the account. The goal is to collaborate with the client to help her feel comfortable enough to approach avoided memories and experience avoided emotions. If a client is particularly reluctant to read the account aloud, suggest reading just part of the account, reading while you look away, or having you read the account aloud. Ideally, however, the client will read the account aloud.

The confidence you display in the client’s ability to write and read these accounts can make a tremendous difference in her feelings about the process. The purpose of exposure is to help clients overcome fear and anxiety by working through avoidance. You should support each client in doing exposures by working to make them achievable. Once the client has read the account to you successfully, ask her to read it multiple times on her own between sessions. Remind the client that she may use behaviors such as the breathing technique (Handout 7, Breathing Retraining), feelings skills (Handout 8, Feelings Skills), and other coping activities after completing the read- through at home.

You should help the client feel calm and fully aware of her surroundings by the time she leaves any session; this is particularly important during exposure sessions. Some clients report feeling “spacey” or “stuck in the story” and need more time to process their emotions, regulate their breathing, and feel grounded enough to leave. It is valuable to note the approaching ending of the session when you have about 10 minutes left. A statement like “I’m aware that we have about 10 minutes left” can help the client begin to orient herself to the ending and to leaving the office, and to engage in grounding or other coping skills if needed. The feelings skills that you have introduced early in the treatment are helpful in this regard, as is your caring presence.

In Vivo exposure

In addition to avoiding memories of the traumatic death, survivors of traumatic bereavement also avoid people and situations that prompt distressing emotions related to the death. Clients may frame this type of avoidance as an inability to do certain things since the loss. Examples include avoiding paying bills because doing so is a reminder of the death of the loved one who used to pay the bills, avoiding seeking support from people who were associated with the loved one, and avoiding pleasant activities because the client feels that pleasure would be a betrayal of the loved one. Clients may report that they do not avoid these situations completely, but that they tolerate them with distress or they tend to escape from the situations early. In vivo exposure allows clients to habituate to such feared or anxiety- provoking stimuli. In vivo exposure is based on the same rationale as imaginal exposure: Facing anxiety- provoking situations allows clients to process and habituate to their emotions. Habituating to the emotions that these situations provoke decreases avoidance and reduces fear and anxiety. Research suggests that tolerating the fear for at least 45 minutes at a time, three times a week, allows clients to habituate to their fear (Foa et al., 2007).

Effective in vivo exposure exercises require careful planning with each client. The two of you will spend time discussing situations that the client avoids because they are distressing reminders of the traumatic loss. Together, you will then create a list of very specific feared or anxiety- provoking situations, which the client then rates in terms of how much distress they are likely to cause. You then instruct the client to approach the feared situations, beginning with the point in the hierarchy where the client feels mildly uncomfortable and working his way toward more difficult activities. We describe this process in more detail below.

Fear and avoidance Hierarchy

It is important that the two of you collaborate in creating a list of feared situations. As mentioned above, the list should include very specific situations. After developing the list of avoided situations, the client ranks each situation on a 0 – 100 scale according to the level of distress it would provoke. The 0 – 100 scale is known as a Subjective Units of Distress Scale (SUDS). This scale gives you a common language or metric for describing the difficulty of many assignments; it will guide the two of you in choosing appropriate exposure situations to approach. More specifically, you will use the SUDS rankings to create a fear and avoidance hierarchy (using Handout 25, the Fear and Avoidance Hierarchy Form).

It is important to create a list that includes a wide range of distress ratings. This will provide the client with a sufficient range of exposure activities to help address his avoidance and gain confidence in his ability to do so through engaging in numerous activities. If a client has identified avoided situations that all fall within a particular range of the SUDS, encourage him to identify situations that seem easier or more difficult than those identified thus far. You may need to alter one avoided activity slightly to turn it into several. For example, if a client says she avoids going to the grocery store where she used to shop with her partner, you might ask her to rate driving to the parking lot and spending 45 minutes watching people go in and out. Alternatively, you could ask her to rate going shopping at the store with a trusted friend. For some people, altering the time of day or location of an activity (e.g., going at night or to a different store) changes the rating. It is important to spend adequate time exploring the list with the client, so that you will have a clear basis for the work.

Once the two of you have developed the hierarchy, you keep it, and you and the client choose situations as weekly assignments. This process provides a concrete plan for helping the client reengage in avoided activities: You guide the client in a “stepladder” approach to choosing in vivo exposure assignments. Clients with relatively good coping resources may choose to complete an exercise rated at around 40 or 50 on the 0 – 100 scale initially, and repeat the same exercise three or four times a week. Clients who are more vulnerable may start lower on the hierarchy. Clinical judgment will help guide where a particular client should begin. Regardless of where he begins, moving up the hierarchy by choosing increasingly distressing situations allows the client to get used to each level of distress before approaching the next level of difficulty.

In some instances, you may be able to accompany the client on one or more in vivo exposure activities during sessions. This support may help to lower the SUDS rating enough for the client to feel comfortable with the exercise. Use your judgment and consult colleagues, supervisors, and insurers (if necessary) before deciding whether or not to conduct exposure activities outside the office as part of a clinical session. The two of you can use the SUDS to keep track of the difficulty and helpfulness of exposure activities (whether these are conducted alone or with you).

Client Instructions for In Vivo Exposure Activities

The client should understand that the primary goal of exposure is to tolerate the distress of the situation for 45 minutes (although you may set a shorter goal if necessary to build the client’s confidence). Clients often misconstrue the goals of exposure, so you should clarify that the goal is not for a client to feel calm, appear happy, or even complete the task well. As an example, a client may choose an exposure of having dinner at a restaurant that she used to frequent with her husband. The exposure would count as a success as long as she tried to remain at the restaurant and did not try to distract her attention from her emotions by reading a book or newspaper.

Ask the client to rate her anxiety three times on the 0 – 100 scale: just before the exposure, at its peak, and when she has completed the activity. This method will allow you to determine whether the client is habitually under- or overestimating the difficulty of exposure activities, and will allow the client to see the decline in difficulty of each exposure exercise over time.

You should ask the client to do the same in vivo exposure three times in a week. Some situations are very difficult to recreate in the same way three times. Very similar exposures can be substituted in this case. For example, a client may be uncomfortable initiating three different conversations with the same person. In this case, it is useful to identify three neighbors or new acquaintances with whom a conversation would provoke a similar level of anxiety. Clinical judgment is invaluable to this process. Consider what you notice as clients discuss activities and situations they avoid or tolerate with discomfort. You can use this information to modify exposures to provide the desired level of challenge.

Assessing client SUDS ratings during the exposures builds their confidence and eases them into the exposure work. As an example, a client may choose to pursue an exposure that is rated at a 20 (of 100) level of distress. He does the exposure activity three times in a week, 45 minutes each time. At the next session, he reports that by the last time, his distress level was a 2. He is now ready for the next exposure activity on the hierarchy, which he would initially have rated at 25 or 30. Clients gain confidence from each exposure, and since the activities are often related, conquering one makes the more difficult ones seem easier. Since the client (with your assistance) creates the hierarchy, modifies it as needed, and chooses where to begin, he regains a sense of control over his thoughts and memories.

It is fine to alter ratings or reassign the same exposure activities for a second week, based on information from the client. For example, if a client reports that an in vivo exposure prompted more anxiety than anticipated but she thinks she can conquer it, she might choose to attempt it again the following week. If a client believes that she rated the exposure activity inaccurately and it is too difficult to pursue at this point, she may decide to re-rate it with a higher distress rating and wait to try it until she has done the exposures that have lower distress ratings. The goal of each in vivo exposure is for the client to make it through the exposure without escaping the situation. You should congratulate the client enthusiastically for remaining in an uncomfortable situation for the agreed- upon time limit, even if she was anxious throughout the exercise. Your role will be to guide clients along their hierarchies. You want to ensure that they don’t move up their hierarchies too quickly, but that they do move up as their anxiety in lower-ranked situations starts to diminish.

The nature of in vivo exposure requires that clients seek out real-life situations, which often include surprises. An exposure trip to a local restaurant rated at a 40 may suddenly jump to an 80 if the client unexpectedly encounters the best friend of his deceased wife. It is important to help the client realize that being unable to accomplish his goals in that situation does not constitute a failure, since it was no longer the exposure activity he had planned. When the client is able to go to the setting agreed upon in a session but is unable to remain in that situation, it is far more therapeutic to praise the client for his effort, explore the obstacles, and reassign the exposure than to frame it as a failure.

As with imaginal exposure, the client’s in vivo exposure goal is to be able to experience her feelings and thoughts without trying to escape them. This can be difficult, especially for extremely anxious clients. The emotion- focused coping skills covered earlier in the book can be very helpful to clients in this process. Ideally, clients will use breathing retraining, Automatic Thought Records, or other emotion- focused coping skills to calm themselves when the exposure is over. However, it is sometimes difficult to gauge the level of in vivo exposures correctly. If a client finds herself in a situation that is too uncomfortable, practicing breathing retraining midway through the exposure in order to make it to the time limit is a far better alternative than escaping the situation. In general, however, the client should try to make it through the

Processing Trauma

exposure without using self- soothing techniques, if such techniques inhibit the full experience of anxiety and the consequent learning that the anxiety will not destroy the individual and will pass on its own.

Suggestions for helping a client to engage in avoided activities include encouraging the client to use social support by calling upon a friend to be with him through the activity; advising the client to challenge automatic thoughts (e.g., “I will humiliate myself and lose a friend if I confide in her”) that may be getting in the way; or reminding the client to utilize breathing retraining or another coping strategy in order to help decrease anxiety before beginning or after completing the activity. These coping strategies will set the stage for a successful exposure experience.

Behavioral interventions

If a client is finding that an automatic thought continues to cause distress even after several attempts at challenging the thought, the two of you can often design a “behavioral experiment” to test whether or not the automatic thought is true. For instance, if a client believes he cannot pay the household bills, you can work with the client to develop a plan to pay one or a few bills. This may require steps such as recruiting help from a friend or consulting his bank, which can be included in the plan. We have found it useful to agree with a client on a time by which he will have completed each step.

Behavioral experiments allow clients to test negative beliefs about themselves, the world, and their ability to operate in the world. In many situations, behavioral experiments are very similar to exposures, in that a client must overcome his anxiety in order to complete the experiment. As clients test their negative beliefs in the real world, they have opportunities both to gather new information. This process increases their awareness of the ways in which distorted or outdated automatic thoughts and associated schemas may be keeping them from moving forward.

Processing through interaction: activity scheduling

Cognitive- behavioral theory suggests that individuals can learn new associations, even in the absence of overt cognitive processing, by interacting with the world. This concept is very useful with traumatically bereaved individuals who have come to view the world as inhospitable or to view themselves as unfit for the world. As described earlier, it is typical for these individuals to withdraw and avoid interaction with the world. The behavioral technique of activity scheduling is a form of behavioral experimentation in which a person forces himself to go out into the world in order to get feedback about its hospitability or his ability to cope with life.

Activity scheduling requires a client to compel herself to plan activities and pursue them, regardless of whether they are pleasurable at first. Continuing efforts at activity scheduling generally result in increased pleasure during the activities. It has been hypothesized that anxious and depressed clients tend to isolate themselves and engage in passive activities (e.g., watching television, sleeping) that give them no information about themselves or the world. Without the information gained by interacting with the world, people may have difficulty relinquishing their negative views. Activity scheduling has been shown to decrease depression and increase involvement with life (Jacobson & Gortner, 2000). The values and goals work described in Chapter 10 is a specific application of activity scheduling.

Clinical integration

It was a clear December day, and the sun shone in through the window of Michele’s office. She was meeting with Larry, a 44-year-old man whose teenage daughter had died in a hurricane 5 years earlier.

At some point about halfway through the therapy session, Michele noticed Larry lowering his eyes and picking at his fingernails. Having met with Larry for about 12 weeks now, she recognized these gestures as the ones often accompanying a particular automatic thought that continued to trouble her client.

“I noticed a shift just there as you were reading your written account of your daughter’s death, Larry. Are you aware of any thoughts that you’re having in this moment?”

“Um, yeah. Whenever I recount the horror of Lucy’s death, I can’t help but think that I should never have let her go to the Bahamas with Annie’s family during hurricane season. I was her father, for God’s sake! I should have known the weather in August was too unpredictable.”

“OK,” said Michele. “Let’s pause here and explore this thought. You ‘should have known about the weather in August in the Bahamas.’ What does this mean for you – that you should have known?”

Michele and Larry had been identifying and challenging automatic thoughts for several weeks now, and so this manner of exploration was familiar to both.

Larry answered quickly, “It means that I should have protected my daughter. It means I failed as a father.”

“You failed as a father?” repeated Michele.

“Yes. Parents are supposed to protect their children. I should have known. I should have protected her. I failed.”

“And what does it mean for you now, if you failed?”

Larry’s voice sounded more agitated as he spoke. “It means my father was right – that I’m a good-for- nothing jerk. He said I would never amount to anything, and it looks like he was right. I’ve amounted to a complete failure as a parent and as a man. I should have protected her; I should have kept her alive.”

“Do you really believe you have that much power, Larry? To foresee the future and keep people alive?” Michele was surprised by her own voice as she asked the question. She usually encouraged her clients to ask their own challenging questions. The question startled Larry, too, and although he didn’t answer, the slight blush of his face seemed to indicate that he was taking in her question.

Michele continued, “OK. We both know that this thought – that you failed as a father and as a man – is not new. And you’ve listed evidence in favor of and against this thought in the past. I want to focus on the related thought that your father was right – that you are good for nothing – and I want us to spend some time evaluating its legitimacy. This gets to the issue of self-worth that we have explored before. ‘You are good for nothing.’ Do you think you might be using all-or- nothing thinking here?”

“Well, maybe,” replied Larry. “I know what you would say. And I know that on most days, I believe that being a construction manager and a volunteer fireman is good for something.”

“And can you think of any other ways to challenge the thought that you are good for nothing? Feel free to use your Challenging Questions Worksheet to help you.”

“I may be taking things out of context – you know, evaluating my whole life on the basis of Lucy’s death. I do know that I loved Lucy. From the minute she was born, I used my anger toward my own father to fuel my desire to be the best father I could be.

My wife tells me I was a good father to her.”

“Is it possible that Nancy sees this issue more clearly than you do?”

“I suppose so.”

“And what does it mean if, perhaps, you are good for something?” Emotion became visible on Larry’s face as he slowly answered, “It means – it means my father was wrong.” His voice quivered.

“Do you know what it is that you’re feeling right now, Larry?”

“A lot of sadness.”

“And what are you thinking about?”

“It’s like my whole life is turned upside down. Maybe my father was wrong. Maybe the fear that I’d never amount to anything didn’t have to be there all of these years. Maybe I would have been a better parent without the fear; or maybe it inspired me to be different from him. I’m not sure. It’s all just a little confusing right now. I’m not sure what to believe.”

Larry and Michele sat in silence for a moment. Michele wanted to provide the space needed for her client to take in this shift. Larry broke the silence: “I never thought Lucy’s death would lead me here. It looks like I still have issues with my father and the way my father affected how I feel about myself.”

Concluding remarks

Losing a child unexpectedly is traumatic for surviving parents. This was certainly true for Larry; he was struggling with mourning his daughter’s death as well as with the traumatic elements of her death, which gave rise to his belief that he should have prevented it. What is interesting within this example is the way in which this maladaptive belief quickly spiraled down to “I am good for nothing,” and how this belief had its roots in Larry’s upbringing. Often, this will be the case: The problematic beliefs that surface during times of stress or trauma have their foundations in clients’ early years and interfere with their ability to process trauma or move through mourning. At other times, a belief may come into being as the direct result of the later traumatic event. For Larry, processing his daughter’s death meant dealing with some childhood memories and familial dysfunction.

The fact that problematic beliefs surface during or are triggered by trauma is significant. Confronting the traumatic stress, in whatever form that might take, offers a person the opportunity to become aware of and then challenge these beliefs. In other words, exposure to the traumatic material and cognitive processing go hand in hand. Exposure also offers the opportunity to experience the emotions affiliated with the traumatic event and its aftermath. It is therefore a significant and foundational aspect of this treatment. In the example of Larry’s therapy with Michele, we can see how the work of recalling the traumatic death as well as his traumatic childhood, and the work of challenging related problematic beliefs, enabled Larry to experience feelings such as helplessness, sadness, guilt, and confusion. Together, these elements are the work of our integrated therapeutic approach with traumatically bereaved clients, and they combined to help move Larry through the process of mourning for Lucy. In the next chapter, we provide a comprehensive framework for understanding this movement through mourning.



Chapter 12. Facilitating mourning

“How did the date go?” asked Ross. He and Zac were eating dinner together at a local bar, as they did every Tuesday night. Best friends since childhood, they could talk about anything. They knew each other’s histories, families, dreams, and insecurities. Ross had known Courtney and stood up for Zac as his best man when he married her. He had also been there for Zac when Courtney died unexpectedly 10 years ago. In fact, Ross had been there for his best friend every Tuesday night since Courtney’s death. He had just recently convinced Zac to start dating again, using an online dating website. He was now asking about his best friend’s recent first date.

“It was OK,” said Zac. “We’re just not a match, though.”

“Well, tell me about the date anyway. I’m curious. I haven’t been on many of my own recently, as you know.” Ross had been going through a dry spell.

“We met for drinks. She’s a vet. She talked about her work. She was nice. She laughed at some of my jokes. We had a good time. Something was just missing for me.”

“Something or someone?” asked Ross, knowingly. “You’re never going to find another Court, ya know. And that’s not the point. Courtney’s been dead for 10 years, Zac. It’s time you started living your life again. Listen, man, I know how much you loved her. I also know that you idealized her when she was alive, and I think you’ve been idealizing her and your marriage since she’s passed. I didn’t lose my first wife; I divorced her. There’s a big difference, and I don’t pretend to understand everything you feel. But I know you, man, and although you spent a lot of time grieving in those first years after her death, I think you may still be stuck in some way.” Ross paused, then added, “I’m saying all this because I care.”

As discussed throughout this book, the elements of this treatment are designed to support the client’s movement through the six “R” processes of mourning. As a reminder, the “R” processes are as follows: Recognize the loss; React to the separation; Recollect and re-experience the deceased and the relationship; Relinquish the old attachments to the deceased and the old assumptive world; Readjust to move adaptively into the new world without forgetting the old; and Reinvest.[10]

There are many reasons why traumatically bereaved clients may have more difficulty with the mourning process than those who lose loved ones through natural causes. For example, as discussed in Chapter 3, those who experience the sudden, traumatic death of a loved one have far more difficulty accepting the death, and its many ramifications, than those whose loved one died in other ways. Since the mourners had no opportunity to prepare for the loss, the initial weeks and months following the death can be more agonizing. In most cases, it is difficult for survivors of traumatic loss to call up memories of the deceased because these are often accompanied by disturbing images of the death. Moreover, survivors of sudden, traumatic losses are mourning the loss of the world as they knew it (e.g., they don’t feel safe now), in addition to the death of their loved one. For all of these reasons, it is easy for traumatically bereaved clients to get stuck in the mourning process. As you assist a client in moving from acute grief through these processes (described below), you facilitate healthy accommodation of a loved one’s death.

In this chapter, we provide a rationale for the importance of each “R” process and guidance for moving through them. Rando (1993, 2014) offers further details about this process. The “Rs” are broken down into subprocesses to clarify the most significant elements of each “R” process. We illustrate how specific types of resource- building elements can promote the mourning processes. In addition, we offer suggestions regarding how to draw from your knowledge of trauma processing to assist clients who appear to be stuck in the mourning processes.

In most cases, the “R” processes tend to unfold from one another, with earlier processes serving as prerequisites for later ones. For example, the main task of the fourth “R” process (Relinquish… ) is a precursor to the fifth (Readjust… ); change requires letting go. However, there are times when the “R” processes can overlap or occur simultaneously, such as the first (Recognize… ) and second (React… ). Because the course of mourning is nonlinear and fluctuates over time, some movement back and forth among the processes is common. For example, the mourner may vacillate between the second (React… ) and third (Recollect… ) “R” processes. The important issue is to track whether a client appears to be moving forward. That is, is the mourner working to accommodate the loss, or is he avoiding, resisting, or otherwise stuck within one or more of these processes?

First “r” Process: Recognize the Loss

In order to begin mourning, a survivor must acknowledge that the death has occurred, and come to an understanding of its cause (however incomplete and imperfect). In the first subprocess of this R, Acknowledge the death, the initial concession that the death has occurred is intellectual only. Emotional acceptance of the death typically takes much longer. If the death is not acknowledged, there is nothing to mourn. A lack of confirmation of the death (e.g., the body is not recovered, due to the loss of a boat at sea) makes it challenging to acknowledge the death. There is no proof to contradict the survivor’s normal desire that this reality not be true. This is why treatment providers often encourage viewing the deceased’s body after a sudden death. As discussed in Chapter 5, available evidence suggests that if a mourner wishes to view the body, doing so is usually beneficial, even if it has sustained significant damage (Bower, 2010; Chapple & Zieblanc, 2010). Unfortunately, relatives and friends often try to “protect” the mourner by strongly discouraging her from viewing the body.

If it is not possible to view the body, a survivor is more likely to deny the loss and avoid its implications. If the status of the loved one is unknown, such as when a loved one in the military is missing in action, it may be extremely difficult to commence with the mourning process. The mourner may be plagued by the following kinds of concerns: “Is my loved one dead or alive?”, “Maybe he is out there somewhere, but unable to come home,” “Maybe he developed amnesia and cannot find his way back home,” or “Should we be trying to find him?” (Rando, 1993). As we have discussed in Chapter 5, the distress of a person whose loved one is missing can be greater than the distress of someone whose loved one is confirmed to be dead.

The second subprocess, Understand the death, means developing an explanation of it that makes sense to the bereaved. Such accounts must explain the events that led up to the death and clarify how, why, and under what conditions the loved one died. Unfortunately, in many traumatic deaths, such information is lacking. For example, it may be unclear whether a death was a suicide, a homicide, or an accident. Not knowing why a significant other died or what led to the death is extremely upsetting for most survivors. Unanswered questions interfere with healthy mourning and can turn into unfinished business that adds to the client’s distress. In addition, such questions can fuel feelings that the world lacks meaning, orderliness, or predictability. Others need not agree with the mourner’s explanation, as long as it suffices for that mourner. For example, a mourner may insist that a loved one’s death by gunshot was an accident, while others perceive the gunshot as deliberate and the death as a suicide. Although the explanation may not fit the facts of the death, it serves a psychological purpose at this point. The lack of fit can be addressed later.

facilitating the first “r” Process

You can assist a client in recognizing the loss by facilitating those subprocesses that permit him to acknowledge and understand the loved one’s death. A survivor typically requires repeated confrontations with the reality of the death in order to grasp what has happened. This process cannot begin until the mourner concedes that the death occurred. Your goal as the therapist is to help the mourner comprehend what has happened. It may take many months (and, in some cases, years) to recognize the reality of the loss on a consistent basis. In the interim, the mourner’s ability to grasp the finality of the death and its implications fluctuates. This highlights the difficult, time- consuming nature of incorporating such a painful reality.

To assist a mourner with the first subprocess of recognizing the loss, Acknowledge the death, you must gently help the client to comprehend that the loss is permanent and irreversible. In almost all cases, this part of the mourning process is agonizing for clients. As Wolterstorff (1987) expressed it following the death of his son,

It’s the neverness that is so painful. Never again to be here with us, never to cry with us, never to embrace us as he leaves for school, never to see his brothers and sister marry… Only our death can stop the pain of his death. A month, a year, five years – with that I could live. But not this forever. (p. 15; original emphasis)

It may be important to help the client build resources (see Chapter 10) as a foundation for acknowledging the death, so she can manage the feelings this acknowledgment is likely to evoke. Interventions to help the mourner accept the reality of the death may include discussing the absence of the significant other; the frustration and other feelings the client experiences now that her loved one is gone; and what it has been like for the client to go through her daily routine without the deceased. Rather than push the client to accept the fact of the loss, you can clarify what may be interfering with her ability to acknowledge it.



You can help the client recognize the loss through exposure activities, such as inviting her to bring in some photos of the deceased, or asking her to write a statement about the impact of this loss (see Handout 5, Exploring the Impact of the Death). Some mourners persistently avoid anything external (such as a person, place, object, or activity) or internal (such as a thought, feeling, or memory) that is associated with the loved one, in order to avoid acknowledging the death. Below, we describe some additional strategies you can employ to address such avoidance.

The inability to recognize feelings is often an obstacle to the client’s acknowledgment of the death. It is therefore useful to introduce the concept of feelings skills or self-capacities along with this “R” process – or in any case, early in the treatment (see Chapter 10 for a discussion of developing feelings skills, and Handout 8, Feelings Skills, for information on this topic designed for the client). Sometimes a mourner keeps refusing to acknowledge a death that you may believe she should have acknowledged by now (based on appropriate expectations for her, given her unique situation). If so, you could inquire what might be interfering with her ability to do so by asking her to complete, with as many responses as possible, the sentence “If I were to recognize my loved one as dead, that would mean…”. For example, the mourner may respond by stating, “It would mean that I am all alone.” Raising such questions can help both of you understand obstacles to be addressed. If the mourner has problems because an intact body is not available or there is no body, you can help her recognize that the death occurred by suggesting that she attempt to obtain and examine available data, such as newspaper articles, that could confirm or deny her loved one’s death. If there is no body and hence no actual evidence of the death, you can encourage the client to consider circumstantial evidence, such as her loved one’s continued absence, knowledge of the death of others, or the small chance of escape from the situation. This was the situation facing many families who lost loved ones in the 9/11 terrorist attacks.

As noted above, it will be important to the client to Understand the death – that is, to comprehend how it occurred. This subprocess involves the mourner’s constructing a causal account of the death. You can assist with this subprocess by helping her identify what she does and does not know about the death, what she needs to know, and what will and won’t be possible for her to know. If important gaps remain, you can work with her to strategize how to get additional information and/or how best to manage the feelings created by the lack of closure. It is important to be cognizant of the anguish many clients may experience if they do not have the information they desire. You can work with a mourner to assess the costs and benefits of pursuing particular kinds of information, such as police reports or traffic crash reports, as well as how she would deal with any distressing information she might receive. If the mourner is unable, despite considerable effort, to obtain information about how the death occurred, you can help with the feelings of anger and frustration that may emerge.

second “r” Process: React to the separation

Once a mourner has recognized the reality of the death, he must react to the separation it brings. This reaction involves three subprocesses. The first, Experience the pain, is one that mourners naturally want to resist. In the wake of a traumatic death, a mourner may be so overwhelmed or numb that it takes a while to feel the pain. This can further delay the process of reacting, since a person cannot process pain without experiencing it.

Traumatic death can bring excruciating pain. Here is where work on affect management (see Chapter 10) can be especially important. This is not to say that one must never avoid, delay, or minimize pain – only that one must use such actions as part of a plan to dose oneself and to learn to tolerate and process pain over time. The dual- process model, described in Chapter 7, provides guidance regarding how to work with the client so that intensely painful aspects of the work are alternated with activities that are restorative (such as going to see a film with an old friend).

Feeling the pain is also critical because, without it, the mourner will lack the experiences necessary to face the reality of the loved one’s death. For example, a bereaved individual usually makes conscious or unconscious efforts to search for and recover the deceased. The failure to recover the loved one, and the pain associated with that failure, are what teach the mourner over time that the person is truly gone and that adjustments to this new reality are necessary. It typically takes many such “lessons” for the mourner to react to the death when it has come suddenly and unexpectedly.

The second subprocess is to Feel, identify, accept, and give some form of expression to all the psychological reactions to the loss. The mourner has to label, differentiate, and trace his feelings in all of their complexity and attempt to process each of them. The circumstances of traumatic death can bring many additional, often intense reactions beyond those commonly experienced in expected, natural deaths. You can assist the client in feeling and expressing his emotional reactions to the loss in ways that are appropriate and constructive for him in his unique situation. For many mourners, failure to do so can lead to adverse effects that come from unfinished business.

The third subprocess is to Identify and mourn secondary losses. For some, a secondary loss can be more difficult than the death. This was the case for the sister of a famous actress, who found it harder to lose the social status she had because of who her sister was than to lose her sister. She had envied her sister but had never been close to her.

As noted earlier, it can take months or even years for the survivor to become aware of the secondary losses associated with the loved one’s death. For example, nearly 3 years after his wife died following an aneurysm, a man suffered a bad fall. His doctor told him that it was necessary to undergo hip replacement surgery. His recognition that his wife would not be there to care for him following this surgery, or any subsequent health problems, constituted a powerful secondary loss for him.

facilitating the second “r” Process

The first subprocess under React to the separation, Experience the pain, can be facilitated by broadening the client’s perspective on her pain. You can do so by legitimizing and normalizing the client’s pain. It is common for clients to infer from their pain that they are not moving forward. In addition, you can facilitate the mourning process by conveying that (1) the desire to avoid pain is natural and accompanies almost all major losses; (2) people vary in what is painful and in what strategies for dealing with the pain are most useful for them at any time; (3) successful mourning will help to alleviate the pain; (4) maintenance of pain as a testimonial or as a form of connection to the deceased is not healthy; and (5) there are strategies available to keep mourners from losing control or being overwhelmed with their pain, which tends to be the main impediment to this subprocess. You can convey to the mourner that she will be able to bear the pain, and help her develop the skills to do so.

It is useful to break the client’s pain into its component parts and work on one at a time. For example, the mourner may feel angry that her partner has left her alone, frightened of her future as an aging single woman, and bereft of her partner’s loving companionship. Each of these feelings can be addressed separately. In addition, you can tell your client that she can go as rapidly or as slowly as she wishes, and she can stop whenever she feels overwhelmed (Rando, 1993). You can also explain the rationale for alternating painful phases of the treatment with activities that are more restorative. Shifting between these types of activities, as the dual- process model would advocate, can energize the client so that she can deal with her pain more effectively.

It is important to recognize that some mourners do not view their pain as an aversive stimulus. They may regard it as the only way to maintain a connection to their loved one. If this is true for your client, the usual approaches to alleviating the pain will be ineffective because the mourner’s suffering often comes from the thought of not having pain (Rando, 1993). In this case, you will need to work with the client to find healthier ways to maintain a connection with her loved one. (See the section on the fifth “R” process later for information about how to do this.)

There are several ways to assist a client with the second subprocess, which is to Feel, identify, accept, and give some form of expression to all the psychological reactions to the loss. Many factors may influence a mourner’s style of expressing emotion following loss, including (1) beliefs based in the mourner’s religion, culture, or ethnic identity; (2) coping skills; (3) habitual ways of expressing emotion; and (4) prior life events such as the early death of a parent, which can be triggered by the loss. It is essential to assess each client’s particular ways of dealing with emotions. If the client feels uncomfortable with outward displays of emotion, such as crying, you could help her explore the obstacles and/or alternatives to expressing feelings in that way.

Conveying your desire to understand the full range of the mourner’s feelings allows them to be addressed in treatment. In this “R” process, the emphasis may move from becoming aware of feelings to tolerating strong feelings, which is another dimension of affect management, a feelings skill. To support the client in reacting to the separation, it is essential to continue helping her build affect management and coping skills, as described in Chapter 10.

At any point when the focus is on the client’s feelings, it may be useful to refer to Handout 8, Feelings Skills. (For further information on assessing self-capacities, see Table 8.1.) Exposure activities, such as writing and reading an account of the death daily, can also help the client move through the “R” process of reacting to the separation. Both the process and the content of the activities strengthen clients’ ability to manage strong feelings, opening doors to Reacting. (For more information on this work, see Chapter 11; Handout 16, First Account of the Death; and related handouts in the Appendix.)

Other approaches besides verbal techniques can help a mourner access unexpressed feelings. For example, you may wish to consider employing the empty-chair technique, also called chair work. Originally developed by Gestalt therapists, this technique is well suited for work with a survivor of a sudden, traumatic death. Ask the client to address an empty chair as if the deceased were sitting in it. You can ask the client to close her eyes if she is comfortable doing so and to initiate a conversation with the loved one, using first person and present tense. Explain that the client can tell the deceased anything she wishes – for example, conveying thoughts or feelings, or asking questions. Ask the client to imagine that the deceased can actually hear her. After the client has spoken, she then gets up and moves to the empty chair. Ask her to take the role of the deceased and continue the conversation. Of course, the client can become engaged in the dialogue without actually moving from chair to chair.

This technique plays a focal role in the treatment for complicated grief developed by Shear and her associates, who provide a detailed account of how to use it. Shear and Frank (2006) indicate that many bereaved individuals wish they could have one last conversation with the persons who died. Also, as noted earlier, some mourners are upset because they were not present when their loved ones died. Others are troubled because their last conversations with the bereaved were conflictual, and now there is no way to make things right. Shear and Frank provide a compelling example of how the empty-chair technique can assist a client in dealing with these painful feelings:

For example, a client might say, “Did you feel that I abandoned you because I was not there when you died?” The response might be, “Of course not. I never doubted for a minute that you love me very much and that you would have been there if you could have.” Although this may be the response the client wants to hear, it is also very convincing that the loved one would have, in fact, responded in this way. (pp. 300 – 301)

There are also several nonverbal techniques for becoming open to feelings. These include utilizing movement and physical activity; drawing or painting; creating a memorial garden with some of the deceased’s favorite plants; or listening to music that reminds a mourner of the loved one. Nonverbal means of expression may be especially valuable for a client who has difficulty putting feelings into words. The goal is to help the client express his reactions to the loss in ways that are both acceptable to and therapeutic for him. Once the client has felt, identified, accepted, and expressed his thoughts, feelings, and memories, his emotions will become more manageable. He will be able to respond to them with greater ease. Although the client cannot choose his feelings, if he can identify them, he can decide how to respond to or hold them. Such choice begins to restore a sense of control to the survivor, which is crucial after traumatic bereavement.

If the mourner is having difficulty getting in touch with feelings related to his loss, you can help him review the relationship, the circumstances of the death, and the changes that have come about as a result of the death. Specifically, it can be useful to discuss the roles and functions the loved one fulfilled; all of the things the loved one did for and with the client; and the hopes, dreams, and plans for the future that involved the loved one’s presence (Rando, 2014). As necessary, you will need to focus on any emotional numbing, avoidance, or other responses (such as guilt or fear of recognizing dependence upon the deceased) that could be interfering with this subprocess. These responses can be addressed by recommending tasks that the client regards as restorative, such as cooking dinner with a son or daughter. The tools described in Chapter 10 (developing self-capacities and approaching avoided feelings) are also very useful.

The final subprocess, Identify and mourn secondary losses, involves working with the mourner to address the myriad secondary losses that accrue from this death. This concept helps clients to understand the pervasiveness of their losses. Specific examples of secondary losses include the psychosocial loss of a positive relationship with God and the physical loss of a house that one can no longer afford (see Chapter 2 and Handout 17, Secondary Losses, for more detailed discussions). Each one needs to be identified, labeled, and separated from the others. The mourner’s reactions to each of them should be processed, just as they are for the death itself. As he reviews each of these secondary losses, a mourner may feel that he is experiencing a nonstop chain of losses. If the mourner is overloaded, it is important to help him manage the timing and dosing so he does not overwhelm himself by looking at secondary losses too soon, too rapidly, or too many at a time. This is also a valuable place to encourage the client to use the coping skills described in Chapter 10 as well as breathing retraining (Handout 7).

In addition to the work in session, the client can make a list of these losses between sessions for use throughout the treatment. Handout 1, Sudden, Traumatic Death and Traumatic Bereavement, as well as Handout 17, Secondary Losses, may be useful to this work. Exposure assignments, as described in Chapter 11, also fit well with work on secondary losses.

As this work progresses, you can reinforce the client for any steps he has taken to relinquish the previous attachments. For example, you might say, “It appears that you have learned to do many of the things your spouse used to do, such as paying the bills and managing the finances. How do you feel about taking on these responsibilities? How do you think your [spouse] would feel?” (Rando, 1993).

Third “r” Process:

Recollect and Re-experience the deceased and the Relationship

The third “R” process paves the way for relinquishing inappropriate attachments so that the client can eventually establish new ones. It also enables the development of a realistic composite image, or internal representation, of the loved one. This process also helps you and the client discuss any unfinished business with the deceased. In the first subprocess, Review and remember realistically, the mourner reviews her relationship with the loved one. Ideally, this review will start at the beginning of their relationship. It should be both accurate and comprehensive, and include such things as how and when the mourner and the deceased met (if the deceased was a spouse or partner); how they grew important to each other; life milestones they shared; areas of serious conflict in their relationship; and their shared goals, values, and interests. A comprehensive recollection is important because any elements that are omitted can cause problems at later stages of the mourning process.

As noted above, a major problem for traumatized mourners is that thinking of their loved ones can trigger recollections (e.g., a gruesome death scene) that retraumatize them. This can seriously inhibit recollection, since survivors naturally try to avoid such memories. In addition, mourners may avoid this realistic review because of other negative emotions (such as guilt) that it may engender. Such avoidance interferes with subsequent readjustment.

In the second subprocess, Revive and re-experience the feelings, you can assist a mourner in experiencing the emotions associated with what he has remembered. The focus is on feelings because they constitute the “glue” underlying each attachment tie to a loved one. As the mourner experiences his feelings, he defuses the emotional strength of his former attachments to the deceased. Such reduction is necessary if the mourner is to be able to alter his former bonds with the loved one to take a new form that is more appropriate to the reality of the situation. Attachment ties that are affected include such elements as needs, feelings, thoughts, memories, assumptions, expectations, and interaction patterns. Although the memory of the tie remains, the power of underlying connective emotion is lessened so that it can be sufficiently modified or relinquished. Consequently, the mourner will have the emotional freedom to form new attachments in the future.

facilitating the Third “r” Process

To help the client with the Review and remember realistically subprocess, you can encourage her to recall as many memories as possible of the deceased and the relationship. Ideally, the client will remember and review her full range of memories (e.g., good, bad, happy, sad, fulfilling, disappointing, etc.). It is helpful to think of this process as reviewing the client’s life story with the loved one, looking at what he was and wasn’t.

A complete and accurate picture of the loved one should emerge from this “R” process – one that captures the real relationship that existed. An inaccurate, idealized, or “sanctified” image signifies that some aspects remain unavailable to the mourner for processing, leaving her vulnerable to untruths that could emerge later (e.g., “He wasn’t very considerate of my feelings”).

Many mourners resist this process because it reminds them of things about their loved one, the relationship, or both that they would rather forget. In particular, they are likely to avoid material that could elicit such feelings as sadness, regret, embarrassment, anger, or remorse. For example, a woman who has lost her spouse may find it extremely distressing to discuss her husband’s seductive behavior toward other women; instead, she may choose to remember his strengths. She may fear that addressing the former may invalidate the latter. Mourners who are angry at their loved ones may resist this subprocess (e.g., a mourner who is furious at a loved one for killing herself). Mourners may also wish to avoid discussing their dependency on their loved one. For example, a husband whose wife was killed might feel very uncomfortable describing all of the ways he relied on his wife, as this may engender feelings of helplessness, insecurity, or guilt.

Giving the mourner a rationale for moving through this process can help enormously. It may be useful to tell a traumatized mourner that although painful or traumatic memories can temporarily be disruptive and take precedence until integrated, these traumatic memories do not have the power to invalidate positive ones. You can also help the mourner appreciate that many memories are bittersweet because they include happiness (when recollecting events from the past), such as when a woman reminisces about the time when her husband took her on a cruise, and deep sadness, because such trips will never occur again.

The next subprocess, Revive and re-experience the feelings, allows a client to connect his feelings to his thoughts and other memories of the deceased and to experience them, which typically lessens their intensity. Both remembering the deceased fully and experiencing and integrating the feelings that such memories bring up will help the mourner to adapt and move forward.

In discussing the client’s memories of the deceased, you may find it useful to ask her what she appreciated most about the deceased and what she did not appreciate; what she misses the most and what she does not; and what she wishes could have been different in the relationship. You can explore how realistic/complete the client’s memory of the deceased is. You can also try to identify specific places where the client is stuck. For example, has the client under- or overemphasized certain aspects of the deceased or of their relationship? If the client’s memories of the deceased seem distorted or incomplete, what are possible places where she is blocked in this process? It can also be useful to acknowledge that all relationships include ambivalence, and then ask the client whether she is able to discuss both the positive and negative aspects of the relationship. If she can’t do this, you can ask whether the client would be willing to talk about or question any fears she may have about discussing the omitted aspects of the relationship (“talking about talking about it”), which can give the client some emotional space and perspective. Handout 24, Positive and Negative Aspects of Your Relationship with Your Significant Other, may be useful in this process.

Of course, for a client who experienced a largely negative or ambivalent attachment to the deceased, recalling the negative aspects of the relationship may be the easier task. If this is the case, then it will be important to help the client to remember and articulate whatever positive aspects of the relationship existed.

Working with the client to identify and re-experience feelings constitutes one of the most challenging aspects of treating traumatic bereavement. Mourners often experience intense pain as they recount their feelings. As Rando (1993) has noted, this can be an excruciating time for both therapists and mourners because acute grief reactions fuel and are fueled by remembering and re-experiencing. The resources discussed in Chapter 10 will be particularly valuable in supporting clients in this process.

fourth “r” Process: Relinquish the old attachments to the deceased and the old assumptive World

The first subprocess under the fourth “R” process is to Let go of old attachments to the person who has died. The material on continuing bonds, reviewed in Chapter 7, provides information that may be helpful in formulating this part of the treatment. The mourner must ultimately let go of old bonds to the deceased that are no longer appropriate, given that person’s death. For example, a young man will have to give up his attachment to the expectation that his father would take care of him financially. Of course, mourners do not want to let go of former connections. Relinquishing these bonds is difficult and forces a mourner to contend with secondary losses and to cope with insecurity, anxiety, and the fear of losing his connection to the deceased. Nevertheless, when it becomes increasingly apparent that holding onto old ties, hopes, or expectations is useless and perhaps even harmful, a healthy mourner starts to give them up (Rando, 2014). He does not have to abandon all ties; for instance, he still can have feelings for the deceased. However, he must modify the old ties sufficiently to establish new ties that are more suitable. The new ties involve recognition that the person is dead and cannot return the mourner’s emotional investment or meet his needs as before.

The other subprocess under this “R” process is Letting go of one’s old attachments to the assumptive world that the death and its consequences have invalidated. In order to move forward, the mourner must give up specific assumptions predicated upon the loved one’s physical presence in the mourner’s life (e.g., “My mother will always be there for me,” “We’ll grow old together”), as well as any global assumptions that the loss has shattered (e.g., a child’s death may shatter the assumption that “God protects the innocent”). Especially after a traumatic loss, a mourner has to surrender a number of assumptions pertaining to the self, others, life and the way it works, the world in general, and spiritual matters (Rando, 2014).

facilitating the fourth “r” Process

You can explore the disruptions in the client’s assumptive world by highlighting violated or changed assumptions that have emerged in the work to date. Reviewing the client’s initial impact statement (see Handout 16, First Account of the Death) is a useful way to identify assumptions that the death has affected. This can be followed by addressing automatic thoughts related to disrupted assumptions, as described in Handouts 9, A Model for Change; 10, What Are Automatic Thoughts?; and 11, Identifying Automatic Thoughts Worksheet.

Handout 23, Psychological Needs, can also be useful in identifying central assumptions about the world and related beliefs. You and the client can challenge automatic thoughts, helping her recognize her views of the world as they arise. This process will gradually decrease the power of these beliefs.

The client may experience intense pain while reviewing the ties that must be relinquished.

You can help the client by normalizing the overwhelming desire to avoid letting go. As Rando (1993) has indicated, it is important to empathize with and legitimize the mourner’s wish that things could be different. Nonetheless, you must, with compassion, maintain the position that they are not.

fifth “r” Process: Readjust to move adaptively into the new World Without Forgetting the old

This fifth “R” process is where much of the major action is in mourning. Letting go of the old, obsolete connections to the deceased and to the old assumptive world frees a mourner to accommodate the loss in his life. This occurs in four areas, each of which is a focus of a subprocess.

The first subprocess, Revise the assumptive world, involves modifying a mourner’s assumptions to eliminate the painful discrepancy between what the mourner thought life would or should be like and what it actually is in the aftermath of the loved one’s death. Ideally, the mourner will be able to let go of some of these assumptions and revise or combine some with others. The mourner may add new assumptions that reflect the way he perceives life now.

As with all trauma, basic global assumptions about such things as fairness in the world, the orderliness of the universe, personal invulnerability, and the trustworthiness of others are often shattered as a result of the death (Janoff- Bulman, 1992; McCann & Pearlman, 1990b; Rando, 2014). Still, one may be able to retain some assumptions. For example, while some of the mourner’s global beliefs may have changed (e.g., “I can never feel completely safe again”), he can still retain some old beliefs (e.g., “It’s worth doing whatever I can to take care of those I love”). He may add completely new assumptions (e.g., “I can’t expect my partner to take care of me; I must learn to do it on my own”). One man who lost his partner had to revise his notions about fairness and predictability after the partner died suddenly in a boating accident, but he retained his belief in the goodness of others since so many people helped him afterward. A woman who lost her child melded some former assumptions with new ones (e.g., “I was naïve when I believed that God protects good people. I still believe in God, but I no longer believe that being good ensures protection from adversity”). Modifying such core assumptions can precipitate additional grief reactions, which you and the client will need to address.

Some changes to a mourner’s assumptions happen quite quickly (as in the loss of feelings of safety after the murder of a loved one). Others may emerge over time or become more powerful as a result of events stemming from the tragedy. For example, a young man lost his fiancée in a motor vehicle crash perpetrated by a distracted truck driver, who was texting instead of looking at the road. He anticipated that the truck driver would be sentenced to some jail time and also lose his license. However, this did not occur. The truck driver received no penalty of any kind, and was back on the road within a week. This event confirmed the man’s shattered assumptions about justice and fairness, which his fiancée’s death initially violated. Her death provided a powerful lesson that “Life is not fair,” and the man realized that this was something he would have to learn to live with.

In the second subprocess, Develop a new relationship with the deceased, there is a movement from a relationship of physical presence to one of physical absence. As discussed in Chapter 7, many professionals and mourners mistakenly assume that a mourner has to let go of all connections to the deceased. Rather, if the mourner desires continued connections, they must be transformed. A healthy new relationship with the deceased must meet two criteria (Rando, 1993). First, the mourner must truly comprehend the death and its implications, which should be reflected in his expectations of, symbolic interactions with, and connections to, the deceased person. Second, he must continue to move forward adaptively into his new life in the absence of his loved one. For example, he might take active steps to spend more time with his grandson. If the mourner is not able to do these things, it may be too early for him to develop such a new relationship, or he may be maintaining an unhealthy connection with the deceased. For example, he may be so focused on the deceased that he cannot engage constructively in day-to-day activities. (We refer readers to Rando [1993, 2014] for more detailed discussions of this issue.) It should be noted that in some cases, a continued connection with the deceased may be unhelpful or even detrimental to the bereaved. This may be the case, for example, if a survivor was neglected or abused by the person who died. If the bereaved is left with such a negative legacy, discussing this in treatment can be invaluable. This can help the bereaved to attain valuable self- knowledge (e.g., “I deserved to be with someone who treated me better”).

The third subprocess, Adopt new ways of being in the world, involves adding, relinquishing, or modifying aspects of the mourner’s life to accommodate the losses and unmet needs the death has created. The number, extent, and types of changes depend on the particular relationship that existed between the mourner and the deceased, and the specifics of that person’s involvement in the mourner’s life. The mourner will have to find ways to meet the needs that the deceased previously met for her, or to learn to do without having these needs met. In almost all cases, the mourner will have to adopt new roles, skills, behaviors, and relationships to compensate for what was lost with the loved one’s death. For example, a parent who loses a spouse now must assume the roles and responsibilities of parenting that the partner previously fulfilled.

The final subprocess, Form a new identity, involves integrating the new and old selves so that the mourner’s new self-image reflects all the changes he has undergone. For example, after a spouse dies, the mourner may develop a new identity, viewing himself as more independent. A further transition that the mourner must undertake at this time is to change from a “we” orientation (comprising the mourner and the loved one) to an “I” orientation. This will involve relinquishing, modifying, or taking on new ways of thinking, feeling, and being that reflect the reality of the loved one’s death. Over time, the mourner will usually benefit from developing some perspective on what he has lost and gained. He must recognize and mourn what has changed, affirm what continues, and incorporate what is new.

facilitating the fifth “r” Process

The previous process of relinquishing defunct connections to the deceased and the old assumptive world (the fourth “R”) frees the mourner to create new connections to the deceased (and ultimately to new people) and to develop new assumptions about the world. The first subprocess, Revise the assumptive world, is challenging for clients because in addition to global assumptions they may have held all their lives, they must relinquish or modify any assumptions that were predicated on their loved ones’ presence. It can be helpful to encourage a mourner to identify what has remained the same for her, despite all that has changed. Seeing that some things are unchanged, even with all that has happened, can provide some measure of reassurance and promote a sense of security. At proper times, the mourner can be encouraged to test out her revised or new assumptions to determine their validity. For example, someone who has lost a spouse may feel that she will never again be able to take a vacation because traveling alone would intensify her feelings of loss. After working on this belief, the client may develop a new one, such as “Traveling by myself will be difficult, but I can do it.” Planning and taking a short vacation, even a weekend away, can be a test of this new assumption.

This is also a natural place to work with automatic thoughts, since such thoughts are indicators of assumptions or beliefs about the world. Because automatic thoughts often become habitual, clients may benefit from challenging them to determine whether they still hold true (see Chapter 11). Mourners can have difficulty with this subprocess if they fail to change assumptions in order to avoid the reality of their loved ones’ deaths. If so, you can confront this issue gently at the proper time.

The second subprocess is Develop a new relationship with the deceased. As long as they meet the two criteria above (i.e., a mourner must comprehend the death and move forward adaptively) for a healthy new relationship, there are many ways that a mourner can maintain meaningful connections to a loved one (Rando, 2014):

  1. Appropriate identification with a loved one occurs when a mourner adopts the attributes or views of the deceased. For example, a son may attempt to be as patient with his own children as his father was with him.
  2. Mourners can benefit from both personal and collective bereavement rituals. A ritual can take the form, for example, of planting a tree in honor of the deceased each year on her birthday.
  3. Possession of tangible objects – including, for example, photographs, mementos, gifts, or the loved one’s creations (e.g., artwork) – can be comforting because they provide the basis for a connection that does not rely on the loved one’s physical presence.
  4. The surviving family members and/or social group can benefit from such activities as telling stories or sharing information about their loved one. Active reminiscing allows survivors to keep their loved one’s memory alive by reminding themselves of what kind of person he was. This can be particularly beneficial to mourners who are concerned that they may forget what their loved one was like, and thus lose contact with him forever.
  5. Some individuals are comforted by maintaining certain routines that were part of the relationship, such as doing things that they used to do with their loved ones. For example, having coffee in the morning while gazing out into the garden, a formerly shared activity, can be a valuable connecting behavior.
  6. Purposeful use of triggers can stimulate a connection with the deceased. For example, a client may listen to a loved one’s favorite songs, which will remind her of the life they shared together.
  7. Daydreaming and fantasizing allow survivors to interact symbolically with the deceased. As long as a mourner recognizes a fantasy for what it is, and does not use it as a substitute for engagement in life, this process can be beneficial.
  8. Communication with the deceased loved one, which includes “talking” with the loved one or expressing one’s thoughts, feelings, or requests for guidance, allows for continuing connection.
  9. Reflecting the loved one’s values in the mourner’s day-to-day life can continue the loved one’s legacy. By acting on his values and concerns, and considering his perspective on subsequent decisions, the mourner can retain a healthy connection.

In recent years, there has been interest in connections in which a deceased loved one serves as a moral compass or guide (see, e.g., Klass & Walter, 2001; Marwit & Klass, 1996). Glick, Weiss, and Parkes (1974) found that at 1 year following the loss, 69% of those who lost a spouse expressed agreement with the statement that they try to behave as the deceased would want them to. Similarly, Stroebe and Stroebe (1991) found that at 2 years following the death of their spouses, approximately half of the respondents indicated that they consulted the deceased when they had to make a decision. Many similar kinds of attachment behavior have been described in the literature, including relying on the deceased as a role model, incorporating virtues of the deceased into one’s character (Marwit & Klass, 1996; Normand, Silverman, & Nickman, 1996), and reflecting on the deceased person’s life and/or death to clarify current values or value conflicts.

Some mourners believe that concrete reminders of the deceased will help them live a life that honors that person’s memory. For example, John got a tattoo following the death of his older brother, George, who was killed in an industrial explosion. The design of the tattoo incorporated the letters of his brother’s name. “George was the adventurous one,” John said. “I have always been reluctant to try new things. Now I push myself a bit. The tattoo helps me to imagine that he is encouraging me. This happened last month when I went whitewater rafting.”

Those working within the continuing- bonds tradition (e.g., Klass et al., 1996) have frequently discussed legacy work as a way of maintaining an appropriate bond with the deceased. For example, it is common for people to honor their loved one’s memory by becoming involved in social action. As one mother indicated, “I felt compelled to do everything I could to reduce the chances that what happened to my child would happen to others.” Legacies of this type are often referred to as living memorials. Karla Frye-McGill established such a memorial for her 10-year-old son Bradley, who was fatally shot in the back. A 14-year-old had been playing with a gun, firing it out of the second- story bedroom window in his apartment, when Bradley was killed. As Mehren (1997) has explained, As Lewis and Hoy (2011) suggest, creating a legacy to honor a loved one’s memory can play a vital role in facilitating the healing process. These authors discuss how therapists can assist their clients in creating meaningful legacies. They recommend starting with “the deceased’s unique features – of personality and character, accomplishment, human passion” (p. 318) and developing a legacy that embodies these qualities. According to Lewis and Hoy, the creation of such legacies can help survivors draw strength from the evidence that their loved ones are still having an influence in this world. This can help the mourners to go forward without the living presence of the loved ones.

As a teacher, his mother, Karla Frye-McGill, channeled her grief into developing a gun safety program for children. Using her family’s tragedy as the focus, she began her own curriculum in her school in New Mexico. In the first year alone, she visited more than seven hundred New Mexico schoolchildren. Soon Frye-McGill joined a task force to address child safety issues. She persuaded colleagues to fund a firearm injury prevention curriculum, using the facts from real firearm deaths of children as its foundation. Inspired by and dedicated to Bradley, the program is now in place in elementary and middle schools across New Mexico and, Frye-McGill notes, “the concept of the curriculum could be used anywhere in the world.” (pp. 78 – 79)

As we have discussed in Chapter 10, many people use Facebook Memorial Groups and other memorial websites to create a lasting testament to their loved ones’ lives. In most cases, these websites also provide a continuing connection to the deceased and the people who were important to him.

You can work with a client to develop healthy ways of using these resources to relate to and stay connected with a lost loved one. Handout S8, Continuing Your Relationship with Your Significant Other (available on the book’s website supplement), may be useful in working on this process.

Others in a mourner’s life may mistakenly conclude that continued connection with the deceased is pathological. In fact, it is not uncommon for therapists to view such behaviors as “talking” to the deceased as pathological and inappropriate. Available evidence suggests, however, that such “interactions” are normative (see, e.g., Klass et al., 1996; Klugman, 2006; Sanger, 2008 – 2009). In a telephone survey, Klugman (2006) found that 69% of the respondents reported having conversations with their deceased loved one. Additional ways in which a mourner may feel connected with the deceased include an overwhelming sense of the loved one’s presence; the physical sensation of being touched, held, or kissed by the loved one; dreams in which the mourner believes that the deceased was actually present; feeling watched over and protected by the deceased; or the movement of objects believed to be a sign from the deceased. Evidence suggests that these ways of maintaining a connection are very common. In the survey by Klugman, 55% of respondents felt the presence of the deceased, and 37% reported seeing a vision of the deceased.

In our experience, these ways of maintaining ties to the deceased are comforting to some mourners. Some benefit from the belief that although their loved ones are dead and will never come back to life, they may still exist in some form. As one husband indicated, “When my wife died, I found it unbearable that her spirit was gone forever. One night I had the actual physical sensation of my wife next to me in bed, and we embraced. It was incredibly comforting to learn that at some level, she still exists.” In addition, these experiences allow survivors to believe that the deceased are content and in a good place. This belief can be particularly important to bereaved parents.

It is surprisingly common for survivors to contact psychics in order to maintain contact with their loves ones. This phenomenon occurs with many kinds of losses, but appears to be most prevalent following the death of a child. Although systematic studies are rare, Feigelman, Jordan, McIntosh, and Feigelman (2012) assessed the frequency of consultation with a medium among parents who had lost children to suicide, drug overdose, or other causes. They found that across several types of child loss, 30% of parents reported seeking out psychics. However, this figure was dramatically affected by type of death. Among parents whose children died of natural causes, just 13% turned to psychics. Approximately 30% of parents whose children committed suicide or whose deaths resulted from an accident consulted with psychics. Among parents whose children died of drug overdoses, 54% contacted psychics. We address this issue in some detail because consultation with a medium is prevalent among the bereaved, but rarely discussed. Moreover, if it is not handled carefully, it can drive a wedge between clients and therapists and jeopardize their relationship.

In our experience, most bereaved parents are almost desperate to know where their child is. They want to know whether their child is safe and comfortable. They are often concerned about whether the child is calling out for them, and whether he is upset that they have not responded to his cries. The anguish associated with these unanswered questions sometimes leads parents to contact a psychic. In many cases, they receive the answers that they were hoping for – that their child is comfortable and happy. This gives them some peace of mind, and allows them to focus on other important things, such as their relationships with their surviving children. Seeking out a psychic is also common among those who had a troubled relationship with the deceased. In such cases, the person who died typically expresses regret and asks for forgiveness. (For more information about the role of psychics in facilitating grief resolution, see Sormanti & August, 1997; Walliss, 2001.)

Do those who seek out the services of a psychic find them helpful? Although more data are needed, available evidence suggests that much of the time, people view psychics as beneficial. In their book on the death of a child from suicide and drug overdose, Feigelman and colleagues (2012) asked survivors to identify sources of help that they found to be very helpful. They also asked respondents to identify sources that they viewed as providing little or no help.

Those who sought the services of psychics reported the second highest rating for helpfulness of all sources studied, with 34.6% of survivors indicating that this was very helpful. Only support groups for survivors of suicide were rated higher (43.8%). Since participants for this study were recruited through such support groups, this latter finding may be artificially inflated. The percentage of people rating psychics as very helpful was slightly higher than the corresponding percentage for general bereavement support groups (31.6%), and was also higher than the rating for bereavement counselors (27%) or psychologists/psychiatrists/social workers (25.7%; these categories were grouped together for this study). Participants rated psychics considerably higher than members of the clergy, who received the lowest rating of all the sources of help that were studied (21.5%).

For bereaved parents who consulted psychics, the percentage viewing that source as “of little or no help” was quite low (24%) – lower than the percentage of any other source of help except support groups for survivors of suicide (22.2%). Of particular note, the percentage rating psychics as “of little or no help” was lower than the percentage for the psychologist/psychiatrist/social worker category, where 33.3% of respondents felt that they had received “little or no help.” As Feigelman and colleagues (2012) have expressed it, “The help bereaved experience from psychics is likely to remain an enduring feature in the bereavement resource landscape” (p. 145). Of course, it will be important to replicate these findings with larger and more representative samples; nonetheless, these data suggest that many of us may need to reevaluate our beliefs about the benefits of consulting a psychic. It seems possible that psychics can engage with survivors in a sensitive and intuitive way, and at a very personal level. It is especially interesting to note that individuals with solid academic credentials have begun to move into this area. Allan Botkin, a clinical psychologist, has developed a treatment approach based on EMDR that purportedly facilitates communication between survivors and their deceased loved ones (Botkin, Hogan, & Moody, 2005).

It is important not to pathologize clients who turn to psychics. In fact, many bereaved persons choose not to disclose consultations with psychics for fear they will be considered crazy (Rando, 2014). As Rando states:

If a bereaved person wants to consult with a psychic, it’s my obligation to help them secure referrals for individuals reputed to be “legitimate” in their field. It’s not my place to dissuade them or scoff at their need. It is my place, and my duty, to talk with them about what they hope to gain from the consultation and how they’ll cope with what they might hear. It’s my responsibility to psychologically process it with them afterwards.

Again, we maintain that as long as it meets the two criteria described above for a healthy relationship with someone who has died (comprehending the death and moving forward into one’s new life), there is no problem with maintaining connection to the loved one in the ways we have described above. It will take some time before a mourner can reach the point where she can simultaneously meet both of these criteria. If it is too early in her mourning process and she has not yet had the time and experiences to recognize the reality and implications of her loved one’s death, she won’t be able to make the transition to a symbiotic relationship with the deceased. In that case, many of these ideas, such as the purposeful use of triggers, could elicit distress. This is another opportunity to work with automatic thoughts. For example, a mourner may state that she cannot look at old photos because she will not be able to survive the pain. The underlying automatic thought could be “I’ll die if I feel my grief.” If she needs to protest the death continually, or is unwilling to accept the need for a new relationship because she insists on living in the past where the loved one was physically present, it may be premature for the mourner to develop or benefit from a new relationship with the deceased.

Revising the assumptive world and developing a new relationship with the deceased require new behavior patterns on the mourner’s part. Changes in behavior are reflected in the next subprocess, Adopt new ways of being in the world. You can work with the mourner to identify unmet needs as described earlier. The two of you can then determine the best option among (1) meeting the need herself; (2) finding someone else to meet the need for her; (3) determining other ways to get the need met; or (4) learning to do without getting the need met (Rando, 2014). Should the mourner lack the necessary information or skills to move forward, you can assist her in identifying such gaps and strategize how to fill them (e.g., securing vocational training if she needs a new job). The social support network is an excellent resource in this process, and Handout 18, The Importance of Enhancing Social Support, can be helpful here. We also recommend encouraging clients to set personal goals (see Chapter 10 as well as Handout S1, Personal Goal Setting, available on the book’s website supplement). Supporting them to achieve these goals can help clients adopt new interests, activities, and relationships. In vivo exposure activities (described in Chapter 11) can also be helpful in allowing them gradually to test new ways of being in the world.

There are many reasons why problems may occur in this subprocess. For instance, a mourner may refrain from making changes in order to deny that his loved one is gone or because he does not want to go on in the loved one’s absence. Certain personality traits (such as insecurity, dependency, or poor self-image) or the results of personal traumatization from the death (such as feeling that another catastrophe can happen at any time) can interfere with moving forward into the new world. The mourner may also lack the skills needed to adopt new behaviors or to meet his needs. He may restrict his world by not going out or talking with people he doesn’t know well in an attempt to ensure control and protection. Beliefs that he cannot function without the loved one, a desire to punish himself, feelings (often guilt or anger), thoughts (often negative), or omissions or commissions involving the loved one can also be complicating factors. If any of these interferes with this subprocess, you can help the mourner identify and process such obstacles. It may be necessary to remind the client compassionately that nothing can change the reality of the loved one’s death.

The “R” subprocess Form a new identity focuses on helping the mourner adjust her self-image to reflect the changes she has undergone. Although many aspects of the mourner’s former identity may remain, a new identity is now required that integrates the old and new aspects of the self. It often helps the client to understand that most people define themselves in the framework of their relationships with others; when an important relationship changes, so too does a person’s sense of who she is. As the mourner alters her assumptive world, her relationship with her departed loved one, and her ways of being in the world, these changes – whether losses, gains, or modifications of what existed before – alter her sense of self. You can acknowledge that parts of herself that were developed within her relationship with the deceased (e.g., her co- parent self) have died too. If this is the case, it is important to mourn such losses along with the primary loss of the deceased. You can invite the client to remember and honor those parts of herself, both in memory and in her new relationship with the deceased. For instance, she can commemorate the anniversary of her marriage to her husband, wherein she honors that special piece of her history as his wife. The key is to do this in ways that reflect a healthy relationship with the deceased and that don’t prevent her from moving forward when the time is right.

You can further assist the client by facilitating the crucial process of narrative reconstruction (Neimeyer, 2001, 2012; Neimeyer et al., 2010). It will be helpful to acknowledge and address any anxiety the mourner has about the changes in her self-image. These include such issues as the mourner’s fear of the unknown, insecurity over possible consequences of the new identity, or desire to minimize additional secondary losses. The mourner may also have trouble forming a new identity if she relied too much upon her loved one, finds she has little else to define her besides the old relationship, copes poorly with emotions or relationship changes, or feels the relationship was the best thing in a less-than- satisfactory life (Rando, 2014). Your work with the client will help her develop an identity that does not perpetuate her acute grief, inhibit her from moving forward, or limit her (such as the survivor of a public tragedy who is expected to remain focused on that event forever). In vivo exposure activities can be designed to allow gradual testing of the new roles and relationships that involve the new identity.

sixth “r” Process: Reinvest

The mourner must eventually reinvest the emotional energy that was once endowed in the relationship with the deceased in ways that are life- affirming and gratifying. New attachments can provide the mourner with some of the emotional fulfillment that was lost with the death. The reinvestment, however, need not be in a person who has the same role as the one who died, or even in a person at all. A mourner can reinvest in new causes, roles, relationships, activities, projects, and passions – anything that can bring enjoyment and satisfaction. The material in Chapter 10 on values and goals should assist clients in identifying new pursuits and carrying them out.

facilitating the sixth “r” Process

You can convey that reinvesting does not mean that the deceased disappears from the client’s life. The client may find it helpful to hear that the deceased will always be a part of himself and that nothing will erase this. The task is to figure out how to integrate new aspects of his life and new investments with the old.

It is useful to acknowledge to the client that he may not be ready to reinvest in life. The client may benefit from hearing that reinvestment is often a long process that will probably take place gradually, and that he may be able to reinvest his energies in some things or relationships sooner than in others. Clients may find it valuable to explore what reinvesting in a new interest or new relationship means to them, or to pursue ways in which they have already reinvested or would like to reinvest someday. The process of investment can often be facilitated by working with a client to identify and pursue his most important goals, as noted previously.

Many mourners believe that it is an insult to the memory of the loved one to enjoy life again. It may be necessary to explore a client’s beliefs to be sure he knows that the length and amount of his suffering do not constitute a testimony to his love for the deceased or proof that he is not “betraying” the loved one. Furthermore, it is important to address any fears the client may have that he may be hurt in the future if he invests in someone else whom he could lose, or that others could perceive him as not having mourned his loss enough. Mourners will need additional intervention if they are extremely dependent or anxious, lack social or communication skills, have excessive fears of the unknown, or worry that reinvestment signals the end of their involvement with their loved ones. These interventions can take the form of building resources and exploring automatic thoughts.

The reinvestment process can also be affected by the type of death. If the death occurred as a result of suicide or murder, for example, the mourner may find it awkward to reinvest in social endeavors. He may believe that his presence makes others uncomfortable, and this may in fact be the case. Gentle guidance can help such clients attain the courage to invest in the skills to manage interpersonal situations.

Clinical integration

Zac and Courtney had been together for 20 years when Courtney died in a bicycle accident on an unseasonably warm day in December. Zac was lost after Courtney passed away. In the years since her death, he had slowly picked up the pieces of his life – returning to work, forcing himself to go out with friends, working out at the gym. His zest for life was gone, though. And his friends kept telling him he was living in the past. His best friend, Ross, had recently made the observation that he idealized his marriage to Courtney, remembering it in a unrealistic way. This was what Zac reported to Susie, the grief counselor, when he first met her. Several sessions later, Susie would challenge him about his idealization.

“Zac, we’ve been talking about the importance of remembering Courtney in a realistic and complete way. So far, she sounds like an angel. She sounds really, really great, and your love for her is obvious. Your marriage sounds as though it was marked by mutual respect and genuine caring. It’s inspiring. I’m also remembering that you told me that Ross thought you idealized the marriage. Could this be true? Does it seem to you that there are things about Courtney or your relationship with her that you’re leaving out?”

“No. She was special. We were a great couple. Everyone we knew envied us.”

“What was one thing you wished could have been different? One thing that could have been better in your relationship?” Susie wanted to explore how realistic Zac’s picture of his relationship was. She knew it was important for him to remember Courtney in a complete way, and she wondered whether holding on to an ideal image somehow protected Zac from relinquishing an attachment that was no longer possible.

Zac seemed to be thinking. “Well, when Court was alive, I wished we had more sex. It seems so stupid and unimportant now. But I think 15 years ago, that’s how I felt.”

Susie tried not to show her surprise. From Zac’s earlier description, their relationship had sounded so perfect. “Sex is a big deal, Zac. Although it’s more important to some couples than to others, sex is an element of every relationship, whether present or absent. It sounds as though you would have liked it to be more present, and it sounds as though you haven’t allowed yourself to really think about or feel that.”

Zac suddenly felt confused. He wanted to take back everything he’d just said. He felt as though Susie were seeing something within him that he didn’t want to see himself.

“It’s really OK to have some mixed feelings about your relationship, Zac. No relationship is perfect, and no one person can satisfy all of our needs. All relationships contain some disappointment. I’m wondering how it feels for you to acknowledge a disappointment in your relationship with Courtney.”

“I feel really guilty.”

“What do you imagine would happen if you just allowed yourself to acknowledge the disappointments? If you allowed yourself to accept this as part of the story?”

A tear rolled down Zac’s cheek. He reached over for the box of tissues on the nearby table. “I’m afraid I’d be moving away from Courtney. I’m not sure if I can explain it any other way. It just feels like I’d be putting distance between us, and if I did that, she might leave me. How crazy is that? I’m afraid my dead wife might abandon me!” Zac’s sense of humor softened his self- criticism.

Susie laughed along with him. “Remind me to have you challenge that thought – that it’s crazy to feel that way. A little work may help you to see that it’s not crazy at all. For now, I want to stick with a very significant insight you just shared. There is a fear that putting distance between you and Courtney might lead to her abandoning you. You’re afraid of losing the connection you have with her, even in her death, if you were to move on in some way. Does this sound right?” Zac nodded.

“And can you see how this could keep you stuck?” Zac nodded again.

“I’m going to suggest that we work on helping you to remember Courtney and your relationship as realistically as possible. You and she both deserve this: that the reality of your relationship be preserved. As we do this, it’s important that you know that I know how much you loved her, and still do. I know that this was, in fact, a special relationship – a relationship that really worked. And I know that alongside of all that, there may have been disappointments, too.” With that, Susie began to wind down the session and asked Zac to write a realistic description of Courtney for their next session. Zac thanked Susie and rushed out of their session, late for dinner with Ross.

Concluding remarks

This chapter has presented a comprehensive framework for understanding and facilitating the process and evolution of mourning as described by Rando (1993, 2014). Our task as therapists is to facilitate this process for clients: to help them to move through their mourning, as Susie was doing with Zac in the example above. Zac was struggling with the third “R” process, Recollect and re-experience the deceased and the relationship. Susie correctly ascertained that his capacity to relinquish unviable attachments to Courtney would increase if he was able to remember her in a more realistic way; she asked him to write a realistic and comprehensive description of Courtney in order to facilitate this process. Susie also alluded to challenging one of Zac’s beliefs that was associated with this process of realistic remembering (cognitive processing); and she assessed Zac’s associated thoughts and emotions, inviting these inner experiences into the therapy room (emotional processing). She might also emphasize drawing on extra social support in the weeks to come, or engaging in breathing retraining or self-care activities in an effort to utilize resources that would assist him in moving through a potentially painful time within the therapy (resource building).

In more general terms, Susie’s work demonstrates awareness of the various treatment elements and how they can fit together for a particular client. The “R” processes provide a framework for the evolution of mourning. As well, they suggest interventions for facilitating this process. Depending on the reasons why a client might be stuck, and depending on what kinds of support might be most useful to him, other interventions can be utilized along the way. As we have emphasized throughout this book, the context of a traumatic death brings about some unique obstacles to moving through mourning. As you read through the case examples, you may want to consider where in the mourning process our characters might be, as well as what (if anything) keeps them stuck in their mourning and what interventions you might use to address these obstacles.



Part V. Challenges in implementing the treatment approach






Chapter 13. Treatment challenges

Joan was shot at close range with a semiautomatic handgun while at work. On what was until then a normal April day, a former employee entered the corporate offices where Joan worked, got off the elevator on the sixth floor, and began randomly shooting people before he was tackled from behind by a security guard who happened to be close by. Joan died en route to the hospital from multiple gunshot wounds, despite emergency personnel’s efforts to control the bleeding. Her two young adult sons were in shock upon hearing that their mother was one of the fatalities in this local tragedy. “My mom wasn’t supposed to die at the age of 48,” said Joan’s older son, Seth, when he began therapy with Dr. Lecia Taylor almost 2 years after his mother’s death. Seth’s younger brother, Danny, was also struggling with acceptance of his mother’s death – and, as Seth was beginning to suspect, Danny seemed to be managing his struggle in problematic ways.

Several weeks into his therapy, Seth, looking exhausted, reported to Dr. Taylor his belief that his 21-year-old brother had begun using illicit drugs. He further reported having had several sleepless nights since the last session. Seth then told Dr. Taylor that he needed to talk about this issue, rather than focusing on the death of his mom.

In this chapter, we discuss challenges in working with traumatically bereaved clients. The first section focuses on aspects of the treatment that you may find challenging and provides guidelines for identifying them. The second section provides a model for addressing clinical hurdles. The chapter ends with a discussion of your possible responses to working as a therapist in a paradigm that may be unfamiliar to you.

Potentially Challenging Aspects of The Treatment

The elements of this integrated treatment approach form into a whole that is greater than the sum of its parts. By focusing on specific components of this approach, we hope to identify why some of these elements may seem challenging to implement. The descriptions of potential difficulties associated with each treatment component serve, in and of themselves, as a sort of intervention or aid for all of us who do this work. Recognizing ourselves in these descriptions gives us labels for our experiences as well as potential relief, knowing that our responses are expectable. The goal for all of us who wish to use this treatment approach effectively is to maintain awareness of our responses and to make decisions from that awareness.

Within each component of our treatment, there are various approaches to addressing the challenges presented. We describe some of these below, in the section entitled “Challenges Arising from Working in a Different Paradigm.” In general, the best approaches to these aspects of the treatment are (1) to increase your knowledge and understanding through study of the relevant material in this book and other sources; (2) to practice the treatment elements and note both the clients’ responses and your own; and (3) to obtain consultation from clinicians who are familiar with the treatment approach or components that you find challenging.

Development of Self-capacities

Therapists accustomed to working with people who had adequate childhood attachment experiences may not have familiarity with adult clients with interpersonal trauma histories. Often these latter individuals may be reasonably capable and effective in the world (or have strong ego resources, to use CSDT terminology as described in Chapter 2). In contrast, they have great difficulties regulating their internal states by tolerating strong feelings, maintaining a sense of self-worth, and gathering support from an internal psychological experience of positive others (i.e., they may have underdeveloped self-capacities). These clients have often been termed “resistant.” One way of understanding so- called “resistance” is that it signals something a therapist doesn’t yet understand about the client, and may require modification of the treatment to meet a client’s needs.

It’s understandable that therapists may feel confused or impatient with clients who strongly resist emotions, avoid relationships, or react strongly to seemingly small slights. Yet these behaviors are common in clients with complex trauma (Courtois & Ford, 2009; Pearlman & Courtois, 2005). Therapists with their own complex trauma histories may have difficulty tolerating rapidly shifting or intense emotional states, whether these are their own or their clients’ (Pearlman & Saakvitne, 1995). If this is the case for you, seeking additional consultation and support can be helpful, as can using the resource- building strategies discussed in Chapter 10 for yourself. Using breathing retraining (see Handout 7) to regulate your own physiological arousal, for example, can be helpful for therapists with or without trauma histories after sessions in which clients express strong feelings or report gruesome details of a violent death.

This treatment emphasizes the importance of resource- building activities within the context of a supportive therapeutic relationship as a path to developing three self-capacities: affect management, self-worth, and inner connection with benign others (Pearlman, 1998). Unless you assess – and, where indicated, build – traumatically bereaved clients’ resources, therapy may not produce the desired success with the exposure work. This is particularly likely when clients have complex trauma or are otherwise particularly strongly affected by the death of their loved ones.

One factor that makes an important difference between effective trauma processing via exposure and retraumatization is the adequacy of a client’s self-capacities. Understanding this is part of the preparation that is an essential element of providing a healing as opposed to a retraumatizing experience. Therefore, building or strengthening a client’s self-capacities, in addition to assessing them along the way, is a key part of this treatment approach. This process takes time and requires patience from you as the therapist. This patience will be enhanced by understanding that clients’ early experiences may not have allowed them to develop the internal capacities needed to tolerate the strong affective responses that sudden, traumatic deaths can trigger. Individuals who have had early experiences of abuse or neglect often suffer physiological effects that correspond with their sometimes exquisite emotional sensitivity or emotional reactivity (Schore, 2001). Knowing this can move you and your clients alike toward a greater and more compassionate understanding of these affective responses. We discussed the development of self-capacities in Chapter 10 and in Handout 8, Feelings Skills. This process is beautifully articulated in Jon Allen’s (2013) book Restoring Mentalizing in Attachment Relationships. (See Pearlman & Courtois, 2005, and Saakvitne et al., 2000, for more on developing and maintaining a therapeutic relationship with a client suffering from complex trauma.)

Trauma Processing

Cognitive Processing

As discussed in Chapter 7, cognitive therapies for PTSD have strong research support (Foa, Keane, & Friedman, 2000; Resick & Schnicke, 1993). Cognitive restructuring work with automatic thoughts and the beliefs that underlie them is a significant aspect of this treatment. This approach addresses problematic beliefs or automatic thoughts actively and directly. Therapists who are accustomed to discussing negative cognitions only as clients bring them up may not feel comfortable actively encouraging clients to look for them. Those who view affect as the core aspect of problematic responses to life circumstances may not feel comfortable highlighting thoughts (although highlighting cognitions certainly does not imply ignoring affect, as we elaborate below).

Even those therapists who would describe their approaches as cognitive may find this element to be challenging because of the structured format we recommend for the exploration of cognitions (by using worksheet- style handouts – e.g., Handout 11, the Identifying Automatic Thoughts Worksheet). The structured format is important for two reasons. First, it gives clients a sense of active participation in their treatment and provides them with concrete tools to use outside of treatment sessions. Second, this approach ensures that each problematic belief receives detailed attention.

If you are not a cognitively oriented therapist, you may find that the skills involved in identifying and challenging beliefs take practice. We have included information in Chapter 11 to help you learn these skills, and we invite you to give this approach a try. Some of us who had not used worksheets such as Handout 11 in the past were surprised and pleased to see how well clients responded to them. Novice users have also commented on the depth of this work. They have noted, for example, that this approach allows problematic beliefs to come to the surface much sooner than do traditional methods. Otherwise, such beliefs may remain unexpressed and pose obstacles to accommodating the loss.

emotional Processing

Similarly, exposure treatment can feel uncomfortable if you are not familiar with it. You may feel that talking about potentially painful topics will be harmful to a client. In U.S. mainstream culture, we learn not to talk about dying, death, and bereavement, which is one reason why it is so difficult for many Americans to process the loss of a loved one. Those social norms can easily carry over into the therapy room. Alternatively, you may simply be accustomed to allowing a client to determine when she is ready to address a particularly sensitive topic. For these reasons, you will want to be alert to the danger of collaborative avoidance. As described in Chapter 7, research has consistently shown exposure treatment to be an effective means of helping clients with PTSD. If you understand the critical importance of exposure to recovery, you can help clients to approach rather than avoid painful material. Of course, one still must be sensitive to clients’ feelings and respectful of their right to choose whether, when, and how to engage in a particular exposure activity. Each client is the best judge of her own capacities, and you must respect the client’s instincts and preferences. That said, it is also your responsibility to encourage each client to participate to the best of her ability. It is possible to deliver an exposure treatment gently, supportively, and compassionately. This is the art of psychotherapy, and it is what we have worked to create and support within this integrated treatment approach.

Focus on Loss and Mourning

As discussed throughout this book (see especially Chapter 12), we use Rando’s six “Rs” to guide clients through the mourning processes (Rando, 1993, 2014). Focusing on the active tasks of mourning may be challenging for some therapists. Trauma- trained therapists may not be familiar with treatments for grief. Moreover, therapists with more general practices may be unfamiliar with the subtleties of grief- related issues. Therapists may also find that the work activates their own losses; they may then tend toward shutting down or avoiding aspects of processing their clients’ losses that they find most challenging personally. In the next chapter, we address both the effects this work can have on therapists and the needs of therapists related to these effects, with suggestions about how you can meet such needs in your own practice.

Structured Treatment

The active and directive approach needed to implement a structured treatment may not be the norm for many therapists. Although it will be challenging at times, if you choose to use it, you should find that the structure offers many advantages. It can provide a level of confidence for both you and the client. It helps the two of you manage potential avoidance. It provides the foundation for an introduction to and overview of the treatment elements, so that the client knows what to expect. (You may want to give the client Handouts 2, Orientation to the Treatment, and 3, Treatment Goals and Tools, to provide additional information about the treatment approach.) In addition, a structured approach may be particularly appealing to traumatic bereavement survivors. These individuals may be uncomfortable with open-ended or unstructured therapy for fear it would open up painful feelings or last forever.

One of us (Christine H. Farber) who pilot- tested the treatment generally works from a client- centered and intuitive approach to therapy, which is open-ended. She found that the structured nature of the treatment acted as a container, which allowed for deep, intensive work in a safe, effective, and relatively quick way. Interestingly, the narrow focus of the treatment approach (i.e., one particular death) allowed themes that were more pervasive in a client’s life to emerge in high relief; they became easily identifiable and thus more readily available for exploration. Both clients and therapist experienced a sense of empowerment within the treatment and a deep sense of satisfaction with its completion.

relational Focus within a structured treatment approach

The unique nature of this treatment is nowhere more evident than in its focus on the relational aspects of structured therapy. Therapists who do not use structured approaches sometimes characterize these as “impersonal.” The clinical literature presents many structured approaches in outline or list formats, which may lead therapists to believe that these approaches lack relational components. The true nature of CBT and structured therapy then gets “lost in translation” because most authors, for good reason, tend to focus on the details of how to do it and the theory behind it, while the relational aspects of implementing the therapy remain implicit.

Throughout this book, we address the many issues this survivor population faces, while making the relational aspects of the therapy explicit. We recognize the individuality of each client and therapist; the importance of empowering the client; the sensitive nature of the issues the treatment approach addresses; the need for explicitly addressing the client – therapist dynamics as appropriate; and the power of a planned therapy ending for someone who has lost a loved one without saying goodbye. All of these elements call for a collaborative relational approach that includes the client as a partner.

Relational therapy, as the term is used by the writers based at the Stone Center at Wellesley College, means that what happens between a therapist and client – their interactions with and experience of each other – is part of the “conversation” between the two parties (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991). Our use of the term also includes adjustment of the treatment to each individual client, collaboration on goals, respect for the client’s sensitivities, and awareness of the client’s authority about his own needs. The most skillful application of this approach will include balancing all of these matters with the tasks outlined in the treatment description, including the resource- building, trauma- processing, and mourning work.

Psychoeducation and independent Activities

Both psychoeducation and independent activities between sessions are essential to the success of this treatment approach. These processes require a level of activity that may not be familiar to some therapists. Furthermore, both processes lead a therapist into the role of educator and coach in a way that may be uncomfortable to those who practice from a more receptive, intuitive, relational, or psychodynamic stance. Certainly, at the outset of the treatment, you will have a lot of information to share, and you may feel ill at ease with how much of the time you are talking. The independent activities require you to check in with a client, which may feel like checking up on him. Some clients will not be surprised that you are doing a lot of the talking, and some may experience relief that they are not expected to know what to do or say on their own. Whatever a client’s reaction may be, it is important to respond to it in ways that build the therapeutic relationship and further the treatment goals.

focus on Termination

For therapists who have not worked on their own issues related to loss, abandonment, and endings, the focus on termination in this treatment approach, as well as the process of ending itself, may be challenging. As a therapist, you can become attached to clients, and even without a personal loss history or with a planned ending, you may feel a sense of absence when clients leave. Rynearson, Johnson, and Correa (2006) have observed, “Therapists may have difficulty accepting that their role as rescuer or advocate is no longer needed” (p. 151).

Termination can be particularly disruptive for you if a client ends the treatment prematurely. You may feel surprised, frustrated, angry, or abandoned if the ending is not adequately planned and accomplished. (See Chapter 9 for more on termination in this treatment.) If you have your own traumatic loss history, an unplanned or premature ending can renew feelings of loss.

Although these feelings are natural, it is essential that they not color treatment decisions. A client in time- limited therapy often expresses a wish to continue treatment as the ending approaches. You and the client must consider this wish as a feeling, not as a mandate. There may be good reason to continue the treatment (such as the client’s unresolved trauma or loss issues that further treatment might address successfully). However, we strongly recommend that you work with clients to process their feelings before making any decisions. In addition, we recommend seeking consultation to process your own feelings about ending, so that these responses do not unduly influence your behavior with clients.

Rynearson and colleagues (2006) have noted that therapists working with this population may distance themselves as treatment draws close to the end. Traumatically bereaved clients are likely to feel such a withdrawal and experience it as another loss. Rynearson and colleagues stress that it is important for therapists to “control their own anxiety [and] sustain empathy” (p. 151).

Guidelines for identifying treatment challenges

The guidelines provided in the box on the next page are a tool to help you identify challenges such as those outlined above, which may not be immediately clear to you while in the midst of the treatment. It may be helpful to revisit these guidelines once you are engaged in the treatment.

responding to Clinical hurdles

Human beings bring some element of unpredictability and surprise to all of our experiences, and therapy is no exception. Responding to the unexpected requires sound clinical judgment based in theory, science, and experience. When you use your clinical judgment creatively, it contributes to the effectiveness of the treatment and to the personal and professional rewards of the work for you. In this section, we anticipate some of the issues and challenges you may encounter while implementing this therapy approach. We underscore the importance of using your clinical judgment. We also offer a framework for thinking through additional challenges and dilemmas you may encounter. This framework supports the best use of your clinical experience, judgment, and creativity.

The four “e” strategies

The key to managing challenging client responses is the following four “E” strategies: Explore, Empathize, Educate, and Encourage (reinforce). The effective use of these strategies will be based on your knowledge of the treatment approach and its underlying philosophy, on your clinical experience, and on your clinical judgment based on your work with each client. We describe and illustrate these strategies below, offering guidelines that will help you to address three specific challenges – staying on task, lack of treatment progress, and worsening symptoms – as well as providing a process to use with other issues as they arise.

identifying Treatment Challenges

• What are the indicators that something challenging is happening?

• Unexpected or unusual emotions (yours or client’s)

• Unexpected or unusual thoughts (yours or client’s)

• Unexpected or unusual behaviors (yours or client’s)

• Treatment not progressing as expected • If something unexpected is happening, what might be some of the reasons?

• First (or an early) time you’ve done this type of treatment (or some aspect of it)

• First time working with this client population

• External events or processes in your personal or professional life

• External events or processes in the client’s life

• Unexpected turn of events in the therapy (e.g., client reveals important material that shifts the focus from the target death)

• Could the client be introducing this issue in order to avoid working on the target loss?

• Avoidance on your and/or the client’s part

• Lack of adequate self-capacities on the client’s part • What might help you work with this challenge?

• Review relevant portions of this book.

• Find additional relevant readings (see the References list for possibilities).

• Seek clinical consultation with someone who has experience with this population or with those elements of the treatment with which you’re currently working.

• Gather more personal support for you or the client. (For the client, this could take the form of resource building; for you, this could mean, e.g., clinical consultation, personal support, journaling, or resource building.)

• Discuss with the client what’s happening in the treatment (e.g., “We seem to be stuck. I think that this is because of X Y Z [observations]. Do you have any thoughts about it?”).

• If the client seems stuck, review the elements of the treatment with her that best address the obstacle she is facing.

• If all else fails, what would be the advantages of seriously modifying or even ending the treatment at this point?

• What types of changes might allow the client to benefit from the treatment?

• Would another approach to treatment be likely to benefit this client more at this time?

• If the right decision is to end this treatment, how can that be done most constructively? (See the “Focus on Termination” section of this chapter. See also Chapter 9, as well as Handout S2, Ending Therapy [available on this book’s website supplement], for ways of thinking about ending treatment.)

Staying on Task

Part of your role as the therapist is to keep the treatment on track and to motivate and gently guide each client through the process. Common issues that can arise in all treatments – missed sessions or incomplete independent activity assignments, for example – may be more significant in this treatment because staying on task and completing the independent activities are essential to the effectiveness of the work. Furthermore, such issues may be signs that a client is avoiding the difficult emotions associated with the loss.

A main premise of this treatment approach is that many traumatically bereaved clients are stuck because they have been avoiding painful memories, feelings, and thoughts. As emphasized

Challenges in implementing treatment

throughout this book, this treatment approach invites clients to experience the pain of their loss consciously and intentionally, while calling on a variety of supports in doing so. Consciously experiencing pain with adequate support allows the clients to process or work through the elements of their responses to the loss. This in turn helps clients to continue their movement through the six “R” processes (Rando, 1993). In attending to the need to stay on task, you will experience a heightened attention to the issue of avoidance. Whereas in a nondirective therapy you would go with the flow, in this treatment approach you will be asking yourself, “How do I keep us on task?” This question will lead to potentially productive musing about avoidance.

Let’s consider the following example: Melinda comes into session and introduces material that falls outside the purview of the treatment. Initially she sought treatment in order to address the deep feelings of grief she still holds after losing her mother in a boating accident 3 years earlier. On this particular day, she comes in distraught and tells you that she and her boyfriend have been fighting again. In some treatment approaches, it is possible and even preferable to follow the client’s lead. Because this therapy is focused on a particular loss, however, you will need a strategy for addressing Melinda’s concern within the frame of the treatment approach. This entails evaluating the needs and motivations that underlie the specific concern or behavior. You might ask yourself, “Is Melinda avoiding the loss work? Does she need to attend to this other issue before she can focus on the work at hand? Or is this somehow related to her loss work?”

When the dilemma of staying on task presents itself, more often than not the issue you will need to evaluate is whether going “off task” is motivated by or will support avoidance in some way. This attention to avoidance will keep the treatment moving and promote its effectiveness. Still, remaining focused on the target death can be challenging. The processes listed below will help you to sort out avoidance- related concerns.

Explore. Based on your knowledge of the treatment approach and its philosophy, your clinical judgment, and your experience with this client, what might help the two of you to stay on task? The first step is to understand why the client is behaving as she is. A conversation with the client about a missed session or forgotten independent activities can illuminate her understanding of the reasons for the behavior. Of course, it is possible that the client is unaware of or unable to articulate her fears about facing potentially painful feelings. If you believe these fears are part of the problem, you can suggest this to the client, respectfully and compassionately. In many cases, naming the dilemma in which you find yourselves opens up collaborative exploration. In the example of Melinda above, you might simply observe, “I know your relationship with Thomas is difficult for you right now, and I’m also aware that going down this path today will take us off track. I know that your goal in coming here has been to feel better about the loss of your mother. I’m wondering whether there is a connection between what’s happening now between you and Thomas and your feelings about your mother’s death.”

Empathize. This treatment approach, like all change- supporting activities, is tough. It will be helpful to remember that your main task is to keep the treatment moving by embodying the openness to try new things, take risks, express emotions, and change. Compassion and empathy are the foundations of support that will allow the client to progress through the treatment. This last statement probably strikes you as self- evident. Even so, you may find compassion and empathy particularly difficult to maintain if you are feeling frustrated or under pressure to keep the treatment on track. At these moments, it helps to go back to basics: Try to identify with the client, and imagine (or recall) what it’s like to lose a loved one unexpectedly and traumatically.

Expressions of empathy are often helpful in moving clients through avoidance: “This is really hard, isn’t it? I know at least part of you wants to do it, and I believe you can.”

Educate. Reminding the client of the rationale for this treatment approach and the particular elements of it can help her to renew her commitment. Tailoring this rationale to each client’s situation is valuable. You might say something like this: “We both know how hard it has been for you to experience the feelings of grief about your mom’s death. We also know that this has kept you feeling stuck for a long time. This approach is the best way we know of to help you to get unstuck.”

Encourage (or Reinforce). In this treatment approach, you play many roles as the therapist, including teacher, companion, and coach. Encouraging, or reinforcing, largely falls within the role of coach. Taking the time to acknowledge, highlight, and praise a client’s success at facing a painful feeling, completing a treatment task, and being fully present in sessions can provide essential support to clients. It’s easier for clients to do something daunting if they know that you are in their corner, noticing their struggles and acknowledging their successes, however small they may seem. You might say, for example, “Good job. I know that was a hard independent assignment, and you did it!” or “I want to make sure we both acknowledge the victory of your visiting the gravesite. It took a lot of courage, and you worked hard to get yourself ready to face this challenge.” Remembering to wear the hat of coach will go a long way in this treatment.

As you use these strategies, you will gain a fuller picture of what will help you and a particular client to stay on track. When in doubt, remember that you always have several choices in session. These include (1) naming the dilemma (e.g., “We had planned to move to a new task today, and yet it seems like the activities from our last session might need more attention”); (2) consulting with the client (as in the example of Melinda above); (3) suggesting that you spend part of the session talking about the current situation (in the example of Melinda, the boyfriend) and part of it doing what was planned for that session; (4) suggesting that you continue as planned if the client feels able to do so; and if not, (5) spending this session on the current situation and returning to the treatment plan next time. A sixth option often arises as you Explore, Empathize, Educate, and/or Encourage: (6) understanding how the client going off track can be brought into the frame of the treatment. In the Melinda example, you might come to appreciate how much Melinda misses being able to talk with her mother about her relationship issues. This might lead to a discussion of secondary losses that is in line with the session tasks for the day or another important treatment element. The path to take depends on the nature of the challenge; the relationship between you and the client; and, ultimately, your clinical judgment and the client’s priorities.

Lack of Treatment Progress

Another challenge comes about when a client’s symptoms seem not to be improving or he is remaining entrenched in the difficulties with which he came into treatment. With this particular challenge, evaluation entails assessing where the client is stuck. You can use the six “Rs” and Handout 11, the Identifying Automatic Thoughts Worksheet, as tools to run through possible ways of understanding where the client is stuck. In addition, your clinical judgment may help you understand the lack of movement and determine how to address this challenge. What does your clinical judgment tell you about the client’s difficulties? Are you aware of a particular memory, emotion, belief, or activity that the client seems to avoid, skirt around, or gloss over? Can you identify any patterns that would help you understand the lack of progress at a deeper level? For example, does the client consistently not complete independent activities that relate to one of the “R” tasks, to social support, or to exposure tasks? Each of these patterns will invite a different solution (see Chapter 12 for information about moving through the “R” processes, Chapter 10 for more on social support, and Chapter 11 for exposure tasks). The “E” strategies will also help you to evaluate and respond to this category of challenges.

Explore. If a client continues to seem stalled in the same ways that brought him into treatment in the first place, it might be helpful to explore this together. Are you and he on the same page? Does he in fact feel as though nothing has shifted? If so, what is his understanding of why and how he remains entrenched? If not, what are some changes that he has noticed? Have you noticed any changes in the client, and if so, can you share these observations with him? You may also want to explore which aspects of the treatment have been particularly difficult for the client and whether any have been either tolerable or helpful from the client’s perspective.

In exploring the client’s understanding of his lack of movement, do you notice any resistance to “getting better”? Do you notice avoidance of aspects of the treatment, or avoidance of aspects of his experience? Referring to self-care activities, one client told a therapist, “I don’t go for that fluffy stuff you want me to do between sessions.” Upon exploration, the therapist learned that the client’s feelings came to the surface when he engaged in self-care activities. The therapist concluded that an emphasis on feelings skills (Chapter 10) would be useful to this client. This discovery led to an increased emphasis on managing emotions, which helped the client to move through the rest of the treatment.

Empathize. Empathize with the difficult feelings a client may be experiencing, as well as with the strategies he may be using to avoid such feelings. For example, you might say, “I understand that your daughter’s piano lesson conflicted with our meeting, and I’m also wondering whether you had some misgivings about coming to see me last week. Our work together is challenging, and sometimes it’s hard to keep going.” This will help both of you to remember that you are in this together, that motives are sometimes complex, and that you will continue to work toward the client’s treatment goals.

Educate. After exploring where the client is stuck and empathizing with him, educate him about what you have observed and what strategies you might use to address the challenges. In doing so, you provide a collaborative foundation for moving forward. Education about the rationale of the treatment as a whole (Handout 2, Orientation to the Treatment) and about its individual elements (Handout 3, Treatment Goals and Tools) will help map out the territory ahead in a way that holds hope for healthy accommodation of the loss. You might say, for example, “I know you are feeling stuck right now. I believe that if we continue to explore your belief that getting better is a betrayal of your son, you will eventually break through this stuck place. Remember that what we tell ourselves and what we believe may be distorted. Challenging such beliefs is part of the process of recovering from trauma and adapting to loss.”

It can help to remind the client of the exposure rationale – that avoidance prolongs pain in the long run (see Chapter 9) – while empathizing with the fact that avoidance can seem like a better approach in the moment because the client does not want to experience painful feelings, and because he may have difficulty believing that doing so will help him move forward.

Encourage. Finally, it will help to encourage or reinforce what the client has been doing that will help him to move through the mourning process. Clients may not recognize the value of, or give themselves credit for, small steps toward their goals. You can support them by noticing and naming these steps.

Worsening of Symptoms

It is not unusual for individuals in this treatment, as in other treatments, to experience a worsening of symptoms before feeling better. Engaging with painful memories, thoughts, and emotions definitely hurts at first, which is why people avoid them. However, this engagement will allow people eventually to move through the pain and bring it to tolerable levels. Again, you can use the four “E” strategies as a framework to help you evaluate what a client needs when she is getting worse, as well as why she may be getting worse. As you evaluate such challenges, you will want to look for whether the worsening symptoms are a result of increased engagement with painful thoughts, memories, and feelings. Alternatively, are the worsening symptoms a result of a client’s increased resistance to confronting the pain? This is also an expectable response in this treatment approach. Are symptoms worsening due to the normal fluctuations found over the course of traumatic bereavement? Are these symptoms caused by reactions to external events (such as legal trials or major life changes that the survivor must face without the deceased)? Finally, you will want to evaluate whether the client needs more support to tolerate and eventually move through her symptoms, and if so, what kind of support would be most helpful.

The client’s sense of daily well-being is very important. Can the client manage her day-today life and current symptoms? If she is having greater difficulty managing, what additional supports might she need? If she becomes symptomatic in ways that interfere with her daily life, she probably needs more support. This will be true whether the pain results from rigid avoidance or from distressing thoughts and feelings. Such symptoms may include dissociation, substance overuse, self-harm, aggression, increasing depression, social withdrawal, self- sabotage, suicidality, and psychosis, among many possible others. None of these responses is in itself a reason to discontinue the treatment. You and the client must decide together whether and how the treatment can continue. There is little doubt that more support (e.g., independent activities, more frequent sessions, more social support, or a medication consultation) is indicated at a time like this.

In addition, the hierarchical approach to avoided thoughts, memories, or situations is fluid. A client may initially assume that recounting a specific memory or visiting a place she used to visit with the loved one is low on her fear and avoidance hierarchy, but later may realize that she underestimated the distress caused by the memory or the situation. In this case, you should normalize the experience of “guessing wrong” about the hierarchy and help the client choose a different, less distressing memory to recount or exposure to pursue. Clinical consultation with therapists who do similar work can be an invaluable resource as you make such decisions.

Explore. Exploration of this challenge involves formally or informally taking an inventory of the client’s symptoms and their intensity. You might begin with a conversation about the client’s understanding of her symptoms and level of well-being. Do you both agree about whether the symptoms are getting worse or better? Are some getting worse and others better? How does she understand why this might be so? Assessment strategies, such as those we recommend in Chapter 8, can provide crucial information about treatment gains that may accompany increased symptoms in other realms. How are the worsening symptoms interfering with the client’s day-to-day activities? Might symptoms be worsening because the client is not moving through the mourning processes? In addition, it can be useful to explore what activities have helped the client to feel supported in the work. To what extent is the client engaging in the independent activities? (This means not only whether she is doing the work, but how she is doing it. Is she actively engaging or just going through the motions? Is she attempting tasks that are too challenging or not challenging enough?)

The next step might involve using structured interviews and/or pencil- and-paper measures, which can provide invaluable information under such circumstances. For example, portions of Rando’s (1993) GAMSII instrument (described in Chapter 8) – such as Topic Area H, “Mourner’s self- assessment of healthy accommodation of the loss now and in the future” (pp. 679 – 680) – can offer information about the client’s perspective on her progress and coping. The Inner Experience Questionnaire (Brock et al., 2006), a paper-and- pencil measure of self-capacities, may also be useful. (For additional information on assessment, see Chapter 8.) Gathering this information will help you with your evaluation of (1) what is causing the worsening of symptoms; and (2) what supports, changes, and/or skills the client might need in order to tolerate and move through the pain.

Empathize. Use your clinical judgment and knowledge of how the client has been moving through the treatment to help you decide how and when to express empathy. If it seems as if the client is getting worse because she is defending against some aspect of the process, you might say, “I know this is particularly frustrating for you right now, especially because you’ve been working so hard. I have a hunch that if we keep at it and focus on the beliefs you hold about [for example] getting better, you will begin to feel better. I do realize how difficult this is.” If it seems as though the symptoms are getting worse because the client is engaging with painful memories, then it will be helpful to empathize with and normalize this.

Educate. If the client notices increased intrusive symptoms, anxiety, or depression because she is beginning to open up to the pain of her loss, then it is important to hold onto the knowledge that this is an expectable part of this treatment and to share this understanding with the client. It can be very useful to explain that the pain often gets worse before it gets better, and to remind the client that it does get better. Part of the purpose of exposure is to elicit feelings that mourners have often suppressed. As clients decrease their use of certain defenses (such as dissociation, denial, and avoidance), they may become more symptomatic. Harvey (1996) found that traumatized clients often exhibited either no improvement or a worsening of trauma symptoms in the early part of therapy, while simultaneously showing positive changes in authenticity and meaning. Such information provides a framework for clients to understand their distress, which usually motivates them to continue the work. If a client is holding onto protective strategies more tightly, and therefore avoiding more intensely, then it will be necessary to go back to the rationale for the treatment as described in Handout 3, Treatment Tools and Goals, and Handout 9, A Model for Change. You may need to review the rationale repeatedly, pointing to examples in the client’s life of how engaging with the pain of the loss opens things up, and avoiding shuts things down. When asked what they fear will happen if they allow themselves to experience fully the emotions related to the loss, clients often describe fears of crying without ever stopping or being so distressed that they cannot function again. Gradually allowing themselves to experience their feelings decreases these fears. Clients come to see that they can allow themselves to acknowledge and experience their pain without being overwhelmed by it. Handout 13, the Automatic Thought Record (described in Chapter 11), may be useful in challenging catastrophic thoughts about what might happen if they experience the emotions they have avoided until now.

Encourage. As described above, reinforcing a client’s progress (however substantial or limited it may be), and holding hope for the future, are significant aspects of working collaboratively with the client and supporting him within a strong alliance.

Attend to safety. Addressing a worsening of symptoms entails careful attention to a client’s safety. If you believe that the client may be unsafe to himself or a danger to others, safety must become the primary focus. Safety is always the top priority. If you have questions about the client’s safety, we urge you to rely on your foundational clinical skills and professional resources to assess safety and respond in an ethical, supportive, and respectful manner. This is one of those moments when we recommend veering from the structure of the treatment approach. Many of the tools we provide will be helpful to establishing and maintaining safety (e.g., feelings skills, social support, self-care activities). If safety is in question, then these tools should be used solely in the service of establishing it. Putting on hold exposure work or exploratory work that opens up feelings or memories may be the best course of action. Once safety is established and maintained consistently for some time, you can talk with your client about whether resuming other aspects of the treatment will be helpful. Clinical consultation with peers, your supervisor, or a more experienced therapist is also an important element of helping a client to stay safe and deciding whether to continue with any aspect of the treatment approach.

Challenges arising from Working in a Different Paradigm: stronger and Weaker suits

Our approach is unique in its combination of elements to treat traumatic bereavement. As previously described, the core treatment components include developing resources (self-capacities, coping skills, social support, bereavement- specific strategies, values, and meaning); cognitive and emotional processing of trauma; and moving through the six “Rs” of mourning. All of this takes place within the context of a strong therapeutic relationship. The treatment approach encourages use of psychoeducation and independent activities. With all of these components, it is likely that you will find areas of greater and lesser familiarity. In addition, you may have positive or negative reactions to certain treatment techniques or philosophies of treatment, based on your experience or on other, more subjective factors.

identifying stronger and Weaker suits

It is natural that we all have, and usually prefer to work within, our “stronger suits.” We may have discovered our stronger suits in our initial professional training, from workshops or self- guided study, from mentors or clinical supervisors, and from our own experiences as therapy clients. Most of us will recognize these strengths. These are the conceptualizations and techniques that we use naturally and intuitively with most clients. They are often well represented on our bookshelves and in the list of conferences we’ve attended. When we’re working from our strong suits, we feel energized and perhaps even passionate about our work, as if we’re in our comfort zones.

Strong suits can include content areas of knowledge or information, process areas of techniques or information, clinical populations, and skill areas like assessment or treatment. For example, one of us (Laurie Anne Pearlman) works most comfortably doing relational psychotherapy with adult clients with complex psychological trauma adaptations. Another (Catherine A. Feuer) works most comfortably with children and adults in a CBT framework. A third (Christine H. Farber) considers her strong suit to be individual psychotherapy with adult clients who are experiencing various life transitions. She prefers to work within a humanistic framework that acknowledges spiritual dimensions of life experiences.

“Weaker suits” are those areas to which we have not been exposed as therapists, in which we have not had a lot of interest, which we have not had a chance to practice and use, or in which we simply lack skill. They may also be weaker suits because we do not feel open to learning about or developing them. These are the areas with which we are less comfortable – t he areas that require us to stretch ourselves professionally and possibly personally as well. Working outside our strong suits most likely entails doing things that are less familiar, and we all have tendencies to drift toward the habitual. Of course, the hazard of this drift away from the elements and techniques that are less comfortable is that we will inadvertently shortchange our clients.

The box below is a tool for identifying your own stronger and weaker suits. You can use this awareness both while sitting with clients and when planning for professional development.

identifying your stronger and Weaker suits • You know you’re working from one of your strong suits when…

• Your physiological indicators are on “go”: You feel calm and relaxed, maybe even slightly aroused physiologically.

• Your energy level is good.

• Your stamina and endurance are strong.

• You feel confident and optimistic.

• You feel creative.

• Time seems to fly by.

• You have a sense of flow.

• Your mind seems to be working very well.

• You and your client seem to be “in synch,” moving forward together throughout the session. • You can recognize your weaker suits when…

• Your physiological indicators are on “interference”: You feel physical discomfort, as if you’re coming down with something – aches and pains (e.g., stomach, neck, back, head), fatigue, drowsiness.

• Your energy is low; you lack interest.

• You find it difficult to concentrate or stay on task; your mind may wander.

• You find yourself looking at the clock more often than usual.

• You exhibit negativity and/or feel self-doubt.

• You feel as if you and your client are at odds with each other or simply not connected.

Building your Weaker suits

Successful application of this treatment approach requires identifying and strengthening the areas that may be less familiar to you. This book provides the background necessary to develop those less familiar areas. Building a weaker suit requires self- awareness and openness to learning. The best approach to building a weaker suit is study, coupled with practice and consultation. We strongly encourage you to read the relevant material in Parts I – III and then to employ the approach, using the material in Part IV for guidance. Specific consultation on particularly challenging elements is a good way to work out rough spots. For example, if you are new to exposure treatment, you might want to arrange some consultation sessions with someone experienced in that approach. Someone who is less familiar with resource- building work may want to consult with a colleague who has done more of it with traumatized clients.

Practicing this treatment approach provides an opportunity for you to expand your therapeutic tool box, while also learning about yourself and the process of transformation through grief. As a step toward growth, we encourage you first to identify your stronger and weaker suits; then to identify what you might need in relation to each area for growth (e.g., information, skills, knowledge, support, self- awareness, experience); and finally to develop a plan that suits you. Your plan might include one or more elements from the following list:

  • Continuing education: Books, journals, websites and other online resources, workshops, conferences
  • Consultation: Peer or expert, individual or group, time- limited or ongoing
  • Training: Online or live
  • Study group: Peer or facilitated
  • Your own psychotherapy

It is also worth remembering that sometimes all of us struggle with a lack of confidence rather than a lack of competence. Clinical consultation can also be a place to explore this issue.

Clinical integration

Dr. Taylor could feel a lump forming in her throat at the beginning of her session with Seth when he asked to talk about his brother’s possible drug use, thereby veering off their treatment plan. She believed that maintaining their focus on Joan’s death was the right thing to do. She had witnessed a lot of clients understandably avoiding the issues they came into therapy to address by presenting other concerns in sessions. Dr. Taylor worried that she would enable Seth’s avoidance by following his lead on this day. At the same time, it was clear to her that he was having difficulty focusing on anything other than his worries about his brother’s alleged drug use. As she sat across from Seth, Dr. Taylor felt confused and concerned. She was unsure how she would respond to his request.

“Dr. Taylor?” Seth was worried that he had lost his psychologist to her own thoughts. She suddenly seemed distant.

“Yes, sorry, Seth. I’m here. I was just thinking about which direction we should head today. Listening to you, I found myself feeling concerned. I can see how upset you are today, and we can certainly take some time to talk about your brother. My concern is that this would take us off track.” Dr. Taylor had made the decision to address this issue directly. Seth was listening. “Before we explore the situation with your brother, I’d like to ask you a few things. Does that sound OK?”

“Yes, sure. I just don’t know what to do about Danny.”

“I can only imagine how challenging this must be for you – to be worried about Danny during this time that has been so difficult for both of you.” Seth seemed to relax a bit upon hearing Dr. Taylor express some empathy. “Let me ask you this: How were you feeling after we discussed doing in vivo exposure last week? And how were you feeling as you anticipated coming to therapy this week?”

“I felt pretty anxious, actually, the day after our last session. The thought of being at my mom’s place and beginning to sort through her belongings, as we had discussed, felt overwhelming to me. I just haven’t wanted to get rid of any of her stuff.” Seth began to tear up. “I don’t want to let go.”

“I understand something about how difficult this must have been for you. Facing these kinds of things can be really hard. You said the thought of being in your mom’s house was overwhelming. Did you actually go into your mom’s place?”

“Yeah, I did. I lasted for about 25 minutes, but then I felt too panicky. When I started to think about getting rid of some of her things, I not only felt anxious, but also angry. I just don’t want to feel all of the grief.”

“Twenty-five minutes is a good start, Seth. In terms of our work together, it’s an accomplishment. I know it didn’t feel good, but you got through it. It must have been difficult to come in here today, knowing we were going to talk about the exposure activity, and that I would likely encourage you to do more of this.”

“It was.”

“Maybe you were also feeling anger toward me? Not wanting to experience those feelings, and here I am giving you activities to do between sessions that ask you to do just that?”

“I’m not sure. I know I was feeling irritable all week. But the thing with Danny is real. He looked high one day last week, and there was another day when he wasn’t at class as he said he would be. I’m worried about him.” Seth’s body language suggested increasing agitation.

“Let’s explore that,” suggested Dr. Taylor. After asking Seth more directly about his experience with in vivo exposure, she felt more comfortable moving into an exploration of his feelings and concerns regarding Danny. She also had a hunch that the situation with his brother was related to his feelings of grief and anger about his mother’s death. “Tell me more about Danny.”

“I’m furious with him. He’s destroying himself rather than coping with our mom’s death. At least that’s how it feels. He’s so angry that she’s gone. I’m so angry that she’s gone. And my mom was the only one who could ever get through to him. I don’t know how to help him, and I’m mad at her for being killed – for putting me, and him, in this situation.” Seth’s voice grew stronger, even as tears were welling up behind his words. “And I feel guilty for being angry at her,” he added in a softer voice. “You can’t be mad at someone for having been murdered!”

“Actually, you can be. And of course you’re angry. In addition to missing Joan as your mother, you miss her as Danny’s mom. This is one of those secondary losses we’ve talked about. Also, it sounds to me as though you really empathize with your brother’s pain. And I imagine that facing his potential drug use is not unlike going to your mom’s house. Both have required you to come face to face with the anger and pain and loss that are within you. Both confront you with the reality that your mom is gone.”

Treatment challenges

Seth was now crying quietly. No longer agitated, he seemed instead to sink into his grief as he sat back in his chair and covered his face in his hands. Dr. Taylor sat with him, quietly. She knew that they could continue to explore exposure activities and the emotional processing that these activities served. For the time being, her client was in the midst of this processing, and she allowed him space for just this.

Concluding remarks

Throughout this chapter, we have explored some common challenges that you may encounter while implementing this treatment approach, as well as guidelines for how to manage them. The example of Seth and Dr. Taylor illustrates how these challenges might manifest themselves in a particular therapy. It might not surprise you to learn that Dr. Taylor struggled with the structured nature of this approach, as well as with the implementation of exposure activities. She was aware that these were her weaker suits, and she had a tendency to compensate for her limitations by “following the rules” more closely with these aspects of the treatment. When Seth asked to address a situation that seemingly fell beyond the scope of their therapy and might have been related to avoidance, Dr. Taylor experienced some of her own anxiety, as it touched on vulnerabilities of which she was aware.

Dr. Taylor offers us an example of how to manage challenges effectively. In various places throughout the session, she chose to address her dilemma directly: She let Seth know of her concern that the topic of Danny’s drug use could lead them off track, and she directly Explored his reactions to doing exposure work. She also collaboratively explored how Seth’s responses to exposure work might have been related to his concern about his brother, and in doing so she expressed Empathy both directly and indirectly. By addressing her concerns directly with Seth, Dr. Taylor also provided Education with regard to the difficulty of exposure and the importance of the structured nature of the treatment, and she reinforced (Encouraged) both how Seth was feeling and the good work he was doing.

As readers and clinicians, we can imagine the challenges that Dr. Taylor, or any of us, might need to address in order to work with this approach effectively. Our final chapter addresses the potential effects on us as therapists of working therapeutically with the traumatically bereaved.



chapter 14. effects of the Treatment on Therapists

It was a brisk, bright October morning, but Mala was having difficulty getting out of bed. She had gotten enough sleep, the sun was up, and she could smell her coffee brewing. Her trouble with waking up on this particular morning confused but didn’t surprise her. She had been feeling this way on and off for several weeks now. Her difficulty in getting going was accompanied by a sense of dread about being at work, and on some level, she was aware of this connection. With a sigh, she got going.

Mala had begun working at the Health Clinic 17 years earlier. She started out as an intake specialist before pursuing her master’s degree in social work and then becoming a licensed independent clinical social worker. Mala was now the clinic’s director, and for the most part she enjoyed her work. She took pleasure in the challenges of her career and especially liked the supervisory work she did with the counseling staff. Over the last few months, however, she’d started feeling tired, unenthusiastic, and even a bit defeated. Whereas Mala had initially dismissed this experience as a phase, telling herself, “This too shall pass,” she was beginning to disbelieve her own pep talks.

On this particular day, as the work day drew to a close and she realized she was anticipating the next day of work with anxiety and dismay, Mala decided to call Nathan – a fellow social worker, mentor, and confidant with whom she had consulted in the past whenever she felt stuck in some way. Mala felt tears in her eyes as she picked up her phone and dialed his number.

This chapter addresses the effects that this work can have on you, the therapist. We discuss those responses that relate to work with a particular client under the heading “Countertransference.” We discuss under the heading “Vicarious Traumatization” those responses that result from therapies with multiple trauma clients over time. We then move to a discussion of training and consultation as ways to support yourself in the work. The chapter also highlights the rewards of working with traumatically bereaved survivors.

Many factors contribute to our own responses to the work, and it may not surprise you to read that in certain ways, our responses parallel those of traumatically bereaved individuals. Put simply, these individuals struggle with the difficulty of accepting and accommodating a reality that they wish were not true. Likewise, we therapists may have difficulty remaining open to clients’ symptoms and adaptations, struggle to accept particular elements of this treatment approach, or experience resistance to our own responses to it. The guiding principle of this chapter is that self- awareness is the key to ethical, effective, and fulfilling therapeutic work. We address each of these effects, as well as how to create support for yourself in order to provide the best possible treatment while honoring your own needs and feelings.


The work of mourning can raise strong feelings in you as a therapist, as well as in clients. A variety of factors will influence your countertransference responses (all of your responses to a particular client). These include your personality, coping style, and strategies; experience with your own losses; family history; and current life stressors. Your comfort with and confidence in this treatment model can also affect countertransference responses. So too can the specifics of each client’s presentation, as well as the client’s ways of coping with and managing the loss. The details and specific nature of the death may influence countertransference responses as well. Although there are many possible sources of countertransference responses in trauma work (Dalenberg, 2000; Danieli, 1994; Pearlman & Saakvitne, 1995; Wilson & Lindy, 1994; Wilson & Thomas, 2004), several responses to the combination of trauma and loss are particular to this work. We delineate some common responses in Table 14.1.

sources of Countertransference in Traumatic Bereavement Treatment

Whatever the source of countertransference may be, awareness is essential to using these responses constructively to help a client (for more on using countertransference constructively with trauma clients, see Dalenberg, 2000; Pearlman & Caringi, 2009; Pearlman & Saakvitne, 1995; Saakvitne et al., 2000). Here we discuss some of the common responses you may experience when using this approach to working with traumatically bereaved clients.


Table 14.1. Common Countertransference responses to sudden, Traumatic death and Traumatic Bereavement

  • Related to a client and her adaptations
  • Compassion for a client who suffers so terribly
  • Assumption of a client’s attitude that life is not worth living without the significant other or that all meaning has vanished
  • Grief consonant with a survivor’s grief
  • Frustration with a client who is unable to take in the many positive elements in his life
  • Related to the death
  • Shock, horror, or disgust at the sometimes violent or otherwise horrific details of the death • Anger at those who may have created, allowed, or contributed to the death or its aftermath
  • Related to the therapy
  • Annoyance with a client who is not fully engaged with the treatment
  • Yearning or resentment that a client is receiving treatment that wasn’t available to the therapist in her own losses
  • Worry that the therapy isn’t “enough”
  • Satisfaction at being able to help someone who has suffered deeply
  • Love for a client who struggles to thrive and move on, against various challenges • Related to the therapist
  • Guilt about having a comfortable life that hasn’t included losses such as the client’s
  • Fear that the therapist will lose a loved one or will die suddenly, leaving his significant others to mourn his death

responses related to client adaptations

Many survivors of sudden, traumatic deaths have spent years struggling with their reactions to their losses. For some survivors, the grief is very visible. One type of client with visible grief is a person who, years after the death, cries readily, has not dealt with the loved one’s belongings, and has not developed or maintained an intimate or meaningful relationship with anyone new. In other cases, particular manifestations of grief may not be obvious to the survivor or those around her. For example, a client may present with psychosomatic difficulties but no reported emotional problems (or perhaps no evident or reported emotions). With other survivors, substance abuse or social or sexual withdrawal may be the main clue to unresolved trauma and grief. As a therapist, you will have a variety of responses to each presentation, finding some more challenging than others.

As an example, a client who has overt, intense signs of grief or trauma may elicit feelings of sympathy, compassion, concern, aversion, dismay, and/or anxiety. You may feel an intense need to do something to relieve the client’s suffering. You may feel helpless and hopeless, perhaps echoing the client’s feelings. If you feel inadequate to conduct the treatment, you may then feel ashamed, annoyed, or angry with the client, and/or resentful of the client’s needs and demands. As another example, a resigned or resistant client may evoke feelings of powerlessness, helplessness, or annoyance. Further countertransference responses may come about as you react to these inner experiences – for example, moving toward over activity, over involvement with, or withdrawal from the client.

responses related to the Death

Many of the events that lead to sudden, traumatic death include aspects that are senseless, shocking, violent, or untimely. Therapists often feel revulsion; fear that such things could happen to themselves or their loved ones; or anger, despair, or cynicism about people who cause such tragedies or about human vulnerability. As a therapist, you may find yourself moving away from gruesome details during sessions when it would be therapeutic for a client to give voice to them. If you fear a similar fate for your loved ones, you may experience the impulse to blame the client, in an effort to ensure that the same thing won’t happen to you.

You may also identify with individuals who were involved in the death. This could include those who contributed to the death or whom others perceive as responsible. For example, you might think, “How awful for that doctor to have misdiagnosed and then lost her patient,” or “I can imagine what the driver of the vehicle is feeling now.” All of these responses are understandable; being aware of them will give you the choice not to act on them in ways that would be counter therapeutic.

responses related to the Therapy

In Chapter 13, we discuss aspects of this particular treatment approach that may be challenging for you. Such issues can evoke countertransference responses in a particular therapy. For example, one therapist struggled with teaching feelings skills. When she worked with a client who was much older than she was, her struggle became more pronounced: She experienced herself as condescending and thus tended to minimize these aspects of the treatment. After exploring her responses with a colleague, she came to understand that her client often did not get the support he needed because others saw him as unusually self- sufficient. The therapist also had not seen his vulnerability.

Alternatively, you may feel annoyed with a client or disappointed in yourself (or both) if a client continues to exhibit distress while not engaging adequately with the treatment. These responses may lead you to exhibit impatience, which may arouse guilt or resentment in the client. As with any lapse in empathy, the client may feel alienated or abandoned, which in turn can affect her motivation.

In the presence of a highly distressed traumatically bereaved client, you may worry that the therapy is too complex, particularly if you are new to this treatment approach. This response can lead to a lack of confidence in the treatment and/or impatience with its pace. In turn, you may convey that lack of confidence to the client, undermining his hope and motivation. Alternatively, you may skip the resource- building elements and move prematurely to the exposure elements, or skip essential “R” processes that the client has not yet completed, unwittingly robbing him of important dimensions of adaptation to the loss.

Responses Related to the Therapist

Your particular responses may depend on such factors as your theoretical orientation, personal style, history, and current life circumstances; similarities between you and the client; and consultation resources available. Most of us have experienced losses of loved ones, whether through death or other types of separations. Many of us also have personal histories of traumatic loss. Identification with a client along any dimension (e.g., age, gender, life situation, and particularly the nature of the traumatic loss) can raise significant challenges. The client and his situation may reawaken your own loss and grief experiences. One danger for the treatment is that, based on your own experiences, you may make assumptions about who this individual client is and what he needs. It is easy in this case to lose sight of the particulars of the client’s situation and needs, and then to veer from empathic engagement.

Batson, Fultz, and Schoenrade (1987) described an important and relevant distinction between empathy and personal distress. They depicted empathy as a process in which one imagines the experience as happening to the other person (the client, in this case). They explained personal distress as arising when one (you as the therapist, in this case) imagines the experience as happening to oneself. They reviewed evidence suggesting that whereas personal distress (“What if this happened to me?”) seems to motivate people to reduce their own aversive arousal, empathy (“How terrible that this happened to her”) seems to motivate people to address the other’s needs. This observation has important implications for the ability to respond constructively to clients in distress. If you are experiencing personal distress as a result of your interactions with a client, you may unconsciously attempt to find ways to reduce your own distress. For example, you may collude in avoidance with a client (e.g., by redirecting her when she talks about her deceased loved one); forget important information the client has shared; feel sleepy or distracted in sessions; or fail to return client phone calls or prepare adequately for sessions.

Personal traumatic experience can come into play when therapists and clients have endured the same traumatic events at the same time, such as natural disasters or community violence. Tosone (2006) has termed such experiences shared trauma. Hurricanes, earthquakes, wildfires, floods, terrorist attacks, and group violence can affect the lives of everyone in a community. When therapists lose loved ones in such events, it is imperative to engage in clinical consultation with an experienced consultant as they find their way through their work with traumatic loss survivors. We also strongly recommend that survivor therapists take time to process their losses in their own psychotherapies before and during their work with survivors.

In addition to losing loved ones, therapists may experience other losses in natural disasters or community violence. These may be tangible (e.g., loss of home or other property) or intangible (e.g., loss of security, predictability, or connection to the community). These losses, too, will affect countertransference responses to survivor clients. Therapists must understand them in order to provide the best possible care.

If you have lost a loved one and mourned the loss without the kind of expert assistance you are now providing to a client, you may yearn for the same kind of help, or regret that it was not available to you. If you are unaware of these feelings, you may unwittingly withhold (or “forget”) essential elements of the treatment, such as the compassionate support, resource- building elements, careful work with automatic thoughts, or exposure elements that would be vital to the client’s recovery. Alternatively, if you have never lost an important loved one, you may feel guilt in your relief that you have not experienced such a loss.

Perhaps too infrequently discussed are the “positive” countertransference responses therapists may have for their clients. As a therapist, you may feel deep respect, admiration, or parental love for a client who struggles to thrive and move on against various challenges. As with all countertransference responses, and as discussed in more detail below, bringing such inner experiences into awareness and using them in therapeutic ways is the ultimate goal. We encourage all therapists to express feelings of respect and admiration (love is generally too strong a word for appropriate use in psychotherapy), although this must be done with sensitivity (Dalenberg, 2000; Kahn, 2006). It is essential to observe a client’s response to such expressions, to discover whether they are motivating, embarrassing, or alienating to the client. Of course, when treatment goes well, you will feel rewarded and satisfied with the work, as well as happy for the client who has reclaimed his life. It is often appropriate to let the client know how pleased you are with her progress.

It is common for these various responses to exist in combination with one another. For example, you may feel constrained by the structured nature of the treatment approach or impatient with a client who you feel isn’t progressing, while remaining unaware of the activation of your own traumatic loss history. Clinical consultation can be useful in sorting out the various contributing factors to countertransference responses; such differentiation is essential to using them constructively to move the treatment forward.

managing Countertransference responses

Paulo sat down with Marta, a new client who came in because she had felt emotionally frozen ever since the death of her infant daughter a few years earlier. Paulo had started to see some traumatically bereaved clients since losing his father in an automobile accident a year before. He had been engaged in his own psychotherapy, and felt he might have something special to offer to other mourners.

As Marta began to tell the story of her loss, Paulo increasingly thought about his own grief and mourning. How could he make sense of the depth of the pain he had experienced, when measured against that of losing a young child? His father had been elderly, not in excellent health, and probably not too many years away from a natural death. In contrast to Marta’s infant daughter, his father had led a long and satisfying life.


Paulo’s guilt began to get in the way of hearing Marta’s story. He began to reassure her that her frozen response was normal. He also stated that her husband, who insisted she come in to therapy, sounded insensitive. He thought that he would not use the exposure elements of the treatment because he thought it would be too much for Marta; instead, he would focus on offering warmth and support.

It seems clear that in this example, Paulo was carried away by his countertransference responses to Marta and her story; these responses interacted with his own feelings. Paulo’s recent loss made it difficult for him to stay focused on Marta and to consider her needs without comparing his situation to hers. His assessment concerning the appropriateness of exposure was probably colored by his wish to avoid his own deep feelings of loss. One hopes that he sought consultation before abandoning a treatment approach – exposure – that might provide Marta with some relief from traumatic bereavement.

Our guidelines for managing countertransference come from the Risking Connection trauma training curriculum (Saakvitne et al., 2000). Risking Connection advises clinicians to (1) notice countertransference, (2) name it (for themselves and possibly with the client), and (3) use it to move the treatment forward. Although these steps sound simple, it may not be easy to implement them. We opened this section with a clinical illustration to bring life to the simple, yet challenging, process of working with countertransference. Paulo first needed to notice that this therapy was eliciting a particular set of inner experiences that could cloud his judgment and interfere with his ability to offer therapeutic intervention. Consultation with colleagues, personal therapy, and clinical experience all contribute to the skill of noticing even subtle shifts of inner experience. Even experienced therapists with well- developed self- awareness can miss countertransference clues, especially without tools to help. We cannot easily will ourselves to be cognizant of thoughts, feelings, and beliefs that exist outside of our conscious awareness. For this reason, tools and activities that require reflection on and expression of inner experience are invaluable to effective and ethical work. Journaling, peer consultation, our own therapy, and self- awareness checklists (e.g., Saakvitne et al., 1996) are examples of useful tools for noticing, naming, and constructively working with countertransference.

Some of the guidelines suggested in Chapter 13 (see the “Guidelines for Identifying Treatment Challenges” section and the accompanying box) may be beneficial. In addition, worksheets such as those in the appendices of Risking Connection or in the workbook Transforming the Pain (Saakvitne et al., 1996) may be useful, as they were developed specifically to support trauma workers in identifying their countertransference. As mentioned, professional consultation, whether with peers or more experienced clinicians, can also provide a forum for noticing various thoughts, feelings, and behaviors. These might suggest a need for more attention to a particular treatment relationship; for deciding whether and how to name these responses with the client; and for using them constructively to help the client.

Another clinical example can illustrate how managing countertransference effectively can contribute to moving a therapy forward. Ms. Black, a 45-year-old woman whose son had been shot and killed in a hunting accident the previous autumn, came to treatment. She presented the story of the death without much emotion, avoiding eye contact with the therapist, Dr. Owens. She repeatedly stated that she didn’t think therapy could help her, that it couldn’t bring back her son, and that she was only here because her trusted primary care doctor had asked her to see this therapist. At the end of the first session, she told Dr. Owens that she didn’t think she would come back, but agreed to an appointment “just in case.” The therapist felt concerned about Ms. Black’s situation. She had described considerable social isolation, evidence of depression (loss of interest in everything she had once enjoyed, including difficulty eating, sleeping, and concentrating), and recurring intrusive thoughts about the shooting. Dr. Owens, who was opposed to hunting, felt angry about the death, which seemed completely avoidable (“Why did the son go hunting by himself? Was he wearing one of those orange vests?”). In addition, he wanted to engage this client, both for her sake and because this was his first referral from her doctor’s busy practice.

Ms. Black returned the next week for a second session. She started out by saying, “Now don’t think just because I’m here that I’m coming back again.” Dr. Owens embarked on a discussion of the treatment, moving into both psychoeducation and assessment issues. In the middle of the session, the client said that she didn’t think this treatment approach would work for her.

The therapist decided to bring his countertransference into the room. After noticing what he was feeling (eagerness, frustration, anxiety, worry, compassion, annoyance), he named it: “I’m aware that I have a lot of feelings right now about your situation. You have had a horrible loss, and you may have lots of confusing feelings about it yourself.” To his surprise, Ms. Black said quietly, “Really, Doc, the worst of it is that I can’t help blaming my son for his own death.” Tuning into his own countertransference responses, Dr. Owens responded, “That really feels terrible, doesn’t it? I think some of the information and activities that are part of this therapy can help with that.” The client seemed to relax for the first time and tentatively decided to continue with the treatment. The therapist felt relieved to have a way of understanding his countertransference and how it resulted in his tendency to blame the victim, perhaps in identification with the client. Furthermore, the client’s ability to respond to his statement gave him hope for their future collaborations.

What did Dr. Owens do in the example above that seemed to help his client? First, he noticed his own feelings and made them explicit to himself. If he had not wondered about his own reactions, he might have agreed that the client should not come back; he might have had difficulty expressing warmth toward her; or he might have found himself becoming disengaged. Instead, Dr. Owens reflected on his feelings in a way that allowed him to move into the client’s experience. Then, with this awareness as his foundation, he made a decision to share some of his feelings with his client. He named them for her in a general enough way to give the client space for any responses she wanted to share: “I’m aware that I have a lot of feelings right now about your situation…” Finally, he was able to use this process to move the treatment forward: “You have had a horrible loss, and you may have lots of confusing feelings about it yourself.” In this example, a therapist’s awareness of his countertransference issues became a primary tool in the therapy.

vicarious Traumatization

In this section, we describe the specific ways in which working with survivors of sudden, traumatic death over time and across clients can negatively affect therapists. Although our focus here is on these negative effects, or vicarious traumatization (VT), we follow this section with a discussion of ways that working with traumatic bereavement clients can enrich therapists.

We define VT 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 (McCann & Pearlman, 1990c; Pearlman & Saakvitne, 1995). Its hallmark is disrupted spirituality (Pearlman & Caringi, 2009) – a concept that is both difficult to define and yet recognizable to many. Nonetheless, most of us have a sense of what spirituality means. We use the term here in its broad sense to refer to those aspects of life that are intangible and that reflect a connection with something beyond our material selves. In the context of VT, we draw on Neumann and Pearlman’s (1992) work to describe spirituality as an awareness of intangible aspects of life, including a sense of life’s meaning and hope for the future. Whereas countertransference refers to our responses as therapists to individual clients, VT describes our responses across clients, over time. Both countertransference and VT are inevitable aspects of psychotherapy with trauma survivors. Both can be harmful to clients. If we are not attuned to these responses, they can lead us to engage in counter therapeutic, unethical, or harmful behaviors with clients. In addition, unaddressed VT can harm us by shattering our worldviews, damaging our spirituality, and interfering with our personal relationships, as elaborated below.

As described in detail elsewhere (McCann & Pearlman, 1990c; Pearlman & Caringi, 2009; Pearlman & Saakvitne, 1995), VT arises from an interaction between aspects of the client and aspects of the therapist, all in a particular social and cultural context. In this chapter, we focus on special issues in VT that relate to work with traumatically bereaved clients. For an excellent review of the effects of trauma work on therapists more generally, see Elwood, Mott, Lohr, and Galovski (2011).

sources of VT

The clients

Although VT responses and adaptations will be unique for each therapist, some responses to traumatically bereaved clients are more common than others. These include responses to typical adaptations of this survivor population, as well as to traumatic death itself. (See Chapters 3 and 4 for more about these adaptations.) Many mourners come into treatment because they are stuck in their lives. They are carrying deep traumatic grief and many other personal and interpersonal problems. Over time, as a therapist working with this population, you may develop your own deep grief in response to the grief – both expressed and unexpressed – of your clients. Working with clients’ grief may lead you to become numb to your own feelings as a way of managing your grief. Alternatively, you may develop a chronic sense of outrage or become cynical in response to the senseless loss of vitality and potential. Your own fear of losing a loved one suddenly, as it accumulates across clients, can lead to emotional reactivity, preoccupation or obsessions about death and loss, overprotection of loved ones, or hypersensitivity to potential danger. You may also feel compelled by your clients’ pain to do more than you should to assist them. Examples of this would be making yourself available without limits, consistently allowing sessions to run over in time, neglecting to ask for payment, and other behaviors that ultimately can lead to burnout.

Loss of meaning is at the core of psychological trauma – a fact that is evident with this population. As described in Chapter 3, survivors of sudden, traumatic death often struggle with the “why” questions: “Why me? Why him, not me? Why now?” As they attempt to make sense of their losses, they also face the task of rebuilding their lives, which have often been shattered by both primary and secondary losses. The disruptions in meaning and hope that characterize traumatic death are also signature symptoms of VT. As a therapist doing this work, you may enter into your own search for meaning, or you may find that the way you once understood life no longer seems to work for you. Like your survivor clients, you may face the task of rebuilding a worldview that can accommodate the fact that such profound losses happen all around us and can happen to you.

The Therapist

Adams and Riggs (2008) assessed defensive styles in 129 graduate students in clinical and counseling psychology. They found that “a self- sacrificing defense style characterized by reaction formation and pseudo altruism” (p. 31), which the authors describe as a “need to maintain an image of the self as kind, helpful, and never angry” (p. 29), was associated with greater vulnerability to VT. Conversely, “the student therapist’s use of adaptive coping mechanisms such as suppression, sublimation, and humor decreases the likelihood of experiencing vicarious traumatization” (p. 31).

In his 2004 review, Bride found that although the evidence was not entirely consistent, the preponderance of the research supported a relation between therapists’ personal trauma histories and VT. The research on this link has not yet explored specific aspects of trauma history that may be associated with greater VT vulnerability. However, Adams and Riggs (2008) found that defensive style moderated the effects of personal history on VT. It seems possible that therapists with unacknowledged or unaddressed trauma histories may experience more VT than do those who are aware of their histories and have worked to understand the effects of traumatic events on their lives (Pearlman & Saakvitne, in press). Of course, a specific personal history of concern in working with traumatically bereaved clients is a history of traumatic death in a therapist’s circle of intimate others.

Various authors have suggested that empathy may be the mechanism through which VT comes about (Pearlman & Caringi, 2009; Pearlman & Saakvitne, 1995; Rothschild, 2006; Wilson & Thomas, 2004). A therapist with a personal loss that has not been adequately addressed may be more likely to identify with his clients by recalling his own experience or imagining the clients’ losses happening to himself, which can elicit personal distress (associated with feelings of alarm and upset; Batson et al., 1987). This could reawaken unresolved memories or feelings related to trauma and loss. “Wounded healers” (to use Carl Jung’s term) may have greater empathy for clients with trauma histories similar to theirs; such empathy could be an asset, helping clients feel understood. On the other hand, wounded healers who have not fully explored the effects of their own histories on their work may violate boundaries with clients in ways that are at best not helpful and can cause serious harm (through, e.g., revealing their own loss histories to clients without clinical reasons to do so or suggesting that what will help the client is the same as what helped the therapist).

When these responses emerge across a professional’s therapies, they can create clinical difficulties in the treatments, as well as personal problems for the therapist. The therapist may find her own grief (and trauma, if she experienced a traumatic death) reactivated and then avoid anything that intensifies it, including whatever aspects of the treatment she finds most difficult.

The challenge for all therapists is to identify, address, and ideally transform VT when we experience it. As in our approach with clients, we advocate an integrated approach to painful feelings, thoughts, and imagery, as a way to transform VT. We describe this approach below.

identifying VT

Risking Connection (Saakvitne et al., 2000) and Transforming the Pain (Saakvitne et al., 1996) provide self- assessment tools for identifying VT. Stamm (2005) has developed the Professional Quality of Life Scale (ProQoL), which allows therapists to assess their compassion fatigue (Figley, 1995), compassion satisfaction, and burnout. Although the compassion fatigue construct differs from VT in its focus on symptoms rather than on changes in the self of the helper (Huggard, Stamm, & Pearlman, 2013), Stamm’s measure provides potentially useful information about the impact of the work on therapists who assist trauma survivor clients.

The important question is not “Do I have VT?”, but rather “How is this work affecting me in ways that resemble trauma, if in a milder form?” You can ask yourself (and your loved ones) how you have changed during the time you have worked with traumatically bereaved clients, and whether and how these changes might relate to the work. Changes in relationships, affect management, and spirituality, as well as the presence of such trauma symptoms as intrusive imagery and dissociation, suggest the possibility of VT and the need to attend to the effects of the work. In the following sections, we discuss both coping with and transforming VT.

Addressing vT

If you become aware that you are experiencing psychological, behavioral, or spiritual changes as a result of trauma work, or foresee that you may, you can and must take action. Such action is an ethical imperative, as addressing VT is essential to providing good clinical services. Activities that focus on rest and play can help you cope with VT. These activities include hobbies, travel, creative endeavors, time with friends and family, and so forth. You can use the checklist on pages 261 – 262 to assess how you are doing in your efforts to address VT. Transforming VT requires attending to meaning and hope, as discussed below.

coping with vT

Researchers have found support for the value of strategies such as educating oneself and others about the effects of traumatic events; obtaining assistance and support from others; using humor, active coping, and planning; countering isolation (in professional, personal, and spiritual realms); developing mindful self- awareness; expanding perspective to embrace complexity; engaging in active optimism and holistic self-care; maintaining clear boundaries; creating meaning; processing with peers or supervisors; and exercising (Follette, Polusny, & Milbeck, 1994; Harrison & Westwood, 2009; Killian, 2008; Pearlman & Mac Ian, 1995; Schauben & Frazier, 1995). In contrast to the work of these researchers, Bober and Regehr (2006) found no association between indicators of VT and coping strategies employed. They maintain that a focus on individual coping unduly individualizes the problem; instead, they recommend interventions at the organizational level, perhaps because the strategies they studied were generic (e.g., leisure and recreation) rather than specific to VT (Pearlman & Saakvitne, in press). Others have argued for the importance of organizational changes for those working in agencies (Bell, Kulkarni, & Dalton, 2003; Fawcett, 2003; Jordan, 2010; Munroe et al., 1995; Pryce, Shackelford, & Pryce, 2007; Rosenbloom, Pratt, & Pearlman, 1995), although not in place of individual interventions. We focus on a few of these strategies below.

Building good personal support networks within your community is an important aspect of coping with VT. Communities allow us all to exercise other aspects of our identities, so that in addition to “therapist,” we engage with the world as “partner,” “pianist,” “jokester,” “gardener,” and a host of other identities. Our communities hold our values, joys, and sorrows with us and remind us that we are part of an interconnected web, which can counter the isolation of trauma.

Another aspect of addressing VT is the use of self-care. Just as we do for clients, we strongly recommend that all therapists – and particularly those working with traumatically bereaved clients – develop solid self-care plans and revisit/revise these plans as their needs change over time. Norcross (2000) has described self-care strategies that have received empirical support in the literature. On the basis of his research, Norcross has emphasized the importance of recognizing and addressing the hazards of clinical practice rather than denying them. He suggests thinking in terms of strategies (such as exercise in general, or building community) rather than specific techniques or methods (such as running or swimming, or going out with friends twice a week). In addition, the research supports using multiple strategies (e.g., exercise, relaxation, and social support). Norcross further recommends attending to stress levels and making choices wherever possible in establishing routines. One therapist found that daily morning exercise helped her feel centered, although it meant not arriving at the office until 9:30 A.M. (a choice she was able to make). Another scheduled his most challenging clients first thing in the morning, when he was freshest.

Norcross (2000) further recommends making the work environment soothing and supportive rather than depressing. One trauma therapist bought fresh flowers for her office weekly – an expense she found worthwhile in elevating her mood, especially as it reminded her of life in the midst of working with death. Norcross also suggests using relationships – personal psychotherapy, peer consultation groups, and loving personal relationships – for support in this work. In addition, focusing on what can be changed rather than on what cannot is valuable in avoiding paralysis. A counselor working in a community mental health clinic consistently reminds herself that accepting the work hours and arranging her schedule as well as possible within that frame is a healthier way of working than railing against the 8:00 A.M. – 5:00 P.M. schedule. Finally, focusing on the rewards of the work – both small and great – is a very important way to sustain oneself in this challenging work, as we discuss below.

The way we do our jobs as therapists can increase or mitigate our VT. Pearlman and Caringi (2009) have presented recommendations about ways of working that can help to prevent or ameliorate VT. Some of these strategies are ways of thinking about the work (such as working from a theoretical base, staying connected to our own experience while sitting with clients, and focusing on process rather than outcomes). A second group of strategies includes practice recommendations, such as managing boundaries thoughtfully, writing progress notes after sessions (as a way of containing affect), using countertransference responses to promote each client’s growth, and doing something between sessions that engages the body (e.g., stretching), the spirit (e.g., meditating), or creativity (e.g., sketching).

Rothschild (2006) has recommended attending to bodily experiences while working with traumatized individuals – for example, adjusting one’s body posture as a way of managing neurobiological mirroring responses. She describes this process as unconsciously mimicking the client’s facial expression or body posture. Additional ways of working protectively include diversifying one’s work (another empirically supported process; Norcross, 2000) to include clients who have not experienced trauma or loss, or work other than psychotherapy, such as teaching and writing; expressing feelings about the work through creative activities, such as drawing or making music; establishing professional networks for vital interpersonal support; taking breaks within each day, across the week, and across months; creating an attractive and comfortable work environment; and finding capable clinical supervision or consultation. Some of these suggestions have been noted above as well.

Finally, Pearlman and Saakvitne (in press) have described some trauma- specific strategies for use in coping with VT. We describe and elaborate some of these in the box on the next page as they apply to traumatic- bereavement- related VT.

strategies to reduce Traumatic-Bereavement-related vT

Manage exposure to trauma material. In addition to limiting the number of weekly sessions or percentage of your caseload represented by traumatically bereaved clients, the following strategies for managing exposure may be helpful:

Choose your listening distance. Pearlman and Saakvitne (in press) note that you can choose to listen to potentially shocking stories from a distance, remaining connected to the client’s experience while retaining an awareness of the present moment. You can imagine watching the terrible scene on a video screen and controlling the speed and volume as a way of feeling some control and regulating your responses (an Ericksonian technique), just as you might invite your clients to do.

Choose whether to visualize. Visualizing the story as the client tells it brings you into closer contact with potentially traumatizing material. Staying with the client and her feelings while she is recounting the story, rather than immersing yourself in the material, is a more therapeutic stance; as one therapist commented, “I have to keep one foot on the shore, or we’ll both drown.” If you choose to visualize, or find yourself doing so, try not to imagine the events happening to yourself, but stay grounded in the client’s experience as she is reporting it to you.

Stay connected to your inner resources. Thinking about things you find comforting or soothing can help you regulate your internal states while sitting with a highly distraught client or listening to a gruesome account.

Stay in the present. Keeping in mind that the events the client is recounting took place in the past and that the client survived can be helpful. The loved one is deceased, but there is life in this room now, where your attention belongs.

Respond to signs and symptoms of VT. Outside of sessions, monitor and manage intrusive imagery, avoidance, hyper arousal, dissociation, and loss of meaning.

Use protective imagery. You can change the intrusive imagery in your mind or add protective elements such as guard dogs or bodyguards to the scene.

Regulate your nervous system. Like your clients, you can use breathing, relaxation, and cognitive appraisal (or reframing) to calm your body and soothe your emotions.

Notice changes in core beliefs. In parallel with your clients, you can experience alterations in your beliefs related to your own and others’ safety, trust, esteem, intimacy, and control. One way to notice such changes is to identify a theme in the aspects of the client’s story that affect you most deeply. It’s likely that troubling images or thoughts have tapped into your core beliefs. Understanding this will allow you to process and integrate the new information into your existing central beliefs. They usually become less intrusive and manageable this way. This work can lead to “vicarious posttraumatic growth” (Arnold, Calhoun, Tedeschi, & Cann, 2005).

Stay connected. A common experience among trauma survivors is a sense of disconnection. This can also be part of your experience of VT. Reconnecting with your inner experience and with supportive others is an important antidote to VT.

Based on Pearlman and Saakvitne (in press).

Transforming vT

In addition to coping with VT, we may be able to transform it. The hallmark of VT is disrupted spirituality. Hence the key to transforming VT is (re)connecting with and (re)discovering the intangible aspects of life and our participation in these nonmaterial aspects of life. This includes finding or creating meaning and reestablishing hope. To be clear, our assumption is that being human entails more than a material and tangible existence, and therefore that spirituality is an inherent quality of each of our lives. Neumann and Pearlman (1992) have defined spirituality as “an awareness of ephemeral aspects of life.” Here we use the word intangible in place of ephemeral, as these spiritual issues may be enduring rather than transient. According to Neumann and Pearlman’s research, spirituality includes meaning and hope, awareness of positive and negative aspects of life, valuing of nonmaterial aspects of life, and an open focus (i.e., a willingness to encounter all of life’s offerings). If VT is the process of negative change within the self of a therapist, then transforming VT requires attention to the self, including inner experience (feelings, thoughts, beliefs, worldview, etc.) and transcendent experience (sense of meaning, hope, connection with something greater than oneself, etc.). In other words, it requires attention to spirituality, broadly understood.

Paths to developing this spirituality include activities and practices that cultivate an awareness of our connection with and participation in the intangible aspects of life: practicing meditation, reflection, or prayer; engaging in significant social or political movements (such as working to address some of the causes of sudden, traumatic death); participating in community; creating art; and being fully present in each moment.

Allowing the work to transform us through engaging with the pain and sorrow is another path to growth. Rather than trying not to feel the pain, opening ourselves to it and growing as human beings through the deeper comprehension of all dimensions of life and the interconnected web of human existence is a way of benefiting from the work. This engagement also allows us to offer those benefits to our clients. When we integrate our clients’ pain into our own life experiences, we deepen our understanding of human strength and resilience. Through this process, we expand what we have to offer others who share their tragedies with us. We have referred to this effect as vicarious transformation (Pearlman & Caringi, 2009; Pearlman & Saakvitne, in press). You can use the checklist on pages 261 – 262 to assess how you are doing in your efforts to address VT.

Training and Consultation: supporting yourself in The Work Training and Continuing education

When any of us takes on a new clinical population or wants to learn a new approach, we need more training. As we have described in Chapter 13, it can be useful to “build our weaker suits” – that is, to try to pick up training in less familiar areas. For this treatment approach, training in CBT; the treatment of complex trauma, grief, and bereavement; or relational psychotherapy can all be useful additions to a personal knowledge base.

Clinical Consultation

Self- awareness and good clinical consultation are essential for all therapists, especially those of us working with traumatically bereaved clients. You may find that at times, self- awareness may prompt you to refer a client elsewhere for services because the client’s concerns are too close to your own unprocessed issues. In such situations, the most ethical and beneficial thing you can do for a client is to find someone else to help her. Of course, you must convey this plan with sensitivity to the possibility that the client will experience it as yet another loss over which she has no control. You might choose to say something like this: “The nature of your loss evokes something from my own experience that would make it difficult for me to give you the help you deserve. I’d like to refer to you to a colleague who I think can be more helpful to you.”


A Checklist for Addressing vicarious Traumatization (vT)

We invite you to photocopy this checklist and use it on a regular basis to increase your awareness of how you are addressing your VT. The activities below relate to working protectively, resting and playing, or transforming your VT.

In the space before each item, write the number of times you engaged in each activity in the past week. (Use your best estimate if you are uncertain.) At the end, add up your numbers to give yourself a total score. See how your scores compare across weeks and across months. Do you think you are making progress in addressing your VT?

during the past week, how many times have you…

1.             Engaged in a hobby, such as collecting or researching something not related to your work?

2.             Planned a trip or traveled to an interesting place?

3.             Engaged in a creative endeavor, such as writing, drawing, or quilting?

4.             Spent time with friends?

5.             Spent time with family?

6.             Consulted with colleagues?

7.             Asked for support from others?

8.             Used humor/laughed aloud?

9.             Discussed your reactions to your work with a colleague?

10.          Acknowledged how challenging this work is?

11.          Engaged in a new strategy for self-care (such as physical exercise, using social support, or getting away from your work regularly and frequently)?

12.          Engaged in new techniques for self-care (such as taking swimming lessons or going dancing) within an existing strategy (such as physical exercise)?

13.          Loafed around doing nothing?

14.          Written in a journal or participated in another form of self-exploration (such as seeking therapy or counseling)?

15.          Reflected on the rewards of working with traumatically bereaved clients?

16.          Thought about your work with traumatically bereaved clients within a theoretical framework?

17.          Attended to your own physical and emotional experience while sitting with clients?

18.          Focused on process (what you are doing with your clients) rather than outcomes

(whether they are feeling better)?

19.          Thought about and managed boundaries carefully?

20.          Written progress notes after sessions with traumatically bereaved clients?

21.          Used countertransference responses to promote a client’s growth?

22.          Done something between sessions that engages the body (e.g., stretching, moving) or the spirit (e.g., meditating)?

23.          Intentionally changed your body posture or facial expression while sitting with a traumatically bereaved client, in order to manage mirroring (i.e., unconsciously mimicking the client’s posture or expression)?

24.          Engaged in professional work other than treating traumatically bereaved clients?

25.          Taken breaks within each day? Across the week?

26.          Increased the attractiveness or comfort of your work environment?

27.          Engaged in clinical supervision or consultation for your work?

28.          Engaged in meditation, reflection, or prayer?

29.          Engaged in a significant social or political movement (such as addressing one of the causes of sudden, traumatic death)?

30.          Engaged with one of your personal or professional communities, such as your faith community or professional society?

31.          Noticed yourself being present in each moment?

Used more than one strategy to address VT?


A decision to refer is best made as early in the treatment as possible (when you become aware of the conflict), and after consultation with a colleague who can help you sort out your responses and develop a referral plan that is in the client’s best interest.

Clinical consultation can also be useful when you are assessing your ability to stay present with a traumatically bereaved client. Rather than a one-time analysis, you must continually review your ability to engage effectively with the client. As described in the case of Paulo and Marta above, similarities or differences between a therapist’s story and a client’s can make it particularly difficult to stay present. Even experienced therapists who feel prepared to work with survivors of sudden, traumatic death can benefit from ongoing expert consultation when working with survivor clients (Pearlman & Saakvitne, 1995).

For example, Chris had been meeting with José for 5 weeks when she decided to seek consultation with a colleague. Conducting the integrated approach for traumatic bereavement was not new to her, and she had seen many clients who, like José, had lost a spouse. Chris was therefore surprised to find herself feeling remarkably sad during and after their sessions, as well as increasingly anxious more generally. She was relieved as soon as she made the call to Suni, a colleague with whom she had consulted many times before.

“So,” said Suni, in the midst of their consultation session, “do you find yourself identifying with José in some way?” And just then, it hit her: Chris realized she was identifying with his dead wife! In other words, she was relating to her client, having empathy for him, as she would for her own husband if he were to experience her death. “Talk about close to home,” thought Chris, and tears welled up in her eyes. Internally, Chris connected with her experience of cancer 2 years earlier, with her husband’s fear and sadness, and with her own guilt about being sick. The sessions with José were triggering this whole experience, though it had been outside of her awareness until now. Meanwhile, Suni watched Chris’s facial expressions and tears, and somehow felt that this sadness was connected with her experience of cancer. She was then able to offer her friend and colleague the support she needed to sort out her feelings and to channel her empathy to work effectively with José throughout the remainder of their treatment.

This example illustrates how a consultant can help identify a therapist’s blind spots. A consultant can also suggest alternative clinical intervention approaches, self-care strategies, and other resources, as well as ways of working self- reflectively (Pearlman & Caringi, 2009). Good clinical consultation can also help to ameliorate VT.

Of course, the potentially powerful meanings and affects related to sudden, traumatic death can touch all of us, including those of us who have not experienced such a loss. In our view, informed ongoing clinical consultation is essential for all of us – therapists with and without sudden death histories, at all levels of experience and expertise – in order to support ethical and effective trauma treatment and to help us to thrive in our professional lives.

What constitutes good trauma therapy consultation? Here are some qualities that apply to therapist consultation related to the treatment of traumatic bereavement. (Pearlman & Saakvitne, 1995, also address this issue.)

  • Respectful. Perhaps the most important element of a useful therapy consultation is that the consultant respect the therapist’s knowledge, experience, positive intentions, and courage in opening his work to a consultant.
  • Collaborative. In a relational therapy or therapy consultation, the parties share power. Each person understands where her own and the other’s expertise lies, and seeks collaboration with the other.
  • Experienced. Of course, the best consultant to a traumatic bereavement therapist is a professional psychotherapist who has experience with this population. A psychotherapist with experience in both loss and trauma and the combination of the two is likely to have a lot to offer. If such a person is not available, a consultant with trauma experience who is open to learning about traumatic loss, or one with bereavement experience who is open to learning about psychological trauma, will be the next best resource. Consultants with special expertise in CBT may also be extremely helpful.
  • Generous. A useful consultant offers her expertise generously. That doesn’t mean telling the therapist how to practice, but rather sharing information as well as her own clinical experience, including mistakes.

Another type of consulting arrangement that can be supportive is a peer support group. A group of clinicians who talk about their therapies (with their clients’ consent) in a confidential professional forum can provide information, support, and opportunities for reflection on the work. This can also be a place to process countertransference responses. The group need not be one that works solely with traumatically bereaved clients or that works solely with this treatment approach. The essential element is that the participants develop mutual trust and respect, allowing them to give and receive constructive feedback.

rewards of the work

Working with traumatically bereaved clients has tremendous potential benefits for us as therapists. The most obvious benefit is the satisfaction that comes from being able to facilitate positive change in a client. It is a tremendous honor when clients entrust us with their pain, fear, grief, and vulnerability. When our clients achieve personal growth, we who have been their partners on that journey are also rewarded. Some of the clients who benefit from this treatment have been struggling, suffering, deadening themselves, living circumscribed lives for years. It’s a wonderful experience to be part of positive change for such individuals.

In addition, mastering a complex treatment approach like this one is gratifying. Some of the elements of the approach are likely to be new to each of us. Learning stimulates us and keeps us engaged in our professional lives. We can integrate the information and skills gained from working this way into our work with other clients, expanding the benefits to others.

Finally, as we accompany our clients in their struggle for meaning, we will face questions of meaning in our own lives. Our clients’ ability to endure their terrible losses can inspire a kind of vicarious resilience (Hernandez, Gangsei, & Engstrom, 2007). What makes life worth living? Why do we do the work we do, and how does it fit into the bigger picture? How can awareness of the finitude of life inform how we live the time we have left? Grappling with these issues deepens our humanity. What a gift to have a job that can do that!

Clinical integration

Nathan saw a vaguely familiar number when he looked down at his buzzing phone. “Hello, this is Nathan,” he said, unsure of who the caller might be.

“Hi, Nathan. It’s Mala. Do you have a few minutes to talk?”

“Mala! Of course I have a few minutes for you. How are you?”

Mala described her recent fatigue and the related anxiety, which seemed to have something to do with her work. She described being confused by these feelings and asked whether Nathan had time to meet with her for some clinical consultation. They set up three appointments over the next month, and Mala felt her worry begin to lift.

Over the next few weeks, Mala and Nathan explored two specific clinical situations as the focus of their consultation. The first was Mala’s supervision of a young woman who was finishing her social work internship at the clinic. Mala liked and identified with Keisha in many ways. She was confused, therefore, also to discover some resentment toward her, related to Keisha’s struggles as a working mother. Keisha was trying to sort out whether she could continue this work and still be the kind of parent she wished to be to her three small children. She was spending some of her supervision with Mala trying to clarify this issue.

The second situation was a 5-month long therapy in which Mala was working with a traumatically bereaved client – a woman, Patty, whose son had died 3 days after birth. Whereas Mala usually found her work with bereaved clients to be especially fulfilling, she was having a difficult time with this therapy.

During one of their consultation sessions, Nathan asked Mala what she felt when sitting with Patty in her grief and mourning.

“I feel mostly numb,” said Mala.

“OK. Stay with that numbness,” coached Nathan. “Let the numbness – the lack of feeling – fill up space, and just allow yourself to be with it.” Nathan paused to allow space for Mala’s inner experience. “Now ask that space, ‘What would be there if the numbness weren’t?’ ”

Mala’s closed eyes began to water. “There is so much sadness. And grief. It all feels so heavy.” Nathan repeated back her words, allowing her to take in the feelings and connect with her new experience. He was aware that Mala had miscarried a pregnancy 2 years ago – a loss that was devastating for her at the time. Nathan found himself thinking about this, wondering whether Mala, too, was in touch with this loss.

“I’m thinking about my miscarriage,” Mala said, and opened her eyes to meet Nathan’s. Over the course of that hour, it became clear that she was experiencing a countertransference response in her work with Patty. She identified with Patty’s grief and felt it as though it were her own. However, because Mala had worked with her grief at the time of her loss, her grief had been outside her awareness, so she hadn’t been able to process much of what she had been experiencing in her work with Patty.

Clarity also began to emerge about a different yet related countertransference response within her supervisory work with Keisha. Mala felt jealousy toward Keisha because she was a mother. In part because she liked Keisha so much, and in part because she did not want to identify as a person who could feel jealous of someone for having children of her own, Mala had managed to push these feelings aside. Nathan’s nonjudgmental attitude allowed her to accept these feelings more easily. Mala again felt relief upon naming the experiences she was having.

These first consultation sessions proved helpful to Mala. After continuing to consult with Nathan for an additional month, Mala noticed several shifts in her experience. First, her therapy with Patty deepened. Acknowledging her own grief to herself allowed her to process her losses. Once she began to do so, the need to repress the awareness of her miscarriage and her associated feelings dissipated, and she was free to use her emotional awareness to work more effectively with Patty. Second, she noticed that her resentment of Keisha also lifted. Rather than feeling jealousy toward Keisha, she focused on the truth of her disappointment about not having children of her own. Mala then felt more compassion for Keisha; she understood Keisha’s concern that her work might negatively affect her availability to her children. The joy of supervisory work returned for Mala, and she started to conceptualize her work as a clinical supervisor as a way of engaging her own maternal instincts and energy.

A third important shift that occurred for Mala involved Nathan’s observation that she was experiencing VT. Mala became more aware of how easily she identified with both clients and supervisees and how much she wished to help each group. She began to glimpse the ways in which her countertransference responses interacted with an overall sense of VT and compassion fatigue. She understood how these processes, when unrecognized, had contributed to a sense of futility and dread in her work, and how this had then precluded the productive use of countertransference reactions as well as her own self-care away from the office.

These insights inspired Mala to address VT and compassion fatigue more directly as she consults with other therapists. She came to appreciate how her own supervisory work contributed to the professional development and personal well-being of her colleagues – a realization that energized her ongoing work.

Concluding remarks

Working with a traumatically bereaved population presents us with rewards and challenges. As we’ve discussed throughout this chapter, these challenges include effectively managing countertransference responses and ideally transforming VT. These therapeutic phenomena can touch us at our core. As therapists, our own inner experiences, life challenges, and encounters with psychological transformation become part of our tool boxes. In other words, we use our selves to do our jobs. Doing this job ethically and effectively requires awareness of our own limitations and vulnerabilities, as well as sensitivity to the vicissitudes of our inner experience, behaviors, and habits. In this chapter, we have outlined some of the factors that contribute to countertransference and some sources of VT with this particular population. We have also offered strategies for addressing both.

The example of Mala demonstrates how countertransference and VT can manifest themselves, how they can interact with one another, and how helpful clinical consultation can be in addressing these phenomena. Like our clients, we can become stuck in our own processes of moving through a situation, a therapy, or a challenging time in life. It is the very nature of our professional role to overlap with personal experience, and it is up to us to bring awareness and sensitivity to this. We owe it to ourselves and to our clients.

In concluding this chapter and this book, we’d like to emphasize a point that we have alluded to within this chapter. We hope that both clients and therapists who work with this treatment approach will encounter spirituality, as defined by Neumann and Pearlman (1992) to include meaning and hope, awareness of positive and negative aspects of life, valuing of nonmaterial aspects of life, and openness to all of life’s offerings. In many cases, a traumatic death will evoke these issues and related questions for survivors, regardless of what they do with the various elements named above. Likewise, as therapists who work with survivors of loss, trauma, or traumatic death, we are likely to experience such spiritual elements within our work. Working actively with these issues and related questions and exploring paths to developing spirituality (e.g., meditation or creating community) can contribute to satisfaction and self-care within the challenging work we do. It is our sincere hope that the information provided throughout this text also contributes to your confidence, satisfaction, and self-care in your traumatic bereavement work and beyond.



Appendix. Handouts

This Appendix contains handouts referred to in the text, which are also available on the website ( You can photocopy these handouts or download them. There is also a list of supplement handouts that are available only on the website. Permission to photocopy the handouts is granted to purchasers of this book for personal use only.

Some of these are psychoeducational in nature; others are rich in detailed exercises for independent activities that will help the client move through the treatment. Although the handouts are written for the client, many provide useful information for you, the therapist, as well. You may use them in any order or combination. We present them here in this order to provide an overview of the treatment’s flow, rather than to prescribe an exact sequence for their use. Permission to photocopy the handouts is granted to purchasers of this book for personal use only; additional copies can be downloaded from the website supplement.

List of Appendix handouts

handout 1. Sudden, Traumatic Death and Traumatic Bereavement 269
handout 2. Orientation to the Treatment 273
handout 3. Treatment Goals and Tools 275
handout 4. Self-Care 277
handout 5. Exploring the Impact of the Death 278
handout 6. The Six “R” Processes of Mourning 279
handout 7. Breathing Retraining 280
handout 8. Feelings Skills 281
handout 9. A Model for Change 288
handout 10. What Are Automatic Thoughts? 289
handout 11. Identifying Automatic Thoughts Worksheet 291
handout 12. Sample Automatic Thought Record 292
handout 13. Automatic Thought Record 293
Handout 14. Challenging Questions Worksheet 294
Handout 15. Processing the Loss 296
Handout 16. First Account of the Death 298
Handout 17. Secondary Losses 299
Handout 18. The Importance of Enhancing Social Support 303
Handout 19. Building Social Support 304
Handout 20. Second Account of the Death 306
Handout 21. Values 307
Handout 22. Third Account of the Death 312
Handout 23. Psychological Needs 313
Handout 24. Positive and Negative Aspects of Your Relationship with Your Significant Other 318
Handout 25. Fear and Avoidance Hierarchy Form 320
Handout 26. Account of Your Relationship with Your Significant Other 321
Handout 27. Guilt, Regret, and Sudden, Traumatic Death 322
Handout 28. Anger and Sudden, Traumatic Death 325
Handout 29. Letter to Your Significant Other 329
Handout 30. Exploring the Meaning of the Loss 330
Handout 31. Spirituality 331
Handout 32. Final Impact Statement 332


Nine additional handouts are available for downloading at this same website supplement only ( materials). These handouts have numbers beginning with S (Handout S1, etc.) and do not appear in this Appendix.

Handout S1. Personal Goal Setting

Handout S2. Ending Therapy

Handout S3. Obstacles to Accommodation Worksheet

Handout S4. Review of Your Relationship

Handout S5. Bereavement-Specific Issues

Handout S6. Getting through the Holidays: Advice from the Bereaved

Handout S7. Your Assumptive World

Handout S8. Continuing Your Relationship with Your Significant Other

Handout S9. Self-Intimacy and Identity



Handout 1. sudden, Traumatic death and Traumatic Bereavement

Human life continually involves loss. All change – whether positive or negative, wanted or unwanted – involves loss. Few losses in life are as painful as the sudden, traumatic death of a significant other. (We use the terms “significant other,” “deceased,” and “loved one” interchangeably throughout these handouts.) We hope that in reading this handout, you’ll recognize at least some of the difficulties you have been experiencing, and will see that others have had similar problems. We also want you to know that you have every reason to expect things to get better – that you can get a handle on these problems, diminish their effect on you, and regain a footing for proceeding with your life.

Typical, on-time deaths versus sudden, traumatic deaths

In addressing how the death of a loved one affects people, psychologists often distinguish between typical, on-time and sudden, traumatic deaths. Typical, on-time deaths include those that we expect to occur during the course of our lives, such as the death of an elderly parent from natural causes. Following such a death, it is common to experience grief and mental anguish. Feelings associated with grief typically include an overwhelming sense of loss, as well as strong yearning or longing for the person who has died. It is common for survivors to feel a profound sense of emptiness, as though a part of them had died. They often lose interest in the world around them. In many cases, they speak of generalized pain or heaviness in the chest. In addition, they may cry easily, find it difficult to eat, and experience physical symptoms such as headaches or stomachaches. Although these symptoms can be painful and debilitating, they typically subside within several months to a year or so after the death.

Evidence suggests that the psychological repercussions following a sudden, traumatic death are very different from those of a typical, on-time death. The survivors of a sudden, traumatic death usually experience all of the sadness and emptiness associated with grief, as well as a host of trauma symptoms. Many survivors develop symptoms of posttraumatic stress disorder (PTSD). They may have intrusive thoughts, flashbacks (feeling as if the terrible experience is happening all over again), or nightmares about the events surrounding the death. They may do things to avoid confronting the pain associated with the loss, such as staying away from activities or places related to the significant other’s death, or numbing themselves emotionally. In the wake of a sudden loss, people may have difficulty sleeping or concentrating, find they’re more irritable and more easily startled, worry that something bad may happen to another loved one, and catch themselves repeatedly scanning the environment for danger.

The combination of grief and trauma symptoms can overwhelm a person’s capacity to cope. Because sudden, traumatic deaths occur without warning, they provide a shock to the system that can have lasting psychological, physical, and spiritual effects. Unlike most typical, on-time losses, traumatic deaths often cause intense distress that continues over an extended period of time.


Traumatic Bereavement: Trauma and grief symptoms

Following a sudden, traumatic death, survivors’ lives are often shattered as they attempt to cope with the tragedy and its aftermath. Feelings of safety, security, and trust can be deeply undermined. Survivors usually experience powerful feelings of confusion and anxiety, as well as the depression and mental anguish typically associated with grief. Trauma symptoms may include feelings of horror and anxiety on the one hand, and a sense of disconnection and feelings of unreality, on the other. Some people cannot remember significant parts of what happened; others are plagued by memories or feel as if they are re-experiencing or reliving the event through painful flashbacks.

In general, survivors of a traumatic death may find it extremely difficult to move on with life – for example, by pursuing new interests. They may start to behave in ways that are not in their best interest, such as increasing their use of alcohol or other drugs. In many cases, these symptoms, along with the grief symptoms described above, interfere with the survivor’s ability to function in many domains of life. The loss may place great stress on the survivor’s relationship with her spouse and surviving children. Such symptoms can also have an adverse impact on the survivor’s performance at work. Relationships with other family members and friends are also likely to suffer. This occurs in part because those in their social environment do not know what to say or do. As a result, survivors of traumatic loss often find themselves withdrawing from others and spending more time alone.

Survivors of traumatic death must contend with a number of additional issues that are difficult and painful:

  1. It is much harder to accept the death of a loved one if it occurred suddenly and without warning. When a death comes about as a result of natural causes, the surviving family members have the opportunity to prepare for what lies ahead, and to say goodbye. This is not the case with a sudden, traumatic death. In most cases, family members learn of the death after it has occurred. There is no chance to prepare for the death or to convey feelings of love. Survivors are shocked and overwhelmed by what has happened. Consequently, it is hard for them to accept the death. They may know intellectually that their significant other is dead, but find themselves expecting that person to walk through the door or call on the telephone. This makes it difficult for the mourning process to begin. Difficulty accepting the death is one reason why it can be so hard to part with the significant other’s possessions.
  2. Survivors have to contend not only with the death of their loved one, but with the shattering of their most basic assumptions about the world. These include beliefs that the world is predictable and controllable, that the world is meaningful and operates according to principles of fairness and justice, and that they and the people they love are safe. The shattering of these core assumptions can have a profound impact on subsequent life. Many people question the value of working toward long-term goals because they know that they can lose everything important to them in an instant. Survivors of a traumatic death that was caused by another person are also likely to have difficulty trusting others, since they may believe that the person who caused the death could not be trusted.
  3. Following a traumatic death, survivors typically report that they are unable to make any sense of, or find any meaning in, what has happened. This adds to the distress they experience as a result of their loved one’s death.
  4. In many cases, the sudden, traumatic death of a loved one can undermine faith in a loving, caring God. Many survivors cannot understand why God failed to protect their loved one. This can result in anger, disillusionment, and feelings of betrayal.
  5. People who lose a loved one under traumatic circumstances are typically preoccupied with issues of causality, responsibility, and blame. They may feel that someone should be held accountable for the death, and they may become angry if nothing is done. If there is evidence that the death resulted from the actions of a specific person, survivors may feel angry if that person fails to acknowledge what he did. They may also experience anger toward the perpetrator if he fails to show remorse. In addition, it is common for them to experience self-blame and guilt. People may ruminate about ways they could or should have prevented the death or how they could have rescued the person. They may also experience guilt about events that occurred prior to the death, such as having an argument with the deceased.
  6. Depending on how the death occurred, survivors may believe that it resulted from the negligence of others. Survivors usually judge such deaths as preventable, which results in intense feelings of anger. They typically conclude that if the person who caused the death were acting responsibly, the death would not have occurred. In deaths of this sort, survivors often struggle with the injustice of what has happened to their loved one.
  7. It is common for survivors of a traumatic death to be preoccupied with what their loved one’s final moments were like, and whether their loved one suffered. This is especially the case when the death resulted from a violent incident and when there was damage to the loved one’s body.

Survivors of a loved one who dies of natural causes rarely encounter these problems. They constitute a special burden for those who experience a traumatic loss.


Mourning refers to the active processes of coping with a death and its implications. It is what a person does to contend with and adapt to the death, making necessary changes in order to accommodate or reconcile themselves to the loss. The active processes of mourning involve change, as well as remembering and integrating what was lost. They will have an impact on your relationship with your deceased significant other and with the world. Traumatic bereavement creates obstacles to these natural, active processes. This treatment is designed to help and support you through the mourning processes.

Because people suffering from traumatic bereavement must come to terms with the death of their significant other, as well as the manner in which it occurred, it can take longer than expected for the painful feelings and thoughts to diminish. As the initial shock of the death dissipates, there may be intervals when a survivor is able to focus on other issues and not feel the pain of the loss so intensely. Gradually, these intervals will become longer, and there will be good days and bad days. Over time, the proportion of good days to bad days typically increases. However, people can experience setbacks during the process. On a relatively good day, a bereaved person may encounter a reminder of the significant other – for example, hearing a favorite song of the loved one – and this may cause the reemergence of painful feelings of loss. People also have difficulty dealing with occasions such as holidays, birthdays, and the anniversary date of the death.

Can you do To help yourself?

You and your therapist will focus on these issues when you meet. But there are some things you could do now. For example, because grief can affect physical health, it is important to maintain adequate nutrition, sleep, and physical exercise. If you have any chronic health problems (such as heart disease), it’s especially important to stay in contact with your primary physician. Survivors are often preoccupied by their grief, and thus are prone to mishaps such as automobile accidents. So use extra care. Similarly, it may be best to avoid making any major decisions for 6 – 12 months after the death, if possible. As a result of everything that you have been through, your judgment may be compromised. Further life changes, even those you choose, can bring on additional stress. Now is a time to take a break from big decisions, if you can.

Most experts recommend that survivors confide in someone about the death. This can be a friend, a member of the clergy, or another person who has experienced a similar loss. It may take some trial and error to identify people who can be good listeners. Since many people do not know what to say or do to be helpful, they may say the “wrong” thing. Some survivors withdraw from social contact because of the possibility of such hurtful comments. This is unfortunate because it cuts them off from interactions that could be healing.

Mourning is a difficult process in part because it involves remembering what happened. The memories may be so upsetting that it can seem like more than you can bear. Hence it is important for you to learn strategies for calming yourself. You and your therapist can talk about this when you meet, but strategies others have found useful include taking a walk, exercising, listening to calming music, or meditating.

The kind of work you will do with your therapist is designed to support you through the mourning process. The treatment will help you process the traumatic elements of your loved one’s death and find ways to learn to live with your loss, to work toward maintaining positive connections with your support system, and to learn coping strategies that will help you to move forward.



Handout 2. orientation to the Treatment

This treatment will help you process the loss and develop coping strategies that will allow you to move forward.

What This Treatment includes

  • Evidence-based approaches. Each element of the treatment is based on research evidence showing that it can help people who have experienced a traumatic loss.
  • Psychoeducation. Your therapist will share information with you about trauma, loss, mourning, and coping. In addition to discussions in sessions, your therapist will give you handouts that summarize important aspects of what you need for recovery.
  • Structure. Your therapist may direct the treatment with a list of tasks the two of you will complete during each session. Alternatively, the two of you may collaborate in structuring each session.
  • Supported exposure. The treatment provides opportunities for you to confront what you’ve found difficult to face, with lots of support. Your therapist will invite you to think, talk, and write about your loved one, the loved one’s death, and how you have been affected by the loss. This probably sounds scary, but the treatment is designed so that you will be ready for those tasks when the time comes.
  • Developing skills and resources. The treatment will help you develop coping skills (feelings skills, thinking skills, etc.), as well as techniques to address beliefs about yourself or the world that keep you stuck in your grief, and techniques for obtaining interpersonal or social support. The goal of this treatment is to help you develop skills that will be useful to you during the treatment and after it ends.

What to expect of your Therapist?

  • Preparation. Your therapist will be familiar with the concepts and tasks that you will address during each session.
  • Direction. Throughout the treatment, your therapist will serve as your guide, and also as a source of support.
  • Collaboration. Your therapist is your partner in your recovery process.
  • Respect. Although your therapist knows what helps people who have experienced sudden, traumatic losses, you are the expert on you.
Your role
  • Show up. Come to each session ready to stay focused on the tasks.
  • Work between sessions. This treatment requires you to engage in various activities between sessions. These independent activities are essential to the success of the treatment, and will also provide you with tools you can use in the future.
What you’ll Take Away (“Tools for The Journey”)
  • New skills.
  • Emotional freedom.
  • A new orientation to your loved one and your loss.
  • A sense of accomplishment and empowerment.
  • Lots of handouts!
Things to remember
  • You are the best judge of how you’re doing.
  • Your therapist can only help with what you can share or discuss in sessions.
  • You may feel worse before you feel better.
  • Staying in treatment is a choice… but don’t give up without giving it your best effort and letting your therapist help you through any rough patches.


Handout 3. Treatment Goals and Tools

This handout describes the primary goals of the treatment, the “R” processes that you will move through as you mourn, the treatment tools, and the independent activities.

Treatment Goals

The goals of the treatment refer to where you are heading: the desired destination or endpoint of the treatment.

  • To feel better.
  • To honor your loved one and the relationship you had with this person.
  • To move forward in your life in healthy, growth-promoting ways.

six “r” Processes: steps to move Through in Your mourning

The six “R” processes of mourning are the steps that bereaved survivors take during the mourning process. These steps overlap, and you may find that you move through some of them more than once.

  • Recognize the loss.
  • React to the separation.
  • Recollect and re-experience your loved one and the relationship you had.
  • Relinquish your old attachments to your loved one and your old assumptive world.
  • Readjust to move adaptively into the new world without forgetting the old. (This includes establishing a new, healthy relationship with your loved one, and integrating your particular loss so that you can move forward in a healthy way.) • Reinvest.

Treatment Tools

Treatment tools are the techniques that you and your therapist will use to move through the six “Rs” and achieve your treatment goals. You will use these tools within sessions and you will practice with them outside of sessions, so that when the treatment is over, you’ll be able to take them with you and use them on your own when needed. They include different types of activities, as described below.


Resource-Building Activities

Resource-building activities will support you through the pain and challenges of mourning, processing the trauma, and moving through the treatment more generally. You may recognize these activities more generally as coping activities. You and your therapist will do some of these activities in session, and you will practice them outside sessions as well. They include the following:

  • Social support activities. These involve building and maintaining positive connections with others.
  • Feelings skills and coping activities. These involve learning new coping strategies that will assist you in managing strong or distressing feelings and taking care of yourself. You and your therapist will also address stressful bereavement-related problems (such as, coping with holidays, anniversaries, and birthdays).
  • Activities for goals, values, and meaning. These include identifying your personal goals and values, exploring how the loss has changed you and your life, and allowing you to make conscious decisions about moving forward and honoring your loved one. These activities will also help you focus on what is meaningful in your life now, which can facilitate the healing process.
Trauma-Processing Activities
  • Cognitive processing. This involves modifying distressing things that you say to yourself about the loss. You and your therapist will work together to notice and change the thoughts, beliefs, and interpretations that may be automatic for you, but that may inhibit the process of mourning your loss.
  • Emotional processing. This entails experiencing your full range of feelings and memories about your loss. The treatment will enable you to experience and express feelings that, at an earlier point, were hard to face.




Handout 4. self-Care

Self-care means nurturing and caring for your body, mind, and spirit. It can also mean reducing the frequency of any harmful things that you do, such as overusing alcohol or other drugs. It involves working toward eating regular meals, exercising, getting enough rest, avoiding reliance on substances that compromise your health, taking time for yourself, and doing things that help you relax and restore your energy for the many tasks you are facing. Self-care requires boundary setting – saying yes to activities that help nurture and sustain you, and saying no to those that do not.

It is important that you recognize those things you already do to take care of yourself. The goal is to add self-care routines to your life in small steps. Making small changes that you can stick with is the key to long-lasting change. Many of the activities assigned in this treatment promote self-care.


independent Activity: self-care

Engage in one self-care activity this week, writing down this and any other activities you have done during the week in an effort to care for yourself.



Handout 5. exploring the impact of the death

The goal of this exercise is for you to begin to think about what your loss means to you. Please write a statement about the impact that this loss has had on you. Some things to consider as you write include your understanding of why the death occurred and the effect it has had on your beliefs about yourself, others, and the world.

It is best to write during a time when you can experience your emotions fully. Try to find a time and place in which you can write without interruption. Try not to worry about whether your writing is neat or grammatically correct. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.



Handout 6. The six “r” Processes of mourning

The six “R” processes of mourning are an essential element of this treatment approach. We list them here in detail. After each “R” process, we list the subprocesses that promote healthy movement through the “Rs.”

  • Recognize the loss.
  • Acknowledge the death.
  • Understand the death.
  • React to the separation.
  • Experience the pain.
  • Feel, identify, accept, and express your reactions to the loss.
  • Identify and mourn your secondary losses.
  • Recollect and re-experience your loved one and the relationship you had.
  • Review and remember realistically.
  • Revive and re-experience the feelings.
  • Relinquish your old attachments to your loved one and your old assumptive world.
  • Let go of your old attachments to the person who has died.
  • Let go of your old attachments to your assumptive world.
  • Readjust to move adaptively into the new world without forgetting the old.
  • Revise your assumptive world.
  • Develop a new relationship with your loved one.
  • Adopt new ways of being in the world.
  • Form a new identity.
  • Reinvest.




Handout 7. Breathing retraining

When people feel anxious, they often start to take in quick, shallow breaths. This rapid, shallow breathing (known as chest breathing) is associated with a number of uncomfortable sensations, including tightness or pressure in the throat or chest, dry mouth, dizziness, tingling in the fingers, and the sensation that one’s heart is racing. All of these sensations contribute to an increase in feelings of fear or anxiety. Something as simple as learning to slow down your breathing can help you to stop feelings of anxiety as soon as they start.

independent Activity: Breathing retraining

This exercise will help you teach yourself to slow down your breathing so that you can relax and decrease your anxiety.

  • Breathe in through your nose with your mouth closed, to a slow count of 4.
  • Exhale slowly through your nose, to a slow count of 4.
  • At the beginning of the exhale, say “calm” before counting to 4.
  • After exhaling, count to 4 slowly before inhaling again.
  • Repeat for 10 inhale – exhale – wait cycles at each practice session.

It is important to practice this exercise at least twice a day when you are feeling calm, especially when you first begin. Once this type of breathing has become familiar to you, you will often find it useful in stressful situations, both in session and between sessions.




Handout 8. feelings skills

Feelings skills are inner abilities that help people remain internally steady in times of distress. A loss often brings up strong emotions. For this reason, feelings skills are a foundational part of this treatment. Having specific skills to deal with intense or even overwhelming emotions will help you to experience your emotions more fully and with less discomfort or fear. These skills will help you throughout this treatment and recovery process.

There are three feelings skills that are essential to this internal steadiness: inner connection (which helps people to stay connected to images and memories of loved ones), self-worth (which helps people to maintain a generally positive and stable sense of being “good enough” individuals), and feelings management (which helps people to handle strong feelings). We describe each of these skills and ways to build them below.

inner Connection

Inner connection is the feelings skill that allows us all to carry images and memories of loved ones with us, even in their absence. When we wonder what a beloved grandparent, former teacher, or friend might say, we may hear words of love, comfort, or support that reflect a strong sense of inner connection with these “loving others.” That connection can help us through challenging times, guiding us and enabling us to feel less lonely.

Why is developing or maintaining inner Connection difficult?

People who didn’t experience much love or affection when they were growing up may not have many positive or loving figures to draw on in times of distress. Even if you have had loving connections with others, you may feel sadness, guilt, or anger when you think of your deceased loved one. This can get in the way of feeling that person’s love and support for you.

how Can you develop or maintain inner Connection?

It’s important to be creative in thinking about who your “loving others” are. Such a figure may be a friend or family member, a former teacher or clergyperson, a pet, an admired public person, or an imaginary character. The “other” doesn’t have to be alive, and you may never have met.

If one of your “loving others” is deceased, thinking about that person may bring sorrow or other feelings. If so, you might want to try to allow yourself to feel the emotions and try to keep this person’s love with you while reminding yourself of loving things the person would say to you and the special connections you had with each other.

exercises for strengthening inner Connection

You can strengthen your sense of inner connection with your “loving others” by practicing calling upon them in your imagination when you feel good. Then when you need support, it will be easier to draw on this resource.

independent Activity: inner Connection

  • Find a quiet spot to sit where you can be comfortable and uninterrupted for at least 20 minutes.
  • Write down the names of three positive figures (for example, people you know or have known; animals; figures from history, public life, religion, or fiction).
  • Imagine one of these characters comforting, encouraging, or supporting you. What advice might this individual give you about yourself, your behaviors, your relationship with your loved one, and your life? How might this person demonstrate understanding or compassion for you?
  • When you finish imagining, take one of these positive words or phrases and repeat it to yourself several times. Then practice using that phrase when you feel lonely or lost.

Feeling worthy or deserving of life and good fortune even when times are difficult is a sign of positive self-worth. It comes from a secure base or deeply felt sense of security in childhood, where adults treat children with love, compassion, and respect. As children grow up, they take in that positive regard and come to feel “good enough” about themselves. It doesn’t mean never having a bad day or feeling bad, but it does mean that even when people feel bad, they know (or can recall) that they are still reasonably good human beings. When they do something they know is wrong, they feel guilty. Guilt is a natural, and sometimes even useful, feeling. It’s easy to confuse bad feelings about what you did or did not do (guilt) with bad feelings about yourself as a person.

Why is developing or maintaining self-Worth difficult?

People who grew up in homes where adults or peers were unsupportive or harsh may have taken in negative messages about themselves. This makes it difficult for them to feel like “good enough” persons, especially when things go wrong. It may be natural to move to self-blame or feelings of worthlessness when bad things happen.

how Can you develop or maintain self-Worth?

Associating with people who respect you, treat you with dignity, and bring out the best in you is an important way to develop a sense of self-worth. In addition, treating yourself with respect, doing things that are consistent with a positive self-image, and not doing things that diminish you in your own eyes can increase your self-worth. Acknowledging your mistakes, apologizing, and making amends when you do something wrong can help to build your sense of self-worth as well. Building skills and developing your knowledge and talents can also contribute. Finally, helping others and treating them with respect, compassion, and dignity can increase your own self-worth.

Exercises for Strengthening Self-Worth

The next time you are in the company of someone who likes you, ask yourself what that person values about you. You may also ask that person the same question.

Notice how you feel when you offer someone else assistance or support. What does that say about you as a person?

Independent Activity: Self-Worth

  • Make some notes about the kind of person you would like to be – your “best self.” This is your ego ideal, something to which you aspire. When you consider various actions in advance, try to follow the path to your best self. As you act according to this path, your sense of value and self-respect will grow.
  • Think about something you did (or did not do) about which you feel bad or guilty.
  • Write for a few minutes about what happened, why you made the decision or acted as you did, and what your subsequent thoughts have been about your choices.
  • Think about or write down a few things you might do to make up for your mistake.
  • Identify one or two things that seem possible to do and not too challenging.
  • Experiment by doing one of these things, and see whether you feel better about yourself.
Feelings Management

Feelings management refers to the ways people cope with emotions that are particularly challenging. (We use feelings and emotions interchangeably here.) When most people experience happiness, they will express it easily. An emotion such as anger may be more difficult for some people to express, especially if the anger is powerful. If they have trouble experiencing intense anger, they may “bury” it or try to pretend it’s not there. Some people are so good at this that they aren’t even aware that they are angry.

Emotions – even strong ones – help you to stay connected to yourself, to others, and to the world. This is important because emotions provide you with information about both the world around you and how you relate to that world. If you are feeling angry, for example, this feeling might reveal that there was an injustice or that someone wronged you. Your anger might be a way of recognizing and standing up to the injustice. If you are not aware of it, however, you will miss this connection.

There are four steps involved in feelings management, each of which will be important to you throughout this treatment and beyond. The steps are recognizing, tolerating, modulating, and integrating feelings.

recognizing feelings

Recognizing feelings means being able to sense emotions as they arise in your body and to label or name them. You may find this step to be easy, difficult, or somewhere in between. You may also find that you are able to recognize some feelings more readily than others. Past experiences may help you to identify a specific emotion. You may know that a particular type of experience (such as loss) is often connected with a certain feeling (such as sadness). These links can be another pathway to recognizing your feelings.

independent Activities: recognizing feelings

1. Create a feelings vocabulary. Begin to create a feelings vocabulary by learning the names of feelings and beginning to attach those names to your bodily states. Below is a list of feelings that may help you begin to name your feelings. Use this list to check those you are aware of once or more per day.

• angry irritated helpless restless numb lonely

heartbroken aching vulnerable enraged regretful detached anxious overwhelmed in despair

• ashamed lost crushed

preoccupied exhausted empty isolated annoyed bitter sorrowful in agony frustrated

• sad confused guilty

depressed hopeless embarrassed insecure nervous scared proud disgusted hurt excited mad panicky

• happy frightened disappointed cheerful loving eager

• depleted humiliated calm content

2.                  Link names of feelings with bodily sensations. Once you become acquainted with names of feelings, you can pay attention to how each feeling is present in your body. For example, sorrow may feel like a pit in your stomach. Another person might feel sorrow as tightness in the throat.

3.                  Create a feelings intensity scale. That is, assign levels to each feeling state. For example, someone can feel frustrated, irked, annoyed, irritated, angry, or enraged – all of which are different intensities of the emotion often labeled anger.

4.                  Differentiate feelings from actions. Whereas anger is a feeling, violence is an action. Sad is a feeling that might go with the action of withdrawing. See whether you can create a list of actions you engaged in today, and then list some feelings that might go along with those actions. These associations or connections can vary from one day to the next. So being withdrawn today might have to do with feeling sad, while being withdrawn on another day might have to do with feeling lonely or angry.

5. Pay attention to your body. A tight throat or chest may signal anxiety or fear. Practicing labeling certain bodily sensations, and talking about this with your therapist or another person, will help you to learn which emotions go with different bodily sensations for you. You may find that it is difficult to notice your bodily sensations as you go through your day. The following exercises can help you slow down and focus enough to become aware of what your body feels.

Sit quietly and let your attention go to what you are currently feeling in your body. Focus your attention on any place in your body where you notice a physical sensation. What is the name of the sensation (tightness, pain, ache, etc.)? Do this again for each place in your body where you have a sensation.

Notice your breath. Attend to how the air feels coming in and out of your body. See whether you can feel the air entering your nostrils, lungs, and diaphragm. Notice how your body feels as the air moves in and out. Write down any names of emotions that come into your mind as you breathe.

Move your body. First, move gently – standing up and swaying back and forth, dancing to some music, or bending and reaching. Stop and notice sensations in your body. Let your mind create some names of emotions that might match those sensations. Then try moving vigorously. Walk briskly around the block or do some jumping jacks. When you slow down and then stop, look again for physical sensations, and create emotion names to go with them.

Go back to the checklist above (see Activity 1 in this box) and check off the feelings that you are currently experiencing. Circle the three that are most intense right now.




Tolerating feelings

Tolerating feelings means being able to accept and work with emotions as they arise. The following exercises can help you learn to tolerate feelings.

independent Activity: Tolerating feelings

  • Name early associations (thoughts, images, memories) that you have to a particular emotion. Understanding what might have made feelings seem negative or dangerous can be a helpful step toward tolerating them. This step will also be easier if you can step back from the emotion a bit and observe, name, and discuss it.
  • Understand what current situation triggered the emotion. Once the emotion begins to make sense, you can recognize that it is here for a reason and move closer to accepting and even welcoming it.
  • Try to name associations among feelings (your emotions), thoughts (ideas, things you tell yourself), and behaviors (things you do). Observe any thoughts that accompany the feeling as well as any behaviors that seem to result from, express, or disguise it in some way.
  • Remind yourself that feelings provide useful information. This acknowledgment helps to make them less scary and to remind you that your feelings make sense.
  • Know that emotions exist on a continuum of intensity and always run their course. The next time you have a feeling that you can recognize, take a moment to notice where that feeling is located in your body. See whether you can identify a color, a shape, a sound or song, an animal, or an object that represents the feeling. Try to recall a time in the past when you felt this emotion. See whether you can recall how long the feeling lasted, what intensified or diminished it, and how it began to ebb.
modulating feelings

Modulating feelings entails being able to control the intensity of what you experience, rather than feeling as if the emotion is controlling you. The first step in modulating feelings is to notice that your feelings have different levels of intensity. For example, when you’re upset, you may be very upset or just a little bit upset. Noticing what’s going on in your body is one way of observing your levels of upset. The more intense your feelings are, the more likely you are to have strong bodily sensations. Of course, some people have learned not to feel, in which case numbing may be a sign of intense feelings.

Independent Activities: modulating feelings

Breathe. Breathing is a key to modulating strong feelings. The next time you are distressed, try to focus on your breath. After 10 long, slow breaths, see whether the intensity of your feeling has changed. You might also try the breathing retraining exercise described in Handout 7.

Name your feelings. Being able to name feelings also helps in modulating them. For instance, if you know that you are sad, you may have some ideas about why you are sad and what may help you to regulate your sorrow.

Describe the intensity of the feeling. The next time you are aware of an emotion, write down its intensity on a scale from 1 (very mild) to 10 (very strong). At the end of one of the following exercises, come back and rate the intensity of that emotion again.

Examine the emotion. Choose an emotion that you experienced very recently. Try to figure out when you started feeling this way and what was going on around you, between you and other people, and within yourself.

• Write down the name of the feeling, and then write down what happened and what you were thinking about just before you started feeling it.

• Ask yourself, “What is this feeling trying to tell me?” and write down any responses that come up for you.

Choose a calming word or a phrase. You can say this to yourself when you notice the impulse to run away from or bury a feeling. For example, it can be helpful to say, “Calm,” “Breathe,” “It’s only a feeling,” “Feelings can’t harm me,” or “The name of this feeling is . Its intensity is (1 to 10). That feeling is difficult for me because .”

Imagine that your feeling is on a video or audio recording. You can regulate the intensity of your feeling by turning the volume down, rewinding or fast-forwarding it, or letting it play more slowly. You can practice turning it up, down, off, or on.

Choose to do something constructive or soothing. When you need help modulating a specific emotion, pick a soothing alternative activity and engage in it. This might include playing your favorite music, watching a favorite movie, going for a walk, praying, meditating, connecting with nature, reading poetry, working in the garden, or the like.

Connect with someone who cares. Sometimes talking with a friend about what’s going on for you can help you modulate your feelings. At other times, you may simply want to spend time with a friend or family member, not necessarily talking, so that you don’t have to be alone with your feelings.

integrating feelings

Integrating feelings means connecting emotions with their context and incorporating them into the narrative or story of your life. You can learn to integrate your feelings by paying attention to the broad context of the feeling. Spend some time exploring a particular emotion within the context of your life story. This can happen within therapy, within an intimate relationship with a supportive other, or by yourself.

independent Activity: integrating feelings

Journal writing (which is a way of speaking to yourself) can help enormously with integrating feelings. Try writing about a situation in which you noticed a particular feeling. Allow your writing to lead you, and try not to worry about whether the writing makes sense as you write. Choose a particular feeling that you had in the past day or two, and try to answer the following questions about that feeling:

  • Where do you experience that particular feeling in your body?
  • What was the context that gave rise to the feeling?
  • What are some of your past experiences of the feeling?
  • When do you remember experiencing this feeling before? What was going on then?
  • Are you aware of a connection between this feeling and any physical or psychological needs you may have?
  • With what information does this feeling provide you?
  • What new thoughts or feelings come up for you now as you reflect on the context of this feeling?
  • What does this feeling say about you as a person?
  • Can you see how this feeling might fit into your identity and life in the future?



Handout 9. A model for Change

The following diagram illustrates the model on which the next part of this treatment is based.


This model illustrates the idea that thoughts, moods, behaviors, and physical sensations all influence each other. You can learn to question the habitual or automatic thoughts that have a negative impact on your mood, behavior, and physical well-being. We call these automatic thoughts because you may not even be aware of having them. Automatic thoughts can become part of a negative loop in which a thought leads to negative emotions, uncomfortable physical reactions, and behaviors that create a vicious cycle. The process of identifying and challenging automatic thoughts is a very important part of breaking this cycle and getting through the loss of a loved one.

Automatic thoughts are particularly likely to cause problems after the sudden death of a significant other. These may be new since the loss, or they may be old thoughts that the traumatic death has amplified.






Handout 10. What Are Automatic Thoughts?

The following is a list of 10 qualities that often describe automatic thoughts.

  1. They are usually abbreviated or brief (“can’t go on,” “alone,” etc.). They may actually appear as images, smells, sensations, or sounds instead of words. A thought may obviously relate to your loss, such as an image of destruction related to the death, or it may seem arbitrary, such as the smell of the cologne your significant other wore to a special event you attended together.
  2. They occur as if they were 100% true. You usually believe them, no matter how unbelievable they are when you really examine them. For example, you may have the automatic thought that your significant other died to punish you. You may fully believe it each time the thought occurs to you, even though you know realistically that it isn’t true.
  3. You experience them as spontaneous. Part of the reason automatic thoughts are so believable is that they are automatic. We rarely question them because we hardly notice them.
  4. Automatic thoughts are often expressed as “shoulds.” The phrases “I should,” “I ought,” and “I must” often indicate automatic thoughts.
  5. They often seem to suggest catastrophe. People refer to this type of thinking as catastrophizing. When you catastrophize, you tend to expect the worst.
  6. Automatic thoughts tend to be idiosyncratic. Each interpretation of an event depends on the thinking, past experience, and worldview of the person doing the interpreting. Different people witnessing or experiencing the same event may have very different automatic thoughts about that event.
  7. Automatic thoughts are persistent and self- perpetuating. They can be viewed as “habits of thought,” and so they occur without notice and become a persistent part of your thinking. Each new occurrence of the thought reinforces the last.
  8. They are often more blunt and less intellectual than your normal statements. Automatic thoughts tend to be much more harsh and extreme than what you might actually say to others. You might say, “I made an error in judgment” while thinking, “I’ve ruined everything.” Automatic thoughts may occur simultaneously with other, more logical thoughts.
  9. Automatic thoughts can be grouped into themes. For most people, automatic thoughts tend to run along themes that are associated with deeper core beliefs. For example, thoughts such as “she doesn’t like me” or “I have no friends” may both be related to the deeper core belief “I’m not lovable.” The thought “I’m going to be attacked” and “my children aren’t safe walking to school” may both be related to the core belief that the world is a dangerous place. Thoughts related to the same theme tend to prompt the same emotion. Thoughts related to “I’m not lovable” would prompt sadness, while those related to the core belief that the world is dangerous would prompt fear.
  10. Automatic thoughts are often related more to the past than to the present. Automatic thoughts can be triggered by events or emotions that remind us of the past. They may sound like something a young child would say (e.g., “I’m a loser,” “I’m in trouble,” “Nobody likes me”). When we look more closely at the thoughts, we may realize that they are “old” and have little to do with the current situation.

The following questions will give you a head start on learning to identify automatic thoughts – a skill you will be developing further in Handouts 11 and 13.

Independent Activity: Learning To Identify Automatic Thoughts

  • What was I thinking just prior to the start of a negative emotion?
  • What was I thinking as the situation progressed?
  • What was I telling myself would happen?
  • What was the worst thing that could happen?
  • What was I saying about myself in this situation?
  • What did I worry other people might think about me in this situation?
  • What words, phrases, or images flashed through my head as I started to feel this way?






Handout 11. identifying Automatic Thoughts Worksheet

This worksheet is a tool to use as you continue learning to recognize problematic thoughts and the moods they cause. You and your therapist will use this and similar worksheets throughout the rest of the treatment process to help you identify and challenge those thoughts that are causing you distress and pain.



Handout 12. Sample Automatic Thought Record



Handout 13. Automatic Thought Record

Adapted with permission from B. Thorn (2004). Cognitive therapy for chronic pain: A step-by-step guide. New York: Guilford Press.



Handout 14. Challenging questions Worksheet

Is there an alternative interpretation of the situation, other than your automatic thought?



Is the automatic thought really accurate, or is it an overgeneralization? Is it true that this situation means that your automatic thought is true?



If someone who loves you knew you were thinking this thought, what would that person say to you? Would he or she suggest any evidence that your thought is not completely true?



Are there exceptions to this automatic thought? Can you think of examples of situations that suggest that this automatic thought is untrue or not entirely true?




Are you taking all of the blame for this situation, even if you did not have complete control?




Are there other circumstances that might soften negative aspects of the situation? Are there times when this type of situation has gone well for you? Are there other situations you feel good about?





What are the likely consequences and outcomes of the situation? Can you differentiate between what you fear might happen and what you can reasonably expect will happen?




Have you had this kind of thought before? If so, how often? How many of those times were you predicting the outcome accurately? Based on your history with this kind of thought or prediction, what are the real odds that what you fear happening in this situation will actually occur? For example, if you’ve had this type of thought about twice a month for 5 years (120 times) and you were only right once, your odds of being right this time are 1 in 120 (less than 1%).




Could you create a plan to change the situation? Is there someone you know who might deal with this differently? If so, what would that person do?




Do you have the social or problem- solving skills to handle the situation? If you need help handling it, can you think of people who could help you or ways you might help yourself?




How are you likely to be thinking about this in a year? How would you think about it if you had been feeling good or sleeping enough?




Are there objective facts that would contradict items in the “Evidence That Supports…” column of Handout 13? What are they?





Handout 15. Processing the Loss

One of the most important goals of this treatment is to help you react to your significant other’s death in a way that fits who you are and that is acceptable to you. Once you have identified, felt, and accepted your thoughts, feelings, and memories, you will be able to respond to them with more choice and freedom, and your emotions will become more manageable. This can be a painful process, although the goal is for you eventually to live with less pain. This process allows you to deal with your hurt. It also helps you accept that your significant other is truly gone, honor what the death means to you, and help you prepare to move forward in a healthy way.

Experiencing and integrating your full range of feelings is essential to working through your loss. Although most people tend to avoid feelings and thoughts about loss because they are painful, you may intuitively know that avoiding feelings, events, and reminders of the death doesn’t make the pain go away in the end.

Unfortunately, the pain usually finds its way into your life in one way or another, as flashbacks, intrusive thoughts, intense distress, or nightmares. Avoidance just prolongs this pain. Research has shown that the more you avoid painful feelings, the more they will disturb your life. Your therapist wants to help you not to avoid the loss, trauma, or any feelings associated with your significant other’s death. Experiencing the feelings is the path to recovery.

This treatment helps clients who have lost a loved one to experience emotions in a safe environment, with a lot of support. Throughout the treatment, you will work with your therapist to face your loss and your painful feelings. You will do this together in a safe environment. You will work to face the loss a little at a time, and you will be in charge of choosing what you feel you are ready to face. The activities you and your therapist will develop and work on are called exposure exercises. Your therapist will support and guide you through them.

Sticking with exposure alleviates pain. When you create a safe environment and allow yourself to confront the painful thoughts, memories, and emotions, the pain will gradually lessen. The pain does not diminish as quickly as it does when you escape it by avoiding (leaving the place that reminds you of your significant other, distracting yourself from thinking about your significant other, or working long hours to help keep your mind off of what happened), but the relief is permanent. Escape and avoidance may alleviate your discomfort in the moment, but when you escape by avoiding, the painful emotion comes back full force or even stronger the next time you encounter that situation, memory, or thought. However, when you purposely and repeatedly confront the situation, you will find that the painful emotions decrease more and more, until you can begin to move forward again.

This treatment involves exposure to the images of the death itself (witnessing the death, or vivid imagery of the death even if you did not witness it); exposure to the memory of finding out about the death; exposure to feelings about the loss and about your significant other; and exposure to current reminders of the death. You will work on this gradually through writing and other assignments.

The goal of all the exposure activities in this treatment is for you to think about and remember your significant other’s death so that you can begin to confront the pain that you have been experiencing in a safe environment, rather than continuing to avoid (and thus prolong) the pain. Getting past this pain allows you to remember your loved one more fully.

Your first assignment is to write about your loved one’s death. You should write in a place where you feel comfortable and at a time when you will not be disturbed. Exposure works by allowing you to become used to your painful feelings, and by allowing you to experience them over time so that they gradually lessen. It is important to stick with your writing, even though it brings you in touch with your painful feelings.

Of course, it is important that you not feel retraumatized or overwhelmed. The feelings skills that you and your therapist have talked about should help you to feel safe. For example, if you begin to feel overwhelmed by your feelings, you can remind yourself, “This is a feeling, and it will pass. It is important for me to experience my feelings.” You can know that once you are done with the assignment, you can practice the breathing exercise to help calm yourself, or you can practice a self-care activity in order to soothe yourself. The writing exercise will be most helpful if you complete it all at once, not taking any breaks unless it is necessary. We ask you not to use the breathing exercise during the assignment because that will allow you to escape from your feelings rather than experiencing them fully.



Handout 16. first Account of the death

Please write an account of your significant other’s death. Do this writing activity as soon as possible (ideally, today). Write your account by hand, and write it in the present tense. Try to include sensory and other details, including what you were thinking and feeling at the time you learned of your significant other’s death. Also, include your current thoughts and feelings (that is, your thoughts and feelings as you are writing), in parentheses. Try to experience your emotions as fully as you can. If you need to stop writing at any point, please draw a line on the paper where you stop, and begin writing again when you can. Please read the account to yourself each day before the next session. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.



Handout 17. secondary Losses[11]


Following the sudden, traumatic death of a loved one, most survivors experience a profound sense of loss. They often feel as though their world has been ripped apart. In understanding the ramifications of the loved one’s death, it can be helpful to distinguish primary and secondary losses. A primary loss is the initial loss – in this case, the loved one’s death.

Secondary losses are those losses that coincide with or develop because of the death. In most cases, mourners experience some secondary losses right away. For example, a widow may miss her husband’s companionship immediately after his death. Yet it may take weeks, and perhaps months or even years, for survivors to become aware of the full range of secondary losses associated with the death. When tax season comes around, for example, a widower may recognize that he needs help with a task that his spouse had previously handled. He may be confused about whom he should contact for assistance. It is critically important for survivors to identify and mourn secondary losses. If these losses are not addressed, mourners often get stuck in the mourning process.

Bereaved individuals encounter secondary losses in many domains of their lives – for example, such losses may be emotional, physical, or financial. To aid you in identifying the losses you have experienced, we have listed some of the most common kinds of secondary losses below. In each case, we have provided examples of the types of losses that mourners typically encounter.

  • Emotional losses. Emotional losses are numerous and can be difficult to put into words. With the loss of a significant other, a person experiences the loss of emotional support from that person – the loss of someone to listen, to provide support, and to comfort him when he is upset.
  • Physical losses. Physical secondary losses are those physical things that are no longer available to a survivor since the death. Physical losses include the loss of the physical body of the loved one (which the survivor can no longer touch or be touched by), and the loss of physical objects such as a car or a house (which sometimes must be sold when the loved one dies).
  • Loss of identity. Many survivors report feeling empty inside following the death of their loved one. They feel as though part of themselves has died. They often describe themselves as a “different person” as a result of the loss – someone who is less easygoing, less fun-loving, and more serious. It is also common for survivors to report a loss of self-confidence, and to struggle with feelings of inadequacy following the loss.
  • Loss of our beliefs about the world. Sudden, traumatic losses make us recognize that the things that are most important can be taken away in an instant. As a result, feelings of safety, security, and trust can be shattered by a traumatic death. If a surgeon makes an error that contributes to a husband’s death, this may cause the survivor to question the beliefs she held prior to the loss. Consequently, she may have great difficulty seeking the care of a physician, even when she is quite ill. If a doctor tells her that she or another close family member requires hospitalization, she is likely to experience intense anxiety.
  • Relational losses. The secondary losses that follow a traumatic death are determined in large part by the role of relationship that was lost. Following the death of a spouse, the surviving spouse may struggle with a loss of identity, feeling as though a part of herself has died. She may also experience the loss of a caring presence day to day, the loss of her partner’s participation in childrearing, and the destruction of her hopes and dreams for the future. When a child dies, parents must contend with the loss of their identity as parents, which is centered around caring for and nurturing the child. In many cases, they also lose a sense of meaning and purpose that was provided by the parental role. They are robbed of the satisfaction they would get from the child’s milestones and accomplishments. In addition, children often embody the parents’ hopes and dreams for the future, which are often shattered by the child’s death.

The death of a parent is also associated with a unique set of secondary losses. These may include the loss of a life-long emotionally supportive relationship, and the loss of guidance and advice at important crossroads. Surviving children may also lose an important source of recognition and praise for their accomplishments and achievements. In some cases, they may lose a loving presence of a grandparent in the lives of their children.

  • Financial losses. Many bereaved survivors suffer both direct and indirect financial losses because of the death of their significant other. One financial loss that often accompanies the loss of a spouse is the income formerly provided by the spouse. Another is the loss of health insurance. If the deceased is the one who carried health insurance for the family, this coverage typically ends with her death. This loss may trigger a host of additional losses, such as the inability of the surviving spouse to obtain the necessary medication for his child, who may have a chronic illness. Financial losses are also common following the death of a child. For example, as a result of the death of their only son, one couple felt that they could not bear to stay in the home where their son was raised. They also felt that it would be painful to live in the town, which had many reminders of things the family did together. They put their home on the market, but the only way they could sell it was to lower the price dramatically. This not only reduced the amount of money they had available, but also had an adverse effect on their credit rating.
  • Daily living losses. Daily living losses are those secondary losses that affect a person’s daily activities. Help with the dishes and other household chores, help raising the children, sharing a meal, going shopping with your significant other, and engaging in a conversation about how your day was are all examples of daily living losses. Daily living losses also include the difficulties of coping with special occasions, such as birthdays or holidays, without the loved one.
  • The loss of hopes and dreams for the future. In many cases, the survivor envisions a future that includes the loved one. A couple may have planned to retire together and travel across the United States. As their children grow into adults, parents may anticipate a future that includes grandchildren. A future that survivors eagerly anticipated is now uncertain, and in some cases dreaded.

All secondary losses become part of the experience of grief and mourning and need to be mourned in their own right. Each of your own secondary losses will call forth unique reactions and responses. It is important to be able to recognize, label, and honor these losses, so that you can mourn them in your treatment. Knowing what these losses are and being able to name them can be an empowering experience and can help you to feel less overwhelmed by the enormity of your grief. We encourage you to begin this process by drawing from the material above.


independent Activity: Listing your secondary Losses

Below, please list as many of the secondary losses resulting from your loved one’s death as you can. The categories will help you to think about the different areas of your life that your loss has affected. If you’re not sure which category a loss fits in, just write it under any heading. There is also space for you to include secondary losses that do not fit into any of the categories listed below.

Emotional losses:



Physical losses:



Loss of identity:



Loss of beliefs about the world:



Relational losses:



Financial losses:



Daily living losses:



Loss of hopes and dreams for the future:



Other secondary losses:








Handout 18. The Importance of Enhancing Social Support

Social support is the emotional and physical comfort that people may receive from others, including their family members, friends, co-workers, and neighbors. Social support may take many forms, such as empathy, concern, caring, willingness to listen, and help with practical tasks. If social support is effective, it helps people feel loved, cared for, valued, and understood.

Following a traumatic loss, social support is one of the most important resources for healing. Below are some reasons why it is important to work with your therapist to enhance the social support available to you.

  • Survivors who feel supported are more likely to show a decrease in symptoms over time.
  • Receiving support helps survivors see that there is still some good in the world. As a result, they may become more hopeful about the future.
  • Support is important because it helps mourners to move forward in the healing process. For example, a survivor may recognize that she should get more exercise but have trouble actually doing so. By inviting her for a walk or accompanying her to the gym, a friend can help her get on the right track.
  • Social contact with others can help to provide a respite from the difficult work of mourning.
  • Supportive relationships can help survivors begin investing in the future by exposing them to new people, ideas, and activities.
  • Despite the benefits of support, research indicates that in many cases, those in the survivor’s social network are unable to provide effective support. Some people are uncomfortable relating to survivors of a traumatic death, and may therefore avoid you and your family. Others may wish to help, but do not know what to say or do. Survivors are often disappointed and hurt by others’ comments. Some of the most common types of remarks people make that the bereaved generally regard as unhelpful include the following: Asking questions (e.g., “Was there a lot of blood?” “What are you going to do with his tools?”); giving advice (e.g., “You should not be going to the cemetery every day,” “It’s time to move on”); minimizing the loss (e.g., “At least he’s not a vegetable,” “You’re young enough to have another child”); inappropriate identification with feelings (e.g., “I know how you feel; my dog was run over by a car”); providing a philosophical or religious perspective (e.g., “Life goes on,” “God needed him more than you did”).
  • Not having the energy or motivation to make contact with others.
  • Feeling self-conscious: “I felt that everyone was looking at me.”
  • Feeling guilty, or worrying that others believe the survivors are responsible for the death.
  • Not wanting to encounter unhelpful support attempts.
  • Feeling afraid that they will make others uncomfortable, or seen as a “wet blanket.”
  • Feeling uncomfortable with conversations about everyday things. Such conversations may seem trivial or meaningless.
  • For bereaved parents, feeling uncomfortable when other people talk about their children’s accomplishments and future plans.
  • Difficulty dealing with others’ complaints about their loved ones.

Your therapist can help you develop strategies for dealing with these situations, and for developing supportive ties that are beneficial to you.


Handout 19. Building social support

Social support is important to your recovery. This includes reaching out to people who can help you with specific tasks, finding good listeners, and staying connected to those people in your life who are positive sources of emotional support. This can be challenging, but it is also extremely important to the process of healing. The independent activities below will help you to explore any difficulties you may have had finding or receiving social support since your loved one’s death, and to think of ways you can build support.

independent Activity: Assessing your social support network

Consider the following questions in assessing your social support network. You may want to jot down some notes as you consider these questions.

  • What does your social support network look like now? Who is in it?
  • Socially, what or whom have you lost?
  • How has your support changed since the loss? For example, have some people you thought were good friends stayed away since your loved one’s death? Have some people who were just acquaintances been more helpful than you might have expected?
  • Have some friends who rallied around you after your loved one’s death become less available?
  • Have you bonded with any new friends since the loss?
  • How have your relationships with old friends changed?
  • How do you understand any changes in your support?
  • What are some situations in which you had the experience of feeling misunderstood or not heard? What types of comments have others made that have left you feeling misunderstood? What other feelings have you experienced upon hearing these comments?
  • Are there ways in which you have experienced a loss of connection with others? For example, are you spending more time at home? Are you getting together with people less often than you did before the loss? Are you turning down social invitations, and/or neglecting to initiate contact or maintain social ties?


independent Activity: Beginning to set social support goals

Your answers to the following questions will help you begin to think of small goals that involve relating to others.

  • Whom can you turn to for emotional support?
  • Whom do you know who is a good (nonjudgmental, supportive) listener, and who might be available to you if you feel like talking about your significant other’s death?
  • Are there people in your social network who have invited you to do something, whom you have turned them down because you did not feel up to getting together?
  • Who could help you with daily tasks?
  • What are the attitudes of the important people in your life about asking for help? For example, do they support you in asking? Encourage it? Discourage it?
  • What cultural or religious influences in your life affect your ability or willingness to reach out to others?




Handout 20. second Account of the death

Please write an account of when your significant other died. Do this writing activity as soon as possible (ideally, today). This time, focus on . Include sensory and other details. Also, include your current thoughts and feelings (that is, your thoughts and feelings as you are writing), in parentheses.

As with the first account of the death (Handout 16), write in the present tense, write the account by hand, and write where and when you have enough time and privacy. Allow yourself to experience your emotions fully. If you need to stop writing at any point, please draw a line on the paper where you stop, and resume writing when you can. Please read the account to yourself each day before the next session. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.



Handout 21. Values[12]

The sudden, traumatic death of a loved one can drain your life of purpose, meaning, and vitality. One of the comments we have heard most often from survivors of traumatic loss is that nothing seems to matter anymore. These exercises will help you clarify your values – that is, things that you still care about, despite everything that has happened. They will also help you make some decisions about how you want to live the rest of your life.

In many cases, survivors’ core values and their goals for the future are shattered by what has happened. For example, a mourner may place great value on education. Prior to the loss, she may have decided to go back to school and earn an advanced degree. Following the death of her loved one, she may have to abandon this plan because she is unable to concentrate on her studies. Another survivor may have rated religion and his relationship with God as his most important value. If he loses his child in a needless accident, he may feel betrayed by God and turn against his faith.

For many reasons, you may not feel ready to think about your goals for the future. However, evidence suggests that taking even the smallest steps toward identifying future goals, and developing plans for reaching them, can facilitate the healing process.

Below, we first ask you to complete some exercises that will help you to identify your most important values at this time. Next, we provide information to help you to differentiate among values, which are the principles by which you live your life; goals, which are tasks you can accomplish in the service of your values; and action plans, which are the specific steps you take to reach your goals. Finally, we show you how to set goals and develop action plans that are feasible for your situation.

Some mourners believe that it is inappropriate to think about values and future goals when they are still in so much pain. In fact, values work can be very helpful for people in this situation. Working on values and goals does not require people to give up their pain; it gives them something to focus on in addition to their pain.

Mourners are often reluctant to become engaged in work on values and goals because they believe it is disloyal to their lost loved one. If you feel this way, you might consider the following question: What would your loved one recommend that you do? Most people feel that their loved ones not only would support them, but would actively encourage them to develop goals for the future and to carry them out. The Independent Activity that follows will help you to gain a greater understanding of working with values and goals.


Independent Activity: prioritizing your Values And setting goals

The purpose of this exercise is to identify those values that are most important to you. Below is a list of values or life domains; some of these may be very important to you, while others may be insignificant or irrelevant to your situation. Please look through the list below and check off the five values that are most important to you at this point in your life. We want to emphasize that there are no right or wrong values. Only you can know what is most important to you.

Health/physical well-being Spirituality/religion

Marital or couple relationship Education/training/personal growth

Parenting Service to others

Extended family (parents, siblings) Recreation/leisure/fun

Friendships/social life Financial security Work/career Other (specify)

Now please list the values you have checked off in the spaces below. List these in any order. You don’t have to rank them.


Next, look over the five values that you selected. In so doing, please ask yourself the following questions: What are the real priorities in my life at this time? What do I care about most?

Now go through your top five values again and, keeping these questions in mind, cross off three of the values, leaving the two that are most important to you now. Some people find it difficult to eliminate values they care about. You should keep in mind that once you have made progress on the values you selected, you can begin working on other values.

Experts have found that in doing work with values and goals, clients usually make more progress if they focus on one value at a time. For this reason, this exercise has been designed to help you identify the value that you would like to work on now. Focusing on one of your two remaining values, ask yourself the following question: What would it mean for me to live that value, and what would it mean if I didn’t? Living a value means making day-to-day decisions that are consistent with that value. For example, suppose the value you select is health. What it would mean to live that value is to make day-to-day decisions such as exercising regularly, avoiding unhealthy foods, and cutting back on alcohol consumption or smoking.

Now focus on the remaining value and ask the same question. On the basis of your answers, select the value that you would like to work on at this time. You will be setting goals and developing action plans that will help you live the value you have chosen. In all likelihood, you will feel a sense of accomplishment and pride that you have been able to make choices that will help you move forward.

Below, please write in the value you would like to work on now.



Goal Setting

Now it is time to select a goal that reflects the value you have chosen. Goals help us to focus our energy, and to behave in ways that are consistent with our values. Goals are empowering because they can show us what we are capable of.

Unlike a value, a goal is something you plan to accomplish. Goals are specific, realistic, and concrete. There should be some way of determining or measuring whether you have achieved your goal. To provide an example, “being a good friend” might be your most important value.

“Getting together with one of my good friends each week” is a goal that supports your value. Here are some examples that will help you differentiate between values and goals:

• If your value is financial security, your goal might be to find a financial planner.

• If your value is extended family, your goal might be to plan a birthday party for your sister.

• If your value is your marital or couple relationship, your goal might be to arrange a “date” with your spouse or partner once per week.

In selecting a goal, it can be helpful to raise the following question: What goal could I pursue in the service of my value that is feasible for my situation now? Realistically, do I have the time, energy, and resources to reach that goal?

We would like you to select one goal to work on at the present time. Make sure that the goal you select will help you to live in accordance with the value you have chosen. In deciding on which goal to pursue at this time, select one a goal that is realistic. Your goal should also be measurable – you should be able to determine whether you are reaching your goal or not. We strongly recommend that you discuss your initial selection of values and goals with your therapist.

Once you have identified a goal that meets the criteria described above, please write it here:




Independent activity: Goal’s and action plans

Now that you have chosen the value and goal you want to pursue at this time, the next task is to identify the specific, small steps or actions you will need to complete in order to reach your goal. The most common reason people don’t reach their goals is that they do not have an action plan. An action plan helps you to make steady progress toward your goal, step by step. Here are some examples that will help you differentiate between goals and action plans^

• If your goal is to find a financial planner, steps in your action plan might include:

•              Asking friends, coworkers, or members of your congregation for recommendations.

•              Doing research to learn more about certifications for a financial planner, and deciding on the level of expertise you need.

•              Making an appointment to consult with at least one financial planner during the next 2 weeks.

• If your goal is to throw a birthday party for your sister, steps in your action plan might include:

•              Selecting a date and time for the party, after checking with other family members and friends.

•              Making a guest list and contacting potential guests.

•              Planning the menu and ordering a cake.

•              Arranging for the house to be cleaned the day before the party.

• If your goal is to arrange a “date” with your spouse, your action steps might include:

•              Reading movie reviews to identify a film you and your spouse would both enjoy.

•              Selecting a restaurant and making a reservation.

•              Arranging for a babysitter.

•              Doing extra work at the office on the day before the date, so that you can arrive home on time the day of the date.

In formulating your goals and action steps, it is important to attach a time frame to each one. For example, you might give yourself 1 week to select a date and time for the party, or you might give yourself 4 days to ask people for recommendations for a financial planner. Research has shown that without specific time frames, most people are not able to achieve their goals.

Please list three to five specific actions, behaviors, or steps you plan to take toward reaching your goal. Try to identify a time frame when you will engage in each behavior. Check off each action step once you have completed it. Feel free to add more action steps that will help you reach your goal if you wish.

Specific action steps toward goal: Time frame:

1. 2. 3. 4. 5.

Additional actions:

1. 2.


Please remember to check these off as you complete them.

We recommend that you discuss the exercises in this handout with your therapist before attempting to carry out your goal. Your therapist may be able to provide feedback on the values, goals, and action steps you have developed – for example, whether they are realistic and are attainable for you at this time.

Before you attempt the assignment, you can also talk about potential barriers to reaching your goals. You can write down any feelings or beliefs that might prevent you from completing your goal. Then talk with your therapist about what you might do to ensure that you will be able to complete your action steps and achieve your goal.

Barriers to reaching your goals and Action plans

On some occasions, you may find that even though you worked hard to reach your goal or complete your action steps, something got in the way. For example, maybe one of your action plans involved asking your neighbor for help, and you were just not able to do it. Perhaps you thought your request would be annoying to your neighbor. In discussing these issues with your therapist, you can develop some strategies that will help you the next time you are in a similar situation.

Survivors are often surprised by how they react to working with goals. As one woman who lost a child expressed it, “I didn’t think I could pull off throwing a birthday party for my sister, but I did it. She was so happy that despite everything that has happened, it made me happy too.”



Handout 22. Third Account of the death

Please write an account of when your significant other died. Do this writing activity as soon as possible (ideally, today). This time, focus on . Include sensory and other details. Also, include your thoughts and feelings as you are writing, in parentheses.

As with the earlier accounts of the death (Handouts 16 and 20), write in the present tense, write the account by hand, and write where and when you have enough time and privacy. Allow yourself to experience your emotions fully. If you need to stop writing at any point, please draw a line on the paper where you stop, and resume writing when you can. Please read the account to yourself each day before the next session. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.



Handout 23. Psychological needs safety

A sense of safety (or security) is fundamental to all of us. We all need to feel that we are safe and reasonably invulnerable to harm, and that the people we care about are safe. Without these basic beliefs, it’s hard to feel comfortable. The sudden, traumatic death of your significant other has probably disrupted your sense of safety. Because something sudden and unexpected happened to your loved one, it’s easy to think that something awful could happen to you or someone else you love. You may become extremely anxious if another significant person is late coming home, or if you receive a phone call late at night.

Disrupted safety beliefs can get in the way of activities or relationships. Concerns about becoming close to people when they are vulnerable to harm (because you don’t want to lose someone you’re close to again) can prevent you from seeking relationships. Similarly, you may fear that anyone you love may be endangered simply because of being close to you; you may be using the loss of your loved one as “evidence” for this fear.

independent Activity: safety

Think about how your beliefs about your own safety and that of your surviving significant others have changed since the death. Complete an Automatic Thought Record (Handout 13) about one of those safety beliefs.

Trust Trusting oneself

Self-trust is the belief that you can rely on your own perceptions and judgments. A sudden, traumatic death may challenge these beliefs. It is common (although it may not be rational) for survivors to focus on decisions they made before the significant other died and to imagine that things would have turned out differently if they had made different decisions. This can lead to self-statements like “If only I had [or had not] done [or said] X, Y, or Z, the accident would not have happened.” These statements can then lead the survivors to doubt their judgment: “If I did X before and things turned out so badly, how can I ever trust myself to make good decisions?”

Of course, in all relationships, there are many choices and things we could have done differently. In typical daily life, we don’t have any reason to focus on these small things. We make dozens of decisions every day (including what to wear, what to eat, where to park the car, etc.), generally without questioning our judgment. When something goes terribly wrong, it’s natural to look for reasons for what happened and to question our behavior and judgment. That search naturally takes us into areas of self-doubt.

When your self-trust is disrupted, you may doubt yourself, feel overcautious, or have difficulty making decisions.


Trusting others

Other-trust is the belief that you can count on others to be there for you when you need them – that people will keep their promises. One of the earliest tasks of childhood is developing trust. Everyone needs to learn a healthy balance of trust and mistrust, and learn when each is appropriate. Sudden, traumatic loss can affect your trust in others in a variety of ways. If the significant other was someone who was always there for you, it’s easy to decide that the way to avoid feeling bad in the future is to avoid forming trusting relationships. This might mean not getting close to others out of fear that closeness might lead to trust, dependency, and then more loss. You may go to extremes to avoid relying on others.

If important people betrayed you early in life, you may have developed the belief “No one can be trusted.” The sudden death of a significant other may serve to confirm this belief. If you had particularly good experiences growing up, you may have developed the belief “Generally, people can be trusted.” The sudden, traumatic death of a significant other can shatter this belief.

If the people you counted on and trusted were distant, unsupportive, or judgmental of you and your family after your loved one’s death, your belief in their trustworthiness may also have been shattered.

When other-trust beliefs are disrupted, you may experience a pervasive sense of disillusionment or disappointment in others, fear of betrayal or abandonment, anger and rage at betrayers, fear of relationships (new or old), and general suspicion of others. New relationships may create anxiety because as trust develops, you may feel frightened about the possibility that someone will again abandon or betray you.

independent Activity: Trust

Think about how your beliefs about trust have changed since the death of your significant other.

Complete an Automatic Thought Record (Handout 13) about one of those trust beliefs.

Control self-control

Self-control refers to your beliefs about your ability to feel in charge of your own thoughts, feelings, and behaviors. A sudden, traumatic loss can lead to feeling out of control. This can be frightening, especially if the feelings seem particularly intense or if they lead you to say or do things that don’t feel comfortable or familiar. A sudden, traumatic death can change your beliefs about what you think you are able to control. If, for example, you grew up believing that you could control what happens in your life, the realization that there are important things you cannot control can feel overwhelming.

After a sudden, traumatic death, survivors often find themselves with less control over their own behaviors. That can be scary, especially if they are behaving in destructive ways, like drinking too much, pushing people away, not showing up for work, or behaving aggressively toward others.


Other-control refers to your beliefs about your ability to influence those around you. Many sudden, traumatic deaths leave people feeling guilty. For example, if someone did something that resulted in the death of someone you love, it’s easy to feel as if you should have been able to prevent it. Other types of losses – such as those resulting from industrial or transportation accidents, homicides, terrorist attacks like 9/11, and suicides – can also stimulate a sense of having no control or influence over anything or anyone. When you are upset, your emotions become more intense, and you may generalize from the thought that you had no control over one person in a particular situation to a belief that you cannot control or influence anyone.

independents Activity: Control

Think about how your beliefs about both self-control and other-control have changed since the death. Complete an Automatic Thought Record (Handout 13) about one of those beliefs.

Esteem self-esteem

Self-esteem refers to your beliefs about your own value and the value of what you think, feel, do, and believe. It’s natural for survivors to feel some responsibility for the death of a significant other, or to feel that they could or should have done something differently. Even if groundless, this guilt is a common outcome of traumatic loss. Although doing so is irrational, it’s not a difficult next step for survivors to devalue themselves – to feel bad, unworthy, ashamed, or inadequate. Some people even come to believe that their very presence in the loved one’s life was toxic. This is especially true for people whose self-esteem wasn’t strong before the loss – for example, some survivors of early traumatic experiences. These individuals may have a chronically low sense of self-esteem and may be more susceptible to feeling that way after the death of a loved one. For them, the current loss can become just another example of their inadequacy or unworthiness.

Problems with self-esteem can also arise during the process of trying to make sense of what happened. It is natural to try to find someone to blame for a sudden, traumatic death. Especially when there is no obvious target, survivors may blame themselves. In most relationships, we all sometimes do things that we don’t feel good about, such as speaking sharply to the other person or in some way failing to respond to the other person’s needs. If the person dies in a sudden, traumatic incident, we may then focus on these small failures and use them as proof that we are bad. Guilt is a natural response to loss, and we may have legitimate regret over failures or neglected aspects of our relationships. However, it is important to challenge self-blaming beliefs and thoughts that may be exaggerated. Guilt and self-blame that are out of proportion to the actual relationship are especially likely to emerge if we were having problems with the lost loved one, or had a bad interaction with this person shortly before the death.

People may also experience problems with self-esteem because the challenges that follow traumatic death, such as feeling overwhelmed, difficulty concentrating, or feeling exhausted, can make it hard to function well at work or school or when relating to family members and friends. This can further erode self-esteem.

Finally, feelings of grief often include feeling bad for oneself. Unfortunately, it’s easy to go from feeling bad for oneself to feeling bad about oneself.


Other-esteem refers to your beliefs that others are valuable and worthy of respect. If a significant other has died in some way that involves another person (e.g., a violent death, an industrial or transportation accident, or a terrorist attack), it’s natural to blame the other people involved, who truly may be responsible. From there, it’s easy to generalize to the belief that no one is worthy of respect, people are incompetent, or people are evil.

independents Activity: esteem

Think about your beliefs about self-esteem and other-esteem. Have they changed since the death?

Complete an Automatic Thought Record (Handout 13) about one of those esteem-related beliefs.

Intimacy self-intimacy

Self-intimacy refers to your beliefs about your ability to feel connected to your inner experience, including your thoughts and feelings. After a major loss, survivors often don’t want to feel their pain, anger, terror, grief, sorrow, loneliness, or longing. Although they know that avoiding these feelings is, paradoxically, the thing that keeps the feelings alive and hurting them, avoidance is a natural human tendency – one that takes effort to overcome. Grief often brings fatigue with it, which makes it difficult to exert effort. It may often feel easier for you to have a drink, keep busy, sleep, lose yourself in work, or think and talk about anything other than the death. However, these strategies also separate you from your inner life – from your awareness of who you are and what you need.


Other-intimacy refers to the belief that you can feel close and connected to other people. A sudden, traumatic death can seriously challenge those beliefs. Survivors often feel that their pain after the death relates to the depth of the connection with the significant other, and thus that connection is something to avoid in the future. They may think they have lost the one person who really knew or understood them. This belief may lead to withdrawal from others, with the intention of not investing in other relationships in order to avoid that kind of loss in the future. That decision and behavior can then lead to loneliness.

independent Activity: intimacy

Think about how your beliefs about self-intimacy or other-intimacy, and/or your behaviors regarding intimacy, have changed since the death of your significant other. Complete an Automatic Thought Record (Handout 13) about one of those intimacy beliefs.



Handout 24. Positive and negative Aspects of your relationship with your significant other your relationship

All relationships have positive and negative aspects. Below, please identify at least three positive and at least three negative or less positive aspects of your relationship. Feel free to list more of either if you would like.

Positive aspects of your relationship:








Less positive, or negative, aspects of your relationship:








Personal qualities of your Loved one

When we think about people we care about, it is usually possible to identify some qualities we really like, as well as some qualities that are not so positive. Below, please identify at least three positive qualities of your loved one, and at least three not-so-positive or negative qualities.

Positive qualities of your loved one (that is, things you loved, admired, or appreciated about this person):








Not-so-positive or negative qualities of your loved one (that is, things you did not like or things you found irritating or annoying):









Handout 25. Fear and Avoidance hierarchy form

Situation/Activity Distress Rating (0 – 100)


















Handout 26. Account of your relationship with your significant other

Write an account of your relationship with your significant other, focusing on the time right before the death. Do this writing activity as soon as possible (ideally, today). Include in your account regrets or unfinished business that you may have had with the deceased, and things you wished you could have done or said before your significant other died. Feel free to include aspects of the relationship that you have not yet remembered fully, as discussed at the opening of this session. Also, include your thoughts and feelings as you are writing, in parentheses. As in earlier writing assignments, write in the present tense, hand write the account, and write where and when you have enough time and privacy. Allow yourself to experience your emotions fully. If you need to stop writing at any point, draw a line on the paper where you stop, and begin writing again when you can. Please read the account to yourself each day before the next session. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.



Handout 27. Guilt, regret, and sudden, traumatic death


One common response to sudden, traumatic death is feeling guilty. As mentioned in earlier handouts, survivors sometimes blame themselves, either directly or indirectly, for what happened. Or they might blame themselves for things that happened or did not happen when their loved ones were alive – things about which they now feel bad or responsible. As defined by Webster’s New World College Dictionary (2005), guilt is “a painful feeling of self-reproach resulting from a belief that one has done something wrong or immoral.” To feel guilty means to feel as though one is responsible for a wrongdoing.

Given this definition, we could say that guilt is appropriate when a person has done something wrong. Sometimes this is appropriate: the survivor may have been the one who was driving the car when it crashed. More commonly, survivors feel guilty about innocent acts that set the stage for the death. For example, a parent may berate himself for allowing his teenage daughter to ride in the car with a friend who was speeding and failed to negotiate a turn. Survivors may feel sorry about what happened and wish that they had done things differently with regard to their loved ones. However, wishing that things were different and blaming oneself for these things are not the same. Of course, a survivor may also experience appropriate guilt and misguided guilt at the same time. For example, a person who harassed a sibling consistently may feel guilty when that sibling dies in a workplace explosion. The guilt for the harassment may be appropriate, but the guilt for the death is not.

Guilt can also result from the violation of a personal standard that a person holds either consciously or unconsciously. An example of this would be a father who feels he should be able to protect his child from all harm or pain, and then feels guilty when the child dies, regardless of the circumstances. This is a common state of affairs; the wish to protect one’s child is natural, although the belief that one can protect children from all harm is not a realistic expectation. When guilt arises from the violation of a personal standard, as opposed to arising from objective wrongdoing, we need to ask whether that personal standard was realistic in the first place.

How can you make sense of guilt feelings?

No one can tell whether guilt is appropriate or not merely by how it feels; inappropriate guilt feels just as bad as appropriate guilt. If you are feeling guilty, it is a good idea to check in with your therapist about the legitimacy of your guilt. In other words, what would an objective or neutral person say about whether you committed a wrongdoing? What would a friend, a colleague, or your therapist say about whether you are actually responsible for what happened? Alternatively, if someone you cared about were feeling guilty about the same thing you are – in other words, if this person were in the same position as you – what would you say to that person? Would you hold the person responsible for the action, event, or situation? Looking at your situation from different perspectives can help you to determine whether the guilt you are feeling is appropriate.

If you are feeling guilty, it is also important to ask yourself whether you feel you have violated a personal standard. Again, it can be helpful to explore this question with your therapist or a trusted friend, especially if you are not fully aware of the standards you hold for yourself. For instance, if you feel guilt because you occasionally became angry with your loved one and believe that you violated your personal standard of never being angry with those you love, you need to examine this standard. In fact, this unrealistic standard can never be met in a close relationship.


The concept of regret provides an alternative to guilt as a way of understanding painful feelings about a loss. Regret means “to feel sorry about or mourn for (a person or thing gone, lost, etc.)… [or] to feel troubled or remorseful over (something that has happened, one’s own acts, etc.)” (Webster’s New World College Dictionary, 2005). Regret is an inherent part of loss. All of us make choices in life all the time. When we choose X, we are saying no to Y and Z. All choices, therefore, involve loss, and some may involve regret. Regret is part of life, and it is certainly part of death. We cannot do everything, and we cannot be all things to all people.

Conflict occurs in all intimate relationships. It’s natural to feel bad about disagreements, arguments, differences, or harsh words, especially after a loved one dies. If that death was unexpected, there wasn’t an opportunity to say goodbye, to finish the “unfinished business,” or to place the conflicts in a broader context. Although it is painful, this type of regret is a normal part of unexpected loss.

In a time of sorrow and distress, it can be easy to misinterpret regret as guilt, and this can happen for a variety of reasons.

  • We may feel a strong need to explain the death. If explanations are not readily available, then we may blame ourselves, partly as an effort to make sense of the death.
  • All of us need to have some control over our lives. A sudden, traumatic loss challenges this need. In an effort to reestablish a sense of control, we may blame ourselves for things we did or did not do, thereby believing (on some level) that we could have prevented the death if only we had done X or hadn’t done Y.
  • If we grew up in families that readily and wrongly placed blame (because of stress, fear, anger, or frustration), then we may have internalized these messages, believing that “everything is my fault.”
  • Modern Western culture is litigious. We often seek to blame someone for something that happened. If someone is responsible, then it is not just an accident – not just something about which to feel disappointed, helpless, or regretful, which people often find easier.

After the death of a significant other, hindsight bias comes into play. Hindsight bias means judging something in the past on the basis of knowledge that we have now but did not have then. This belief gives rise to the common saying “Hindsight is 20/20.” Most of us make the best decisions and choices that we can, given what we know and the resources available to us at the time. After the fact, if we gain new knowledge or if circumstances change, we may wish we had done things differently; we may feel as if what we did was wrong when in fact we did the best we could.

How can you Address guilt and regret?

The first step in addressing guilt and regret is distinguishing one from the other. Again, you may be able to do this best with another person who can offer a more objective view of the situation. It is also important not only to distinguish guilt from regret, but also to distinguish guilt resulting from an objective wrongdoing from guilt resulting from the violation of an unrealistic personal standard.

If you are still feeling guilty about a wrongdoing or a violation of your personal standards, it will be important to practice compassion toward yourself and to work to forgive yourself eventually.

Later in the treatment, you will address this issue in more detail and talk about ways of transforming your guilt or regret. For now, it is important to be aware of any guilt or regret that you are carrying, and to find the time and space to express your thoughts and feelings.



Handout 28. Anger and sudden, Traumatic death


Webster’s New World College Dictionary (2005) defines anger as “a feeling of displeasure resulting from injury, mistreatment, opposition, etc., and usually showing itself in a desire to fight back at the supposed cause of this feeling.” The English language has many words to indicate feelings related to anger, including upset, furious, or annoyed; this large vocabulary is a clue to the many levels, sources, and presentations of anger among people. Each survivor’s anger experience is unique, as is the person’s ability to cope with the emotion.

For some survivors, anger is an easily recognizable feeling. For others, anger is a very difficult emotion to feel; they may not have a lot of experience with anger, given their family, cultural, or social background, and so feelings of anger might feel “foreign” or unfamiliar. These same people, however, may be aware of feelings of irritability, frustration, negativity, or bitterness. It is fine to insert these words for the word anger throughout this handout if they are a better fit with your own experience.

Is it natural to feel angry after a traumatic death?

After the death of a significant other, it’s quite common to feel angry. You may feel angry that what happened to your loved one was unfair, that you are deprived of someone you value, that you don’t feel heard or understood, or that your needs aren’t being met. You may feel angry with God for allowing this to happen. You may feel angry at the person or people who brought about the death or those who did not do enough to prevent it. You may feel angry that your loved one didn’t have the opportunity to live out a full life, or that you didn’t have a chance to say goodbye.

You may even feel angry with your significant other. And you may wonder, “How can I feel angry with someone who has died? Does it mean I didn’t or don’t really love this person?” Not at all. Anger can arise in an intimate relationship, for example, when an important expectation isn’t met, including the expectation or assumption that the person would be with you for the rest of your life. In this case and others, it is natural to feel disappointed and angry.

What are some reasons for being angry after a traumatic death?

You may feel angry after the death of a significant other for many reasons:

  • It is common to feel anger toward those who caused or brought about the death of your significant other, or toward those who failed to prevent the tragedy. You may experience thoughts or fantasies of revenge toward the perpetrator, if there is one. You may also feel that both you and your loved one were cheated by what happened.
  • You may also feel angry if the death was preventable in some way. This may be particularly the case if you believe that someone is responsible for the death, but this person is not held accountable for what has happened.
  • Anger is also a natural response to abandonment. You may have felt that your loved one was the one person who really understood you, and that now you are truly on your own. Even if your significant other had no control over when or how the death occurred, you may feel deserted or left behind.
  • Sometimes anger takes the place of other feelings or masks other feelings that are harder to tolerate. In some situations, anger can be empowering, whereas other feelings may confront you with your vulnerability. For example, anger – though legitimate in its own right – may also camouflage grief, sorrow, hurt, regret, anxiety, fear, loneliness, and other feelings and responses. It may be easier to experience anger than grief or fear, for example.
  • Another reason you may feel angry is because of unfinished business with your loved one. You may have been chronically disappointed or unhappy in your relationship with this person. You may feel angry because you didn’t have a chance to say something important – negative or positive – to the loved one. There may have been something (for example, a disagreement or separation) going on at the time of the death that now cannot be addressed or resolved.
  • Anger is also a natural response to secondary losses. You may feel angry about all of the consequences of the primary loss, such as losing your sense of optimism, your financial security (if you are suffering financial consequences), or your social life (if the primary loss has affected it).
  • As a survivor of traumatic death, you may also suffer secondary victimization. That is, you may sometimes be let down or hurt by those you turn to for help, such as the courts, the mental health system, or even your own family members or friends. For example, a friend may tell you that it’s already been 2 years since the death and it’s time to move on. Such comments can precipitate anger.
  • In addition to feeling angry with God, the perpetrator (if there is one), and the loved one, you may feel angry with others after the loss. As noted above, it’s common to feel angry with others for their lack of understanding, apparent insensitivity, or inability to meet your needs. It is also common to be angry that their lives are progressing normally while yours is not. Sometimes your anger may “leak out” in relationships with friends, family members, or co-workers. You may find that you have become more irritable and less patient with others because of the loss.

Why is anger scary?

People are often afraid of their anger, and this may be the case for you. There are multiple reasons for that fear, many of which have a lot to do with how your family of origin handled anger. Anger may be unfamiliar if you grew up in a family that suppressed it. It can be a very strong feeling, and strong feelings in general may seem scary if you didn’t learn how to recognize, tolerate, modulate, and integrate them while you were growing up. In some homes, anger (a feeling) quickly turns into violence (a behavior). Growing up with people who expressed their anger in violent words or acts, or by drinking alcohol or running away, doesn’t teach constructive anger management.

Using Anger Constructively

Anger is a natural feeling that you can use constructively. Anger provides information. For example, it can signal a place where you are stuck in coping with the death, a problem in a relationship, or a need or expectation that isn’t being met. Anger may also signal an injustice and a need or desire to stand up against that injustice.

Using anger constructively means being able to understand it, and to choose how to respond to the feelings of anger and the situations that evoked them. Therefore, using your anger constructively entails taking time out to reflect on exactly what is making you angry. Being aware of the situations in which anger arises, other feelings that may be present with it, and thoughts or beliefs that accompany it can be a useful way of becoming aware of what is making you angry.

Using anger constructively involves tolerating the emotion by learning to sit with it. It also requires making a choice about how to respond to the feeling itself, to the situation that evoked the feeling, and to others with whom you are angry. Talking over your options with your therapist or another person; writing about your anger and other possible reactions; and taking a “time out” to reflect, to experience the emotion, and to think about potential responses may all help you to use your anger constructively.

If you experience your anger as “energy” – that is, if you’re feeling “wound up” or “charged,” or feel as if you might “explode” – then physical exercise can be a useful way of managing anger. In addition, the independent activity below provides ways for you to gain awareness of and insight into your anger, as well as to use your anger constructively.

independent Activity: Anger

When you feel or remember a time when you felt angry, choose two or more of the questions below and write your responses.

With whom am I angry?



What other feelings (such as, loss, fear, vulnerability, guilt, sorrow, or grief) might underlie the anger?



Is fear or another feeling underlying my anger in some way?



Do I feel guilty about something that may be related to my anger?



What do I need that I don’t believe I can get?



Are any of my expectations of other people unrealistic? If so, how can I work to modify them?



Are there other ways I can meet my needs so I’ll feel less angry?




Handout 29. Letter to your significant other

Think about the conversation you had with your loved one during the empty-chair exercise. Then write a letter to your significant other expressing anything else that you would like to say. You may wish to express gratitude, regret, or simply tell the loved one how you are doing in the treatment or in your life. You can also ask for this person’s support as you continue your life. Use self-care and coping skills as necessary before and after (but not during) the exercise to provide support for yourself in this activity. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.



Handout 30. Exploring the meaning of the Loss

For this assignment, please consider what this loss has meant to you. Please find a quiet time and place where you can write freely. Try to write as many meanings as come to you, and try not to edit any out for any reason. When you have finished, read what you’ve written and circle several meanings you feel you could explore further with Handout 13, the Automatic Thought Record. Choose the one that you think about most often or find most troubling. You can use the blank space below to get started.



Handout 31. Spirituality

As human beings, we all need to make sense of our experiences, to assimilate or fit them into our view of the world, and/or to revise our assumptions to accommodate our new experiences. Our spiritual beliefs are a significant aspect of our assumptive world and reflect our ways of making meaning.

The term spirituality refers to those aspects of one’s life in which one is connected with something beyond oneself. This may include one’s connection with God, nature, history, and/or humanity. It is not limited to religious practice. For one person, spirituality can describe his commitment to awareness of the beauty in nature. For another person, spirituality may mean a connection with animals that provides her with a sense of meaning and hope. For many of us, our spirituality can be a source of sustenance in difficult times.

Some people are able to find comfort in their religious or spiritual beliefs following a traumatic death – for example, envisioning the significant other in a better place. However, traumatic losses often lead people to question their spiritual beliefs, or to feel angry, betrayed, or confused. They may wonder, “If such a tragedy could happen, how could there be a loving God?” Practices that once felt restorative such as walking in the woods may no longer work for them. In addition, sudden, traumatic death often robs the survivors of a sense of purpose or meaning. Often the bereaved seek to find meaning for a death that seems to have none. People often simply cannot comprehend why the significant other had to die.

Disruptions in spirituality after a traumatic event are normal. Unfortunately, these disruptions can prevent you from being aware of a larger context and may create another, secondary loss – the loss of a past or potential spiritual connection. Please think about your sense of spirituality and any disruptions you have noticed since the loss. Also, spend some time thinking about how you might redirect, develop, or renew your connection to your spirituality.

Independent activity: spirituality

Creating or reaffirming spirituality after a loss may seem too difficult. You may have to create situations in which you can “hear” your spirituality a number of times before you begin to feel connected to it. Some ideas about ways to begin to renew or create a new spiritual connection are listed below.

• Watching a sunrise or sunset and meditating on it.

• Going to see a choir perform, especially children singing.

• Lying down, closing your eyes, and listening to music (Gregorian chant, Native American flute, etc.).

• Journaling outside, sitting on the grass or near a body of water.

Please try one of these exercises, or something else that appeals to you, as an independent activity for this week. If this feels too difficult, you might complete an Automatic Thought Record (Handout 13) on your beliefs about spirituality or about how the world works.



Handout 32. Final impact statement

Write a statement about the impact that this loss has had on you. Write as much as you want about what the loss means to you. Consider the effects that the loss has had on your beliefs about yourself, your beliefs about others, and your beliefs about the world. Include a description of how you account for this loss having happened – in other words, your understanding of why it happened. Write as much as you want, but write at least one or two pages. You can use the blank space below to get started.