Principles and practice of grief counseling [3 ed.] 9780826173324, 9780826173331, 9780826173348, 9780826173355, 9780826173362

Citation preview

7 × 10  SPINE: 0.57305  FLAPS: 0

Principles and Practice of

GRIEF COUNSELING Darcy L. Harris, PhD, FT

|

Howard R. Winokuer, PhD, LPC, NCC, FT

This core introductory text, with a focus on clinical application, combines the knowledge and skills of counseling psychology with current theory and research in grief and bereavement. The third edition is updated to address issues related to the developmental aspects of grief, including grief in children and young people, grief as a lifespan concept, and grief in an increasingly aging demographic. It describes new therapeutic approaches and examines the neurological basis of grief as well as trauma from disruption and loss. Also emphasized is the role of diversity, along with cultural considerations in grief counseling. Instructor’s resources include a Test Bank, Instructor’s Manual, and PowerPoint slides.

•

Updated research and content on attachment and grieving styles

•

Expansion of social issues impacting grief including political changes, environmental concerns, cultural differences, and exposure to terrorism

•

New theory, research, and practice for grief in non-death losses

•

New information on diversity and grief, the role of grounding and contemplative practices, and grief and developmental perspectives across the lifespan

•

Use of technology in both professional and informal grief support

•

New case studies with additional case scenarios for real-world application

•

Practice examples containing clinical application information in each chapter

KEY FEATURES: •

Focuses on clinical application

•

Combines the knowledge and skills of counseling psychology with current theory and research in grief and bereavement

•

Written in easy-to-understand language, with emphasis on practical application

•

Includes learning objectives, practice examples, glossary terms, and questions for reflection

•

Supplemental Instructor’s Manual, Test Bank, and PowerPoints included

Principles and Practice of

NEW TO THE THIRD EDITION:

GRIEF COUNSELING

User-friendly, while grounded in the latest research and theoretical constructs, the text offers such pedagogical aids as learning objectives, practice examples, glossary terms, and questions for reflection in each chapter. Above all, the book addresses grief counseling and support in a way that is informed and practical. The content explores concepts relevant to complicated grief, while differentiating the normal human experience of grief from mental disorders. Purchase includes digital access for use on mobile devices and computers.

Harris | Winokuer

THIRD EDITION

THIRD EDITION

11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com

THIRD EDITION

Principles and Practice of

GRIEF COUNSELING Darcy L. Harris | Howard R. Winokuer

P RI NCIP LE S AN D P R A C T I C E O F GRI EF  C OUN S E LI N G

Darcy L. Harris, PhD, FT, is an associate professor in the Department of Interdisciplinary Programs at King’s University College at Western University in London, Ontario, Canada, where she is the coordinator of the Thanatology Program. She also maintains a private clinical practice with a focus on issues related to change, loss, and transition. Dr. Harris planned and developed the undergraduate degree program in thanatology at King’s University College, which provides students from around the world with the opportunity to study about death, dying, grief, and bereavement. She has implemented coursework in thanatology in the specific interest areas of critical theory, social justice, and the exploration of grief after nondeath losses. She is also adjunct faculty in the College of Graduate Studies at Western University. She has served on the board of directors for the Association for Death Education and Counseling (ADEC), and she is the recipient of the Death Educator award from this organization. She is also a member of the International Work Group on Death, Dying, and Bereavement (IWGDDB). Dr. Harris has written extensively and is an internationally recognized speaker, providing presentations and workshops on topics related to death, grief, and loss in contemporary society. Topical areas include the social context of grief in Western society, compassion and mindful awareness in the context of loss and grief, and non-death loss and grief. Her books include Handbook of Social Justice in Loss and Grief, Counting Our Losses: Reflecting on Change, Loss, and Transition in Everyday Life, and Non-Death Loss and Grief: Context and Clinical Implications, and she is the co-editor of Grief and Bereavement in Contemporary Society: Bridging Research and Practice. She has also authored numerous book chapters and articles in related areas. Howard R. Winokuer, PhD, LPC, NCC, FT, is the founder of the Winokuer Center for Counseling and Healing in Charlotte, North Carolina, where he maintains a full-time clinical practice. He completed his PhD in 1999 at Mississippi State University, where he developed the first course in grief counseling skills. As the founder of TO LIFE, a not-for-profit educational and counseling organization, he was the associate producer of seven PBS specials and helped pilot one of the first teen suicide prevention programs in the southeastern United States. He has taught numerous courses and has been a guest lecturer at many colleges and universities, including New York University, Rochester University, the University of North Alabama, Queen’s University, Appalachian State University, and the University of North Carolina. Dr. Winokuer has conducted workshops and seminars throughout the United States as well as nine foreign countries, including programs for St. Christopher’s Hospice and St. George’s Medical Center, London, UK; The National Assistance Board, Barbados; and the United States Embassy at The Hague, Netherlands. He wrote a bimonthly column in The Concord Tribune, “Understanding Grief,” and hosted a regular radio show on WEGO, Life Talk. He was a consultant to WBTV, the local CBS affiliate in Charlotte, North Carolina, after the tragedy of September 11 and has been the mental health “professional on call” for Fox TV’s news show The Edge. He has recently appeared on the radio show Healing the Grieving Heart and has been interviewed by the American Counseling Association Journal and Counseling Today, as well as in the Staten Island Advance, The Houston Chronicle, The Charlotte Observer, The Detroit Free Press, and The Chicago Tribune. He also led an international delegation of funeral directors to Russia and Holland to study death and funeral practices in those countries. Dr. Winokuer has been actively involved in the field of dying, death, and bereavement since 1979. He has presented workshops and seminars to many organizations, including the National Funeral Directors Association, the University of North Carolina’s Department of Neurological Surgery, the Tennessee Health Care Association, and the Presbyterian Hospital. He also developed the crisis management plan for the Cabarrus County School System. He has been an active member of the Association for Death Education and Counseling (ADEC) for almost three decades and is a past president of the organization. In his almost 30 years of membership, he has chaired the national public relations committee, co-chaired the 2000 and 2003 national conferences, served on the board of directors, co-chaired the 2011 international conference that ADEC co-hosted with the International Conference on Grief and Bereavement in Contemporary Society, served as president, and was one of the co-editors for Grief and Bereavement in Contemporary Society: Bridging Research and Practice.

PRIN CIPLES A ND P R AC T I C E OF G RIE F CO U NSELI NG Third Edition

Darcy L. Harris, PhD, FT Howard R. Winokuer, PhD, LPC, NCC, FT

Copyright © 2021 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www. copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com http://connect.springerpub.com/home Acquisitions Editor: Rhonda Dearborn Compositor: Exeter Premedia Services Private Ltd. ISBN: 978-0-8261-7332-4 ebook ISBN: 978-0-8261-7333-1 Instructor’s Manual: 978-0-8261-7334-8 Instructor’s Test Bank: 978-0-8261-7335-5 Instructor’s PowerPoints: 978-0-8261-7336-2 DOI: 10.1891/9780826173331 Qualified instructors may request supplements by emailing [email protected] 19 20 21 22 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Names: Harris, Darcy, author. | Winokuer, Howard Robin, author. Title: Principles and practice of grief counseling / Darcy L. Harris, PhD, FT, Howard R. Winokuer, PhD, LPC, NCC, FT. Description: Third Edition. | New York : Springer Publishing Comapny, 2019. | Revised edition of the authors’ Principles and practice of grief counseling, [2016] | Includes bibliographical references and index. Identifiers: LCCN 2019032658 (print) | LCCN 2019032659 (ebook) | ISBN 9780826173324 (paperback) | ISBN 9780826173331 (ebook) Subjects: LCSH: Grief. | Grief therapy. | Loss (Psychology) Classification: LCC BF575.G7 W596 2019 (print) | LCC BF575.G7 (ebook) | DDC 155.9/37--dc23 LC record available at https://lccn.loc.gov/2019032658 LC ebook record available at https://lccn.loc.gov/2019032659 Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected] Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America.

For Brad and Lauren, and to my clients, students, and colleagues who are all my teachers and inspiration. — Darcy L. Harris

I would like to dedicate this book to all my students, colleagues, clients, and friends who have influenced my life both personally and professionally. I would also like to dedicate this book to Dr. Darcy Harris, my co-author, whom it has been a joy, privilege, and honor to work with. —Howard R. Winokuer

C O NTE N T S

Preface  ix Acknowledgments  xiii Share: Principles and Practice of Grief Counseling, Third Edition

Part I: Theoretical Underpinnings 1. Thoughts About Counseling   3 2. Unique Aspects of Grief Counseling   15 3. Theories and Orientation to Bereavement   27 4. The Social Context of Loss   45

Part II: Practice and Process 5. The Practice of Presence   65 6. The Basics of Counseling Practice   79 7. Working With Bereaved Individuals   99 8. Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow   121 9. Working With Emotions—Yours and Theirs   139 10. When Grief Goes Awry   157 11. The Clinician’s Toolbox: Therapeutic Modalities and Techniques in the Context of Grief  187 12. Ethical Issues in Grief Counseling Practice   217

viii

Contents

Part III: Current Issues and Trends 13. Caregiver Issues for Grief Counselors   237 14. Current Issues and Trends for Grief Counselors   259 15. Case Studies in Grief Counseling   281 Afterword  287 Index  291

P REFA C E

This book grew out of our need to have a text for the university-based courses that each of us teaches to students who are interested in furthering their knowledge and skills in grief counseling and support. We found that there are many good texts that explore research and theory in counseling psychology and many other books that expound on grief and bereavement theory and research. However, we have been unable to find a book that combined both the practical aspects of counseling with the current research and the theory related to grief and bereavement. After years of piecing together articles, course reading packets, and chapters selected from different texts, we decided to design a book that would explore both the practical knowledge and skills that are available in counseling psychology with some of the current research and theory in the area of loss, grief, and bereavement. Both of us have been practitioners in this area for over 30 years, and we have drawn on our own clinical work to “flesh out” things that we think would be most helpful to clinicians who wish to work effectively with bereaved individuals. We are often asked by clinicians who specialize in other areas of counseling, “How can you do this kind of work all the time?” We also smile at our students’ surprised faces when they see that we are not (always) dressed in black, morbid, and void of humor, as those who work around individuals who are dying or bereaved are often stereotyped. We try to convey to our students our passion for this area, and the rewards that we find in our practice with bereaved individuals. We realize that every day is precious. Our clients continually remind us that life is a gift, and that our time is limited—so we make the most of it. We firmly believe that working with individuals who are dying and bereaved makes us live our lives more consciously, fully, and with a greater appreciation. In our work with individuals who have experienced all types of losses, we have had the privilege of sharing very personal time with people who are hurting, vulnerable, and broken. However, we also have the opportunity to see how people

x

Preface

are able to draw on their strengths and innate resilience, often re-entering the world later with a stronger sense of themselves and of the gifts that life has to offer. We view the practice of grief counseling as a unique specialized area of practice, which is another reason why we wanted to write this book. Although counseling in general is meant to address issues that occur in everyday life, and loss is certainly a universal experience, we wanted to be able to focus on grief as a painful but adaptive process, with some unique features that separate it from other types of issues that are addressed in general counseling and therapy practice. We further expand on this idea later, but we want to state at the beginning that we believe a key aspect of grief counseling is that it does not focus on what is wrong, but rather on what is right about the grieving process, and our emphasis is on how we can facilitate the healthy unfolding of the adaptive aspects of this process rather than on its containment. One other unique feature of this book is the discussion of grief as a response to losses that are death related and non-death related, tangible and intangible in their description. An individual does not have to lose a loved one to death in order to grieve; grief can occur after placing a loved one with advanced dementia in a long-term care facility, with the ending of an intimate relationship, with the loss of hopes and dreams, and with the loss of self that may accompany life-altering events. Grief is viewed as an adaptive response to experiences that challenge our assumptions about how the world should work, and how we view ourselves and others within that world. Although we devote an entire chapter to this topic, this broader view of grief will be woven through all of the material that is presented in the various chapters. Because we make no assumptions about the background of the reader, we start with the basics of counseling and the therapeutic relationship. In Chapter 1, Thoughts About Counseling, and Chapter 2, Unique Aspects of Grief Counseling, we explore the purposes that counseling may serve, and the unique aspects and challenges that may occur in counseling individuals who have experienced significant losses. We then move into some basic material about current theories of grief and bereavement and how these understandings apply to clinical practice in Chapter 3, Theories and Orientation to Bereavement. In Chapter 4, The Social Context of Loss, we detail the ways that we are socialized to think about and respond to loss and grief. We then focus on issues that are salient to setting up the therapeutic relationship with clients, and specific counseling practices that we believe are relevant to working with bereaved individuals. We devote an entire chapter (Chapter 5, The Practice of Presence) to the cultivation of presence within the context of the counseling relationship, using this material to form the foundation on which grief counseling should occur. In no other form of counseling is the value of presence more relevant or timely; counselors who focus on trying to problem-solve and “fix” things with their clients may find working with bereaved clients to be an exercise in frustration and futility. We think it crucial for grief counselors to understand and embrace the gift of presence as the primary therapeutic stance in working with grieving individuals. We then take the material from the previous chapters and discuss basic concepts of counseling practice in Chapter 6, The Basics of Counseling Practice. In Chapter 7, Working With Bereaved Individuals, we begin to integrate counseling theory and practice directly with grief and bereavement theory. In this chapter, we explore some



Preface

xi

of the “nitty-gritty” expectations of the counseling process with bereaved clients. We then expand on definitions and understandings of loss and grief in Chapter 8, Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow, by exploring grief that may be present, but which may often be unrecognized or invalidated because it is not related to a death per se. We include a chapter (Chapter 9, Working With Emotions: Yours and Theirs) on working with strong emotions because many clinicians find working with clients who are experiencing such intensity to be intimidating or difficult, and their focus is often on containment of emotions rather than on the potential to use strong emotional content to deepen the client’s therapeutic process. In this chapter, we discuss concepts such as emotional intelligence and specific ways that strong emotions can provide valuable grist for the mill in the client’s process (and the counselor’s self-awareness). Chapter 10, When Grief Goes Awry, opens up the discussion of when grief goes “off track,” and how to recognize when additional resources and referrals are indicated in complicated grief scenarios. Chapter 11, The Clinician's Toolbox: Therapeutic Modalities and Techniques in the Context of Grief, provides an overview of some of the therapeutic techniques and tools that we have found to be useful in working with bereaved individuals, adding to the clinician’s “toolkit” some possible resources that may be helpful with specific types of clients and situations. In Chapter 12, Ethical Issues in Grief Counseling Practice, we explore ethical issues that may be particularly relevant to grief counseling, and we make recommendations for how grief counselors can ensure that they are practicing in ways that are competent and ethically sound. In Chapter 13, Caregiver Issues for Grief Counselors, we identify some of the common pitfalls that can affect grief counselors, and how the unique features of individuals who are drawn to this type of work can actually make the counselor more vulnerable to experiences such as burnout and secondary traumatization. In Chapter 14, we explore some of the current and upcoming issues that we see in our field, so that individuals who wish to specialize in the area of grief counseling can critically reflect and incorporate best practices into their clinical work. We include a section at the end of each chapter to allow the reader an opportunity to better absorb and reflect on the content with directed questions and exercises and a glossary of important terms. New to this edition are practice examples that are scattered throughout each chapter, which help to provide reallife application of some of the concepts that are discussed. In Chapter 15, we have provided sample case studies for the reader to analyze using the book materials. We also wish to indicate our decision to make a grammatical change in our writing style in this edition; we have chosen to shift from the use of singular pronouns that are binary in nature (e.g., he, she, him, her) to the use of pronouns that are more inclusive (e.g., they, their, them). It is important to recognize that not everyone identifies with binary pronouns, and in the counseling profession, it is important to follow the lead of our clients and how they wish to be referenced. We hope that you find this book both practical in its clinical content and stimulating in its theoretical underpinnings and philosophy. We find our work with grieving individuals challenging at times, but it is also highly rewarding, both professionally and personally. It is our desire that you learn some things that you might not have thought of earlier, and that you might feel better equipped to offer your healing presence to grieving individuals as a result

xii

Preface

of reading the material in this book. We also hope that you find, as we do, that this work is an opportunity to appreciate the strength, innate resilience, and capacity of human beings. Finally, it is our wish that you find an affirmation of the gifts that are present in your ability to care about others as we encounter fellow travelers in our life’s journey. Darcy L. Harris, PhD, FT Howard R. Winokuer, PhD, LPC, NCC, FT Qualified instructors may obtain access to ancillary materials, including an instructor’s manual, test bank, and PowerPoints, by contacting [email protected].

ACKNO W L E DGME NT S

For both of us, the decision to become counselors and then to write a book about counseling represents the culmination of many life experiences and relationships with people who encouraged, supported, and trusted each of us in many ways. Dr. Harris would like to express her gratitude to the individuals in her life who supported her during her own times of upheaval and loss, and who encouraged her to use the strength she found at these times to embrace the concept of the wounded healer. She would also like to specifically express her thanks to the mentors and colleagues who have offered her inspiration and have served as models to her practice: Anne Cummings, Margaret Rossiter, Marg McGill, Derek Scott, and Robert Neimeyer. Dr. Winokuer would like to express his thanks to his mentors, Robert Rieke, Mary Thomas Burke, Jonnie McLeod, Joe Ray Underwood, and Craig Cashwell, who guided him through the education process; and to Billie Thomas, his friend and colleague, who has been there through both the good times and the bad. Both of us would like to express deep appreciation to our clients, who granted us the privilege of sharing deeply personal and vulnerable times with us. We feel honored by the trust that they have placed in each of us. In addition, we dedicate this book to the students who seek to learn more about this process and themselves in our grief counseling classes. It is a great joy to share this vocation with others who are traveling on the same path. This work constantly reminds us of the profound connection that we share with each other and of the common thread of human experience that binds us together in this world. It is with this awareness that we feel both humility and excitement in sharing this book with our readers.

Share Principles and Practice of Grief Counseling, Third Edition

PART I THEORETICAL UNDERPINNINGS

CHAPTER 

1

T HOUGHT S AB OUT C O U N S E L I N G

LEARNING OBJECTIVES 1. Describe common misconceptions about counseling. 2. Differentiate between counseling and therapy. 3. Identify the components of the therapeutic relationship in counseling. 4. Define the goals of grief counseling.

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

4

I.  Theoretical Underpinnings

WHAT IS COUNSELING? In its simplest form, counseling is about two people sitting down in privacy, with one of these individuals listening intently and responding in a helpful manner to the other person who is expressing his or her concerns about problems in everyday life (Feltham, 2010; Kottler & Carlson, 2014). The field of counseling psychology arose out of a grassroots movement of the 1960s in response to what were viewed as heavy-handed, elitist therapies that focused on the weaknesses and foibles of the client and that were seen as perpetuating client dependence and disempowerment. Counseling is seen as a means to address everyday life concerns and issues related to daily living, not as a means to dissect an individual’s deep psychic secrets and family dysfunctions. The philosophy of counseling is basically that human beings possess innate strengths and resilience that can be drawn upon during times of struggle and crisis. Counseling offers the opportunity to help identify these areas of strength within individuals. The counseling process provides an avenue for empowerment of individuals to draw from these inner resources in order to work through difficult situations. Goals of counseling may include the following: ■■

Assisting clients to gain insight and perspective on their situation, behavior, emotions, and relationships

■■

Providing a safe place for clients to express feelings and clarify their thoughts

■■

Offering a context for clients' experiences within a broader perspective (e.g., within a family context, social and political structures, existential viewpoint)

■■

Enhancing the development of clients’ skills in dealing with painful and distressing situations

■■

Empowering clients to become their own best advocates

■■

Facilitating clients’ process of finding and making meaning in their life experiences

Counseling is an experience, a relationship, and a process. The counseling process is highly dynamic and interactional between the client and the counselor, with the central focus on the client’s needs and experiences. Counseling does not involve having an expert analyze the client with the goal to fix him or her. In the counseling relationship, the counselor and the client work together as a team to help the client to understand his or her experiences, and to develop awareness of what can be done do to work through the current issue. It is important at this juncture to delineate between counseling and therapy. Counselors typically assist people with issues and problems that arise in everyday life that are causing angst and difficulty. Counselors typically engage with clients who are basically functional, but who are struggling with an issue that is having an impact on their lives in a significant way. Counseling is usually short term or limited in the time that the client needs this assistance. In contrast, therapy involves in-depth work with clients, aimed at long-standing struggles and unresolved deeper issues that may require longer, ongoing supportive work. In therapy, clients usually work on restructuring their core aspects. In counseling, clients focus on



1.  Thoughts About Counseling

5

reframing everyday life events and identifying the strengths and resources that they need to draw upon to work through these events.

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

Misconception #1: Only Individuals Who Are Weak Seek Counseling Many people think of going to a counselor as a sign that something is wrong with them, or that seeking professional assistance is an indication of weakness. This commonly held thought is predicated on the belief that people seek professional help because they are somehow inadequate or needy. This misconception is most likely an extension of the value our society places on stoicism and rugged independence, which rewards us for denying and hiding our emotions at times of vulnerability, rather than supporting our healthy need to reach out to our communities and healers when we need to do so. Public expressions of the more vulnerable emotions, such as sadness or anxiety, do not necessarily result in offers of support; rather, their disclosure seems to serve as an invitation for criticism and judgment, along with lowered social status (Harris, 2009–2010, 2016). Our society places a great deal of expectation for us to be “above” emotion and to “overcome” our humanness, and counseling is often associated with emotions that are socially stigmatized. Therefore, seeking counseling is seen as something that “weak” people do because they cannot control their feelings, or they are too weak to manage them according to social expectations. Seeing a counselor is not about whether one is weak, but rather it is more closely associated with our human need to reach out for support at a time when our ability to accommodate something that has happened is deeply challenged. We are social creatures who live in community with others, and yet there is a strong dichotomy in regard to needing to be close to others while not allowing others to see us when we are not strong and independent. Professional counselors understand the courage it takes for a client to be willing to confront his or her problems head on and to expose such vulnerability in order to work through these difficult times (Practice Example 1.1).

Misconception #2: The Counselor Is the Expert Another misconception about counseling focuses on the role of the counselor as the expert. Certainly, professional counselors have usually completed a great deal of training and they

6

I.  Theoretical Underpinnings

P R A C T I C E EXAM PLE 1 . 1 UNEXPECTED BENEFITS OF GRIEF COUNSELING

Debbie’s husband died 3 months ago from a long, debilitating illness. Since his death, she struggled with feelings of guilt that she didn’t do enough to help him when he was very ill. She also had difficulties sleeping because her grief intensified at night and she was overwhelmed by the feelings that surfaced at these times. One of her colleagues at work suggested that she see a grief counselor, but she thought, “I am not that bad off,” and she never pursued it. Later on, one of her friends gave her the name of a grief counselor that she had seen after her mother died. Debbie decided to give it a try. After a few sessions, she noticed that while she still felt very sad at night, she was able to sleep better, and she had a more realistic appraisal of the events that surrounded her husband’s illness. Debbie realized that the counseling gave her a place to talk about her feelings, along with tools to engage with her grief so that she could choose how she wanted to be with her grief rather than being triggered and overwhelmed as much by her grief.

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

Misconception #3: People Who Need Counseling Are Basically Emotionally Unstable Another misconception about the counseling process is that a person must be crazy or unstable if they are seeking help from a counselor. It is true that when someone is going through a difficult time, especially an acute grief reaction, there is a wide range of emotional responses that can be associated with that loss (Worden, 2018). Those emotions are often described by bereaved individuals as similar to riding a “roller coaster,” with feelings changing rapidly and varying widely, and the sense of being out of control often highly distressing. Such feelings have led many of our clients to ask questions, such as, “Am I normal?”; “Am I going crazy?” We often reassure these clients that although they are normal, the disequilibrium that they are experiencing can be the stuff of crazy making! It is not because people are going crazy or



1.  Thoughts About Counseling

7

that something is wrong with them that they seek counseling, but rather it is because they are experiencing a significant challenge (e.g., a death, divorce, grief, a personal trauma, and unresolved childhood issues), and they need to have a safe place to sort these things out with someone who can walk alongside them in an empathetic, yet objective, way.

Misconception #4: People Who Have Good Friends Do Not Need a Counselor Many individuals would say that they could get the same support from having a discussion with close friends or family members as they can by speaking with a counselor, and it is true that most of us have friends and family members who we rely on for support during difficult times. However, sometimes these individuals are also personally involved in the same difficult situations, or they are directly affected by them. As a result, these individuals may have their own opinions or strong feelings that may hinder our ability to openly share our difficulties or to seek their counsel. In actuality, a counselor can provide a listening ear and trained support that a friend might not be able to provide. Lewis Aron describes the special type of listening in which counselors engage: That is what we offer: We listen to people in depth, over an extended period of time and with great intensity. We listen to what they say and to what they don’t say; to what they say in words and to what they say through their bodies and enactments. And we listen to them by listening to ourselves, to our minds, our reveries, and our own bodily reactions. We listen to their life stories and to the story that they live with us in the room; their past, their present, and future. We listen to what they already know or can see about themselves, and we listen to what they can’t see in themselves. We listen to ourselves listening. (Safran, 2009, p. 116) This specific type of listening is unique to counseling and is unlike other types of interaction. Unlike a relationship with a friend, relative, colleague, or another caring human being, counselors do not just listen—they provide a means for clients to hear themselves more clearly and, hopefully, come to some awareness of what is causing them to feel the way that they feel. Although friends might have wonderful listening skills and a desire to help, there is often a problem with friends acting as counselors because it is very difficult to see a friend who is hurting, and the desire to “fix” or “rescue” may interfere with the client’s ability to solve the problem or issue for himself or herself. Suffice it to say that most of our clients have good friends and family members available to them, but they usually find that the unique relationship with the counselor offers something important that these other relationships cannot provide during certain difficulties.

Misconception #5: Focusing on Problems Will Make Them Worse The last misconception that we would like to address is the belief that we should just forget about our problems and move on in life. Although we readily agree that not everyone will find counseling helpful, especially if they are not prone to talking openly with others

8

I.  Theoretical Underpinnings

about the more personal aspects of their lives, it is concerning that there is so much social pressure for people to ignore their feelings and act as if everything is fine when it is not. Unfortunately, this scenario is what commonly occurs, and in many instances, the problem festers and resides in the background, drawing energy away and resurfacing in unwanted ways throughout one’s life. It is true that in counseling we tend to focus on client’s feelings and their expression rather than supporting their suppression, which is more socially acceptable. However, focusing on feelings and actively working with strong emotions will not cause a client to lose control and have a “mental breakdown.” Delving deeply into the difficult emotions that clients bring to the session does not cause depression or encourage the client to “wallow” in pain and self-pity. The contrary often seems to occur, as many of our clients will tell us that they feel lighter and more connected with themselves and others after they have been able to identify and share their feelings with someone who supported them in this way. As a counselor, it is important to be aware of these common misconceptions and how they may influence your clients. Many people are very fearful of pursuing counseling mainly because of these misunderstandings about the purpose and process of counseling. However, if they were to understand what the counseling process is really about, they might view the process differently.

THE THERAPEUTIC RELATIONSHIP Developing a range of skills and techniques is very important and useful in working with clients. However, no intervention is more important than first establishing the relationship on which the therapeutic encounter is founded (Horvath, Del Re, Fluckiger, & Symonds, 2011; Kottler & Carlson, 2014; Norcross, 2010). The relationship between a counselor and a client is both like and unlike any other kind of relationship. What makes this relationship unique? The following list gives an overview of what is unique about what we call the therapeutic alliance with a client: ■■

The relationship exists to meet the needs of the client; the client’s needs and agenda are the primary focus.

■■

Although the counselor possesses training and experience that are unique to the process, there is recognition that the clients are the true experts, because only the clients have had direct experience with their lives and they are really the only ones who know what is best for them.

■■

The relationship is a real relationship; counselors will have real feelings about the process and the client, and the client’s feelings and stories will most likely have an impact on the counselor. Because the relationship is a real relationship, issues of personality and goodness of fit may have an effect on the success of the therapy. It is important for counselors to recognize that they may not work well with everyone, and for clients to realize that finding a counselor who is a “good fit” is as important as finding a counselor with appropriate training and credentials.

■■

The relationship has specific, described boundaries that are in place to protect both the client and the counselor.



1.  Thoughts About Counseling

9

■■

The relationship exists within a framework of defined ethical practices for counseling.

■■

The relationship is not a friendship, a parental relationship, or a teacher–student relationship, although certain aspects of each of these types of relationships may, at times, be present within the therapeutic alliance.

■■

The relationship is built upon a model of respect and empowerment; the counselor follows the lead of the client and builds upon the inherent strengths that are present in the client.

The basic conditions for counseling were defined in person-centered therapy by Rogers (1995) as accurate empathy, unconditional positive regard, and congruence. Accurate empathy refers to the ability of the counselor to enter the client’s inner world of private personal meanings and feelings “as if ” it was that of the counselor, but without ever losing the “as if ” quality. Entering the world of the client in this way conveys a deep sense of the message, “I am with you completely.” Unconditional positive regard is the stance of the counselor to the client, indicating an attitude that, despite one’s failings and faults, the counselor relates to the client with deep respect, with value, and without any conditions. It is not that the counselor “sugarcoats” problematic areas in the client’s life and way of being, or that the counselor ignores negative or unskillful tendencies that are apparent, but the counselor chooses to focus on trusting in the innate tendency of human beings to grow and develop when given the right conditions for this to occur. Finally, congruence is a little more complex in its description within the therapeutic alliance. Basically, when counselors are congruent, they are aware of their own thoughts and feelings within the encounter with the client and share these real thoughts and feelings with the client. A related term to congruence is genuineness, in which the counselor is not merely fulfilling a role within the therapeutic relationship, but is actively engaged as a real person in that relationship, and shares thoughts, feelings, and reflections with the client that are based within the counselor’s personal experience with the client and not just drawn from theoretical knowledge and viewed through a diagnostic lens (Geller & Greenberg, 2012; Slife & Wiggins, 2009; Yalom, 2009). In this book, we repeatedly go back to these conditions as the foundation of the counseling relationship, with an understanding that the concept of engaged presence is the prerequisite to the counselor’s being able to offer these necessary conditions to the client.

GRIEF COUNSELING Now that we have discussed what counseling is and what it is not, it would probably be helpful to discuss the specific subset of counseling practice that focuses on grief and bereavement. In her book, Necessary Losses, Viorst (2010) states that loss is something that we cannot avoid and that loss experiences can be both difficult and transformative. Our lives are often shattered and shaped by the experience of various losses over time. The death of a loved one can certainly be one of the most crippling events that we encounter. Because we live in a society where we expect to live a long, healthy life, and there is little

10

I.  Theoretical Underpinnings

exposure to death on a regular basis, most people do not have the opportunity to develop a repertoire of responses to death before being plunged headfirst into a major loss experience. We also do not have many good role models for how to walk the path of grief in a way that allows for much variation, other than the typical social messages that offer empty platitudes and reward bereaved individuals for being busy and distracted, and for “getting over it” as soon as possible. A counselor who understands the basic tenets of good counseling practice and who also has expertise in the grieving process can provide a highly specialized form of support to an individual who is struggling with a significant loss (Larson, 2014; Worden, 2018).

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

Marriage/Couple Counseling When two individuals who share an intimate relationship experience a significant loss, there are often challenges to the couple in the form of disparities in grieving style. The most common scenario for couple counseling is after the death of a child (Finkbeiner, 2012; Rosenblatt, 2000). The death of a child is one of the most difficult losses that can be experienced; it is expected that we will inevitably bury our parents, and there is a 50–50 chance that we will have to bury a spouse, partner, or significant other. However, it is not the natural order for parents to have to bury a child. It is not unusual, even in healthy marriages, for conflicts to occur. Partners who are already in a great deal of pain after the loss of a child often do not have the energy to resolve conflicts with the other partner. There is also the compounding issue of differences in grieving style that often surfaces during this painful time (Doka & Martin, 2010). As a result, it is common to hear partners grieve the loss not only of their child but also of each other due to the deep, paralyzing grief that each experiences, and the disparities in how that grief is manifest. In this scenario, couple counseling can provide the grieving couple with an understanding of their grief and the tools to explore where they are stuck in their grief. As a result, they may be able to learn new behaviors and skills to break out of the destructive cycle of blame and isolation that can cause a great deal of damage to the relationship between them (Practice Example 1.2).



1.  Thoughts About Counseling

11

P R A C T I C E EXAM PLE 1 . 2 RECOGNIZING DIFFERENT GRIEVING STYLES

Bill and Alice’s 19-year-old son died 5 months ago in a car crash in which his friend was driving and went through a red light and was hit by a truck coming through the intersection. Since the accident, Bill has been consumed by feeling anger at his son’s friend, who came away from the accident with scratches, while his son died. He finds that staying busy with his work and projects is a welcome distraction from his pain. Alice has been despondent and withdrawn. She often sleeps in her son’s room, wrapped in his sheets and clothing that still have his scent on them. Bill feels that Alice is wallowing in her grief, and he gets frustrated when he tries to get her to do things with him and she refuses. Alice is afraid of Bill’s anger. She feels that he doesn’t understand her feelings, and she also gets angry that he doesn’t seem to be grieving at all. At the recommendation of their family doctor, Bill and Alice seek assistance from a grief counselor, who explains their differences in grieving style, and who offers a safe place for them to begin to talk about their son with each other. In the counseling sessions, they realize that they are each grieving uniquely, and they no longer take each others’ reactions to the death of their son personally.

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

GOALS OF COUNSELING The purpose of grief counseling is to help individuals work through the feelings, thoughts, and memories associated with the loss of a loved one in a way that is congruent with the bereaved individual’s personality, preferences, values, and goals. Understanding the goals of grief counseling can help clinicians to work more effectively with clients. Although most people associate grief counselors with assisting individuals who are grieving the loss of a loved

12

I.  Theoretical Underpinnings

one, the scope of grief counseling encompasses supporting individuals through all kinds of change, transitions, and losses. As you look through these goals, think of how they may also apply to losses that may not be related to death, such as the ending of a relationship, the loss of employment, or the loss of functionality or health. Some of the goals of grief counseling are as follows: ■■

Providing the bereaved a safe place to share their experiences and feelings

■■

Helping the bereaved to live without the person who died and to make decisions alone

■■

Helping the bereaved to honor the continuing bond with the deceased person while moving forward into life again at some point in the future

■■

Providing support and time to focus on grieving in a safe environment

■■

Recognizing the importance of important times, such as birthdays and anniversaries, and supporting the client through these dates and special times

■■

Providing education about normal grieving and the normal variations in grieving among individuals

■■

Assisting clients to integrate the loss into their assumptive world or to rebuild that world after a significant loss

■■

Helping the bereaved to understand their methods of coping

■■

Engaging clients to recognize their innate strengths in coping and adapting to significant loss experiences

■■

Identifying difficulties in coping that the bereaved may have and making recommendations for further professionals and resources in the community as needed

■■

Empowering the client in approaching life and others after experiencing a life-changing loss.

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

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



1.  Thoughts About Counseling

13

GLOSSARY Accurate empathy  The ability of the counselor to enter the client’s inner world of private personal meanings and feelings “as if ” it was that of the counselor, but without ever losing the “as if ” quality. Congruence  When counselors are congruent, they are aware of their own thoughts and feelings within the encounter with the client and share these real thoughts and feelings with the client. Core conditions of counseling  Established by Rogers in person-centered counseling; these are the three conditions that must be in place for the therapeutic alliance to occur: accurate empathy, congruence, and unconditional positive regard. Counseling  Professional support that has defined boundaries with the intent of assisting individuals to effectively work through everyday life issues that cause difficulty or distress. Therapeutic alliance  The unique relationship with a client that is focused solely on the client’s needs, whereby the client feels safe, supported, and understood by the counselor. Therapy  In-depth professional work with clients, aimed at long-standing struggles and unresolved deeper issues that may require long-term supportive work. In therapy, clients usually work on restructuring core aspects of themselves. Unconditional positive regard  The stance of the counselor to the client, indicating an attitude that, despite one’s failings and faults, the counselor relates to the client with deep respect, with value, and without any conditions.

QUESTIONS FOR REFLECTION 1. Brainstorm about some of the media personalities and popular depictions of coun-

selors that come to your mind. How are the counselors portrayed in these depictions? How do you think these portrayals influence the profession of counseling and the view of the general public about counselors and those who seek counseling? Based on the information in this chapter, how is the actual counseling process different from these portrayals?

2. In this chapter we discuss how counseling is different from receiving support from

friends or family members. What do you think are the specific differences between support from a counselor and other types of support?

3. After reading this chapter, has your thinking about what counseling offers changed

from what it was previously? If so, in what ways?

4. If you were to provide grief counseling to bereaved individuals, what do you think

would be your biggest challenge personally?

REFERENCES Doka, K. J., & Martin, T. (2010). Mourning beyond gender: Understanding the way men and women grieve. Philadelphia, PA: Brunner-Mazel. Feltham, C. (2010). Critical thinking in counselling and psychotherapy. London, UK: Sage. Finkbeiner, A. K. (2012). After the death of a child: Living with the loss through the years. New York, NY: Simon and Schuster. Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach to effective therapy. Washington, DC: American Psychological Association.

14

I.  Theoretical Underpinnings

Harris, D. L. (2009–2010). Oppression of the bereaved: A critical analysis of grief in Western society. Omega, 60(3), 241–253. doi:10.2190/om.60.3.c Harris, D. L. (2016). Social expectations of the bereaved. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 165–176). New York, NY: Routledge. Harris, D., & Rabenstein, S. (2014). Working with families who have experienced traumatic loss. In D. Kissane & F. Parnes (Eds.), Bereavement care for families (pp. 137–153). New York, NY: Routledge. Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. In J. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 25–69). New York, NY: Oxford University Press. Kottler, J. A., & Carlson, J. (2014). On being a master therapist: Practicing what you preach. Hoboken, NJ: Wiley. Larson, D. (2014). Getting grief working: A guide for the new grief therapist. New Therapist, 90, 25–29. Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 113–141). Washington, DC: American Psychological Association. O’Leary, J., Warland, J., & Parker, L. (2011). Bereaved parents’ perception of the grandparents’ reactions to perinatal loss and the pregnancy that follows. Journal of Family Nursing, 17(3), 330–356. doi:10.1177/1074840711414908 Rogers, C. (1995). Counseling and psychotherapy. Boston, MA: Houghton Mifflin. Rosenblatt, P. C. (2000). Help your marriage survive the death of a child. Philadelphia, PA: Temple. Safran, J. (2009). Interview with Lewis Aron. Journal of Psychoanalytic Psychology, 26(2), 99–116. doi:10.1037/a0015679 Slife, B. D., & Wiggins, B. J. (2009). Taking relationship seriously in psychotherapy: Radical relationality. Journal of Contemporary Psychotherapy, 39(1), 17–24. https://doi.org/10.1007/s10879-008-9100-6 Viorst, J. (2010). Necessary losses: The loves, illusions, dependencies, and impossible expectations that all of us have to give up in order to grow. New York, NY: Simon and Schuster. Worden, J. W. (2018). Grief counseling and grief therapy (5th ed.). New York, NY: Springer Publishing Company. Yalom, I. (2009). The gift of therapy. New York, NY: HarperCollins.

CHAPTER 

2

UNI Q UE AS P E C T S O F GRI EF  C OUN S E LI N G

LEARNING OBJECTIVES 1. Identify the unique features of grief counseling. 2. Differentiate between grief counseling and other forms of counseling. 3. Describe the primary goal of grief counseling. 4. Define the concept of the assumptive world, and identify the three main assumptions that comprise one’s assumptive world.

INTRODUCTION Loss, change, and death are all universal human experiences, and each one of us will become intimately acquainted with the grieving process at many points throughout our lives. Most individuals who are trained in psychology and other counseling-related professions typically have an understanding of the process of therapy after significant life events occur. However, we venture further in this chapter to explore what makes grief counseling a unique form of therapeutic support, and how the practice of grief counseling may differ from counseling for other types of issues. One of the most important aspects of grief that differentiates it from other issues that clients bring into the counseling relationship is that the grieving process itself is an adaptive response and not a form of pathology. Grief is the normal, natural response to loss. Grief is not something that we strive to “overcome” or to which there is “recovery,” as one might

16

I.  Theoretical Underpinnings

recover from an addiction or an illness. Counselors who work with bereaved individuals understand that although the grieving process may involve a tremendous amount of pain and adjustment, the goal of grief counseling is to facilitate the unfolding of the healthy and adaptive aspects of the process as it is manifest within each client, trusting that this unfolding will eventually help the bereaved individual to reenter life in a way that is meaningful.

GRIEF AND THE ASSUMPTIVE WORLD At a basic level, our expectations about how the world works begin to be formed from birth, through the development of the attachment relationships of the infant and young child. Bowlby (1969, 1973) posited that early-life attachment experiences lead individuals to form “working models” of the self and of the world. We essentially learn whether the world is a safe or a threatening place from these working models. Bowlby’s theory of attachment also suggested that significant losses can threaten these working models, resulting in a need to rebuild or restructure one’s working models to fit the post-loss world. Building upon Bowlby’s work, Parkes (1975) extended the concept of the “internal working model” to that of the “assumptive world,” which he stated was “. . . a strongly held set of assumptions about the world and the self, which is confidently maintained and used as a means of recognizing, planning, and acting” (p. 132) and that it is “. . . the only world we know, and it includes everything we know or think we know. It includes our interpretation of the past and our expectations of the future, our plans and our prejudices” (Parkes, 1971, p. 103). Parkes (1971) stated that the assumptions that individuals form about how the world works are based on their previous life experiences and attachments. He also emphasized that experiencing a significant loss can threaten one’s assumptive world. Recent research that links attachment style to the way an individual navigates the grieving process after a significant loss would also support the role of early experiences with attachment figures as a template for how experiences are interpreted and integrated in later life (Burke & Neimeyer, 2013; Mancini & Bonanno, 2012; Mikulincer & Shaver, 2013). In her extensive work that explored the construct of the assumptive world in the context of traumatic experiences, Janoff-Bulman (1992) stated that expectations about how the world should work are established earlier than language in children and that assumptions about the world are a result of the generalization and application of childhood experiences into adulthood. Forming a belief that the world is safe is related to the sense of “basic trust” described by Erikson’s (1968) model of human development. Our assumptive world provides us with a sense of predictability and coherence in our daily lives. Although attachment theory was originally founded in the psychoanalytic tradition of psychology and the discussion here draws heavily upon attachment as a means of understanding how assumptions are developed, the broader context of the assumptive world goes far beyond the realm of psychological theory or cognition. Janoff-Bulman (1992) identifies three major categories of assumptions, which have been broadened and extrapolated for our reference here: 1. Assumptions about how we expect other people and the world to work. For exam-

ple, many people probably assume that overall there is more good than bad in the



2.  Unique Aspects of Grief Counseling

17

world and that people are generally trustworthy. It is important to keep in mind that this category/assumption will vary from person to person. The main point is that whatever an individual believes about how the world works, that belief is foundational to many choices, decisions, and expectations about the world and other people that are taken for granted in everyday life. 2. How people attach meaning to the world and to their lives. An example of this

assumption might be that many people assume that the world is meaningful and that good and bad events are distributed in the world in a relatively fair and controllable manner. The category of meaningfulness emphasizes the ideas of justice and control over certain aspects of life. Most individuals tend to believe that misfortune is not haphazard and arbitrary; that there is a person-outcome contingency attached to negative life events. At a basic level, especially in Western-oriented cultures, negative events are often viewed as punishment and positive events are rewards. Janoff-Bulman (1992) states that this assumption is “that we can directly control what happens to us through our own behavior. If we engage in appropriate behaviors, we will be protected from negative events and if we engage in appropriate behaviors, good things will happen to us” (p. 10).

3. How individuals view themselves, including their worth and how they fit into

their social network and cultural context. Most Western-oriented societies place a great deal of value on the individual’s intrinsic worth and value and on ­individual accomplishments. Other societies may view the worth of an individual in relation to that person’s place within a family system or a larger social context (Practice Example 2.1).

P R A C T I C E EXAM PLE 2 . 1 THE SHATTERED ASSUMPTIVE WORLD

Kaley always dreamed of being a mother. After she married Don, they decided they wanted to start a family right away. However, after 2 years of trying, Kaley had not become pregnant. They then proceeded to undergo medical treatments to try to conceive. The treatments were expensive, painful, and encompassed all of Kaley’s time and energy. Kaley began to feel resentful of her friends who were starting families without any trouble. She began to withdraw from her friends because it was painful to hear them talk about their new babies. One day, when Kaley was driving back from the medical center after another treatment, she saw a teenage girl with a baby in a stroller on a street corner. The girl was disheveled, smoking a cigarette, and paying no attention to the baby. Kaley yelled out loud in her car, “What kind of God allows this to happen?" She felt the weight of the unfairness of her situation, where a child would be welcomed and loved versus the scenario she had just seen on the street. At that moment, she felt that something deep inside her had broken.

18

I.  Theoretical Underpinnings

Janoff-Bulman (1992) stated that these three categories of beliefs can be called world assumptions, and together they make up an individual’s assumptive world. Why are we discussing the development of our assumptive world? Because significant losses assault the assumptions that we have formed about the world from when we were very young. We learn that people can harm, even murder, those we love. We learn that our view of the world as a safe and predictable place, where good things come to those who work hard and where all human beings have value and worth, may not be what we actually encounter in our experiences later in life. Somehow, we then have to reconcile the world that we now know to exist with the world that we believed to exist, and the grieving process helps us to rebuild our assumptive world so that we can feel safe and functional again in this new experience of the world that differs greatly from our previously held beliefs about how that world should work. At this point, a caveat about how our assumptive world works might be in order. Not everyone experiences a world that is basically safe or people as generally well meaning. In fact, for some individuals, their assumptive world may be built around surviving in a world that is chaotic or surrounded by unpredictability. What is important to consider here is that whatever a person’s assumptions about the world might be, it is these assumptions (and the associated thoughts, feelings, and behaviors that extend from these assumptions) that serve to provide congruence and meaning to us, even when the “outside” world is anything but safe, secure, and predictable. For example, children in the foster care system are often taken from their parents due to concerns over their safety within that home. They are then placed in a home with foster parents to care for them. The children may have been acutely aware of the problems at home, but their parents are still attachment figures to them. In their awareness, a professional (usually a stranger) takes them away from their parents and the home they know. They are then placed with strangers, and they may even be separated from their siblings at this time. Many children in foster care are moved from one home to the next due to circumstances that are out of their control (Mitchell, 2016). They learn not to get too close to their foster families because of the pain experienced when they are transferred out of one home to another. They learn that they have no control over the events that happen to them. Some experience poor treatment in their foster homes as well. As a result of these experiences, these children’s assumptions about the world begin to change. Not all people are basically good or mean well. The ideas of justice and cause/effect have to change to accommodate unpredictability and randomness. Finally, their views of self and how loveable and valued they are will also be profoundly affected, as they are bounced from one situation to another with their personal feelings about what has happened not being included in the decision-making. After a few years in foster care, they may be unable to receive unconditional love if it was offered because they have learned to protect and guard themselves so deeply. In this scenario, the assumptive world has become built around experiences that support beliefs that (a) people are untrustworthy and can cause harm; (b) things do not happen for a reason— instead of expecting justice, there is an expectation of randomness and helplessness in situations of vulnerability; and (c) the view of self congeals around feelings that people around them do not want them or they are tainted by the events they have endured. There may also be a sense of being objectified as they are carted from one



2.  Unique Aspects of Grief Counseling

19

family to another. In situations like this, exposing the child to unconditional love or to a family that cares is not going to be received openly; rather, the temptation to draw close will likely be tempered with an assumptive world that is built around lack of safety, inconsistency, and negative views of self. Ironically, grief may surface when these children are exposed to love and true caring. However the assumptive world is revised and rebuilt after a significant loss occurs, the revised assumptive world allows us to exist with a sense of safety in navigating through life. Rather than being a symptom of a disorder, the grief that accompanies the shattered assumptive world is a multifaceted adaptive response to the disorder and disorganization that can occur after our lives (and our assumptions about the world) have been upturned by a significant loss. Instead of attempting to inhibit grief, we recognize that grief needs to be allowed to unfold without hindrance so that the loss experience can be assimilated into one’s existing assumptive world or the assumptive world can be rebuilt in a way that makes sense of the loss that has occurred.

COMING TO TERMS WITH CHANGE AND LOSS There are many misconceptions about what is involved in grief counseling and the way that therapeutic support works with bereaved individuals. It is not uncommon for a grief counselor to receive calls from individuals who think that family members need grief counseling because they are not “over” the grief or progressing through the grief as they should. The common misunderstanding is that grief counseling will “fix” people or return them to the prior level of functioning. Some of these kinds of expectations that are placed upon bereaved individuals are rooted in social norms that reward productivity, stoicism, and materialism (the role of social pressures on bereaved individuals is discussed in a later chapter). It is impossible to reverse time and to control events that are out of our control. We cannot “fix” what has happened (e.g., we cannot bring back the deceased person to relieve the separation distress of the bereaved individual). We also do not focus on helping bereaved individuals to feel better necessarily, because we understand that the process of rebuilding one’s world after a significant loss is naturally going to involve a painful time when the many layers associated with loss must be addressed, and the process of readjustment that occurs can be very difficult. We crave predictability and stability in our lives. In fact, most of us operate on the assumption that we have a lot of control over the events in our lives (Heckhausen, Wrosch, & Schulz, 2010). As stated earlier, one of the basic assumptions espoused by Janoff-Bulman (1992) indicates that most people in Western societies believe that if you work hard, you will be rewarded. In our clinical work, we frequently see individuals who experience profound anxiety because they can no longer live under the illusion that things can remain constant and unchanging; this realization usually occurs as a result of the experience of a significant loss or dramatic change in their lives. Even though we attempt to function as if there is certainty and stability in everyday life, the world around us, including our bodies, serve as metaphors for the normalcy of loss, change, and transition. The seasons change. Living things are born, grow, reproduce, and die. Many of the cells that exist in our bodies today were not present a year ago and may not be present in our bodies in a month from now. This moment is gone

20

I.  Theoretical Underpinnings

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

UNDERSTANDING BEREAVEMENT THEORY IN COUNSELING PRACTICE It is very important for counselors who wish to effectively support bereaved individuals to have a working knowledge of current theories of bereavement. The literature in thanatology is relatively new in comparison to other fields of study, and most of the current thinking in grief counseling is grounded in ways of thinking about grief, loss, adjustment, and coping that have been reported and published within the last 20 years. We will spend an entire chapter exploring some of the current research in bereavement, current bereavement theories, and ways of working therapeutically with bereaved individuals, but at this point it is important to recognize that there is a separate and unique body of literature in this area that has direct application to grief counseling. One important aspect of the study of bereavement that we must keep in mind is that grief is not just a psychological issue that is experienced by the grieving individual in isolation. Grief can be experienced and expressed in many ways, which include thoughts, feelings, and emotions; however, it can also be experienced physically through bodily symptoms, socially through changes in interpersonal dynamics and social expectations for the bereaved individual, spiritually as a quest for meaning or as existential suffering, economically through changes in financial status and expenses incurred after a loss, and practically through the changes that occur in one’s day-to-day routine as a result of a loss. Thus, we look at literature in many fields of study for an understanding of the grief process in all of its many facets and complexities. Another unique aspect of grief counseling is an understanding of the complexity of the experience and the factors that shape an individual’s response to loss. For example, when there is a loss within a family system, each individual family member will experience grief depending on his or her relationship to the deceased person and other family members, the age and developmental stage of the family members, who provided the caregiving if needed, and the grieving styles of the members (Kissane, 2014). Individuals tend to grieve



2.  Unique Aspects of Grief Counseling

21

in ways that are congruent with their age and developmental stage, according to their personalities and attachment styles (Doka & Martin, 2010; Lai et al., 2014; Stroebe, 2002), in the context of social rules and expectations (Doka, 2002; Harris, 2016), and with the influence of other factors and concurrent stressors at that time (Worden, 2018). Thus, grief counselors need to have a good understanding of how many different areas intersect in this one experience. For example, to explore only the feelings associated with a loss without understanding the social underpinnings and the impact of the concurrent stressors that shape these feelings would provide an inaccurate and overly simplistic account of the client’s full experience. Understanding current bereavement theory and research allows the counselor to appreciate the normative aspects of grief that may inadvertently be labeled as pathological or abnormal to someone who does not have this awareness. For example, the dominant view of grief until recently was the “grief work” hypothesis (Stroebe, 2002), which stated that individuals must do the “work” of grief by talking about their loss and their feelings, and if a bereaved person did not do this, it was assumed that something was wrong with that individual or they were not grieving properly. The grief work model also posited that the goal of grief was to help the bereaved individual to “let go” of their loved one in order to move forward in life. However, in the mid-1990s, research with diverse groups of bereaved individuals demonstrated that although many individuals did, indeed, talk about their loss and their feelings as part of the grief response, many others did not have this same need, and these individuals seemed to cope just as well afterward. In addition, the Continuing Bonds Theory, derived from research by Klass, Silverman, and Nickman (1996), demonstrated the normalcy of bereaved individuals continuing a relationship with the deceased. These researchers found that the ability to find a way to remain connected to the deceased individual often helped bereaved individuals to move forward in their lives after a loss (Practice Example 2.2).

P R A C T I C E EXAM PLE 2 . 2 CHALLENGING THE “GRIEF WORK” HYPOTHESIS

Derek’s wife, Shelby, died 3 months ago. At his daughter’s insistence, Derek began attending grief counseling sessions. His daughter was concerned that he never talked about her mother. She felt he needed prodding to talk about his grief. When he met with the counselor, Derek mentioned that he knew his daughter was worried about him because he didn’t talk openly about Shelby’s death and his grief but stated that he had “never been much of a talker.” The counselor reinforced that not everyone needs to talk about their grief with others, adding that his not talking about his feelings didn’t mean that something was wrong. The rest of the session focused mostly on how his daughter was coping with the loss of her mother. Derek thanked the counselor for her time and said he didn’t think he needed another appointment.

22

I.  Theoretical Underpinnings

WHO BENEFITS FROM GRIEF COUNSELING? Most grief counselors assume that their work with bereaved individuals is effective. However, recent research into the efficacy of grief counseling provides more detailed information about who would benefit from, and who might actually be harmed by, grief counseling. Studies by Kato and Mann (1999) and Allumbaugh and Hoyt (1999) implied that professional bereavement support did not provide significant benefit to the bereaved participants. It is probably important to take a step back and to ponder the basic premise of many interventions for bereaved individuals. As we have stated earlier in this chapter that grief is a normal and adaptive process, we need to consider why professional intervention may be needed by bereaved individuals to assist an adaptive process that is at work. Indeed, Stroebe, Hansson, Stroebe, and Schut (2001) observed that the general tendency for many bereaved individuals is to improve with or without professional intervention. In addition, Kato and Mann’s (1999) study revealed that many of the bereaved participants would have had a better outcome if they had been assigned to the control (nontreatment) group than to the treatment group. In another study, Jordan (2000) reported that for some bereaved individuals, professional intervention may actually do more harm than good. Neimeyer (2012) provided reflection on grief counseling research, stating that many studies did not capture the 10% to 15% of bereaved individuals who not only would benefit from grief counseling but also should receive intervention to prevent significant negative consequences that may occur as a result of their losses. In a review of research into the efficacy of grief counseling, Schut (2010) similarly concluded that although it is not effective to recruit bereaved individuals into grief counseling if they are not seeking support, professional support may be beneficial for those who do request it and for those who endure a crippling form of complicated grief. In response to these findings, researchers in the area of bereavement have made some comments and suggested a few guidelines that would be applicable to clinical practice in grief counseling. It is generally agreed that most bereaved individuals are able to adapt to the loss that has occurred with the support of their families and friends and do not require professional intervention. Making the assumption that all bereaved individuals need professional assistance would be inconsistent with the awareness of grief as an adaptive process. It may be the case that although the grieving process is normative and adaptive, if one’s grief does not fit into a socially acceptable or recognized pattern, the bereaved individual may be perceived as abnormal and referred for treatment; when in fact, the social norms that judge the expression of grief in such limited terms may be the issue, and not some dysfunction within the individual. Wolfelt (2005) suggests a model of “companioning” with the bereaved, emphasizing the relational component of therapeutic support, which may be especially helpful if a bereaved individual does not have other supports available to “walk alongside” him or her during the acute grieving process. In their review of bereavement efficacy studies, Jordan and Neimeyer (2003) state: [G]eneric interventions, targeted toward the general population of the bereaved, are likely to be unnecessary and largely unproductive. Instead, interventions that are tailored to the problems of mourners in high-risk categories (e.g., bereaved mothers, suicide survivors, etc.), or showing unremitting or increasing levels of distress after a reasonable period of time are likely to be more beneficial. (pp. 778–779)



2.  Unique Aspects of Grief Counseling

23

Parkes (2002), Schut and Stroebe (2011), and Neimeyer (2012) identified specific at-risk populations that may benefit most from grief counseling. These groups include older men who lose spouses, mothers who lose children, and survivors of sudden or violent losses with traumatic features. Other high-risk individuals may be those with pre-existing psychological disturbances, such as depression, substance abuse, posttraumatic stress disorder, and previous history of psychosis. In addition, individuals with high levels of distress early in their bereavement experience are more likely to benefit from professional intervention. Hoyt and Larson (2010) suggest that some of the research about the efficacy of grief counseling (and the lack of positive effects that have been found in many of the studies with bereaved individuals) may be a result of how participants are recruited versus how clients actually seek counseling for assistance when they feel that they need additional help. These researchers state that there is a big difference between individuals who respond to calls for participation in studies and bereaved individuals who contact a counselor for assistance with a grief-related issue.

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

GLOSSARY Assumptive world  Fundamental beliefs that an individual holds regarding how the world works and how others and one’s self are viewed. The assumptive world is thought to provide individuals with a sense of safety and security in everyday life situations. Attachment  The formation of significant and stable connections with significant people in an individual’s life. This process begins in early infancy as the child bonds with one or more primary caregivers, and later extends to other significant relationships throughout the lifespan. Attachment is thought to be an instinctual construct with the purpose of ensuring safety and survival. Fundamental illusion  The belief that things will always remain the same; maintaining this illusion serves the purpose of allowing people to feel safe and solid in the world. “Grief work” hypothesis  View of grief that individuals must do the “work” of grief by talking about their loss and their feelings, and if a bereaved person did not do this, it was assumed that something was wrong with that individual. Also indicates that that the goal of grief is to help the bereaved individual to “let go” of their loved one in order to move forward in life.

24

I.  Theoretical Underpinnings

QUESTIONS FOR REFLECTION 1. If grief is an adaptive and healthy process, why do you think we have such a great

deal of difficulty acknowledging grief both personally and socially?

2. Think about the section on the assumptive world. What are some of the assump-

tions that you can identify personally that guide you in your life? What are some of the ways that your assumptions have been challenged by experiences that you have had in your life?

3. If, as the chapter states, change and transition are truly constant companions in

life, why do most people have difficulty adjusting to change and loss in their lives?

4. You are a grief counselor and you receive a call from a woman who wants her

father to come to see you for counseling after the death of his wife (her mother). She reports that she is concerned that her father does not seem to be grieving at all, and she thinks that he needs to talk with someone. How would you respond to her request?

5. Perform a search on the Internet with one of the well-known search engines using

the key words of “grief counseling,” “grief recovery,” and “helping bereaved individuals.” Read over some of the material that is presented in these links. How many of them still extol the grief work theory of bereavement? What audience do you think each site is trying to target? Based on your reading of this chapter, do you think there is any potentially harmful content on the sites for bereaved individuals?

REFERENCES Allumbaugh, D. L., & Hoyt, W. T. (1999). Effectiveness of grief therapy: A meta-analysis. Journal of Counseling Psychology, 46(3), 370–380. doi:10.1037//0022-0167.46.3.370 Bowlby, J. (1969). Attachment and loss: Attachment (Vol. 1). London, UK: Hogarth. Bowlby, J. (1973). Attachment and loss: Separation (Vol. 2). New York, NY: Basic Books. Burke, L. A., & Neimeyer, R. A., (2013). Prospective risk factors for complicated grief: A review of the empirical literature. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 145–161). New York, NY: Routledge. Doka, K. J. (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press. Doka, K. J., & Martin, T. L. (2010). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Routledge. Erikson, E. (1968). Identity: Youth and crisis. New York, NY: Norton. Harris, D. L. (2016). Social expectations of the bereaved. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 165–176). New York, NY: Routledge. Heckhausen, J., Wrosch, C., & Schulz, R. (2010). A motivational theory of life-span development. Psychological Review, 117(1), 32–60. doi:10.1037/a0017668 Hoyt, W. T., & Larson, D. G. (2010). What have we learned from research on grief counselling? A response to Schut and Neimeyer. Bereavement Care, 29(1), 10–13. doi:10.1080/02682620903560841 Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY: Free Press. Jordan, J. R. (2000). Research that matters: Bridging the gap between research and practice in thanatology. Death Studies, 24(6), 457–467. doi:10.1080/07481180050121444



2.  Unique Aspects of Grief Counseling

25

Jordan, J. R., & Neimeyer, R. A. (2003). Does grief counseling work? Death Studies, 27(9), 765–786. doi:10.1080/713842360 Kato, P. M., & Mann, T. (1999). A synthesis of psychological interventions for the bereaved. Clinical Psychology Review, 19, 275–296. doi:10.1016/s0272-7358(98)00064-6 Kissane, D. (2014). Family grief. In D. Kissane & F. Parnes (Eds.), Bereavement care for families (pp. 3–16). New York, NY: Routledge. Klass, D., Silverman, P. R., & Nickman, S. L. (1996). Continuing bonds: New understandings of grief. New York, NY: Routledge. Lai, C. Luciani, M., Galli, F., Morelli, F., Cappelluti, R., Penco, I., . . . Lombardo, L. (2014). Attachment style dimensions can affect prolonged grief risk in caregivers of terminally ill patients with cancer. American Journal of Hospice and Palliative Medicine, 32(8), doi:10.1177/1049909114547945 Mancini, A. D., & Bonanno, G. A. (2012). The persistence of attachment: Complicated grief, threat, and reaction times to the deceased’s name. Journal of Affective Disorders, 139(3), 256–263. doi:10.1016/j. jad.2012.01.032 Mikulincer, M., & Shaver, P. R. (2013). Attachment insecurities and disordered patterns of grief. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 190–203). New York, NY: Routledge. Mitchell, M. B. (2016). The family dance: Ambiguous loss, meaning making, and the psychological family in foster care. Journal of Family Theory & Review, 8(3), 360–372. doi:10.1111/jftr.12151 Neimeyer, R. A. (2012). The (half) truth about grief. Illness, Crisis, & Loss, 20(4), 389–395. doi:10.2190/ il.20.4.g Parkes, C. M. (1971). Psycho-social transitions: A field for study. Social Science & Medicine, 5(2), 101–115. doi:10.1016/0037-7856(71)90091-6 Parkes, C. M. (1975). What becomes of redundant world models? A contribution to the study of adaptation to change. British Journal of Medical Psychology, 48, 131–137. doi:10.1111/j.2044-8341.1975.tb02315.x Parkes, C. M. (2002). Lessons from the past, visions for the future. Death Studies 26(5), 367–385. doi:10.1080/07481180290087366 Schut, H. (2010). Grief counseling efficacy: Have we learned enough? Bereavement Care, 29(1), 8–9. doi:10.1080/02682620903560817 Schut, H., & Stroebe, M. (2011). Challenges in evaluating adult bereavement services. Bereavement Care, 30(1), 5–9. doi:10.1080/02682621.2011.555240 Stroebe, M. S. (2002). Paving the way: From early attachment theory to contemporary bereavement research. Mortality, 7(2), 127–138. doi:10.1080/13576270220136267 Stroebe, M., Hansson, R. O., Stroebe, W., & Schut, H. (2001). Future directions for bereavement research. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 741–766). Washington, DC: American Psychological Association. Weenolsen, P. (1988). Transcendence of loss over the life span. New York, NY: Hemisphere. Wolfelt, A. (2005). Companioning the bereaved: A soulful guide for counselors and caregivers. San Jose, CA: Companion Press. Worden, W. R. (2018). Grief counseling and grief therapy (5th ed.). New York, NY: Springer Publishing Company.

CHAPTER 

3

T HEORIE S AN D OR IE N TAT I O N T O  BER E AV E ME N T

LEARNING OBJECTIVES 1. Define grief and describe common factors that affect the grief response. 2. Describe the main features of attachment theory and the relationship between attachment and grief. 3. Explain the Dual Process Model of grief and the overlap of attachment style onto this model. 4. Review current theories and models of the grieving process. 5. Discuss the process of meaning making after significant losses.

INTRODUCTION In this chapter, we briefly look at models and theories of bereavement that help us to understand the grieving process a little better. Models and theories serve as descriptors for us and for our clients. They help us to “map out” what may occur after a significant loss in someone’s life. They may also give us a framework for knowledge and insight into the various ways in which people experience grief and adapt to loss, or how bereavement professionals have observed grief responses in their clients. Research-based theories and models may ground our clinical practice in empirical knowledge, and descriptive models may give us practical insights from the anecdotal accounts of other clinicians who do similar work. It is important

28

I.  Theoretical Underpinnings

to keep in mind that no one theory or model can fully encompass all of the manifestations, expressions, and experiences of grief and loss. However, becoming well versed in these descriptions may be of benefit to both the counselor and the client. Before we embark on our exploration of various theories and models of bereavement, it is important to keep some thoughts in mind. First, although loss and grief are universal experiences, shared by all human beings, the grieving process is highly diverse and variable among individuals. Second, grief is not just an emotional response. Many individuals experience grief in ways that are dominated not by their emotions but by cognitive processes, somatic (bodily) changes, spiritual challenges, and/or changes in their social circles and patterns. In addition, a person who is grieving a loss exists within a broader social and cultural context, and we do a great disservice to individuals by assuming that they exist as separate entities from these spheres of existence. Finally, we tend to think in terms of adapting to losses and integrating these experiences into our assumptive world rather than focusing on “recovery” from grief or “overcoming” a loss, which tend to oversimplify the way loss and grief shape and change us in often very significant ways.

DEFINITIONS AND ANALOGIES For the purposes of this book and our study of bereavement, loss can be defined as an experience where there is a change in circumstance, perception, or experience where it would be impossible to return to the way things were before. A loss can be death related or nondeath related, with the key element being the inability to return to some aspect of life we have cherished or valued that is no longer possible. An image that helps to describe a loss experience is that of a shattered pane of glass. While it might be possible to use glue to put the broken pieces of glass back into place, the glass that once existed as a whole, single pane will never exist in that form again. And so it is with a significant loss experience. There are times when you will not be able to undo what has happened, unknow what you now know, unsee what you have seen, and you will no longer be naïve to an experience that you have now endured. Grief is defined simply as the normal and natural response to loss. However, the use of the word “normal” implies that there is a defined expectation of what normal grief should look like, and that is far from true. Although grief is a universal experience that is shared by all human beings, the actual grief response in each individual is very unique, and the expression of grief can vary greatly from one person to another. Many factors, such as personality traits, the presence of concurrent stressors and previous losses, the nature of the loss(es), and the social expectations that are present, have a great deal of influence in shaping the course of grief for an individual, and these are discussed in later chapters. Sometimes, analogies are helpful to share with bereaved clients to help point out the highly individual and unique nature of grief, especially when these individuals are told by others that somehow their grief response is abnormal. ■■

The grief response can be compared to snowflakes, where we can look at the flakes and identify them as “snow,” but when you look closer, the crystalline structure of each individual flake is highly unique and there are an infinite number of patterns that can be found.



3.  Theories and Orientation to Bereavement

29

■■

The grief response is like a fingerprint; all human beings have fingerprints, but each person is identified by a unique fingerprint pattern that is unlike anyone else’s.

■■

A significant loss can be seen like a deep wound that will heal with proper care and attention. After a deep wound heals, there is usually a scar in its place. So, although the “wound” is healed, the skin is never the same as it was before. (Another aspect of this analogy is that scar tissue tends to be thicker and stronger than the skin surrounding it.)

ATTACHMENT AND THE GRIEF RESPONSE As we discussed earlier, a key aspect of bereavement theory is the concept of attachment. In humans, attachment is based on our most deeply rooted needs for safety and security (Bowlby, 1969, 1973). Attachment bonds exist at a level in the human experience that is usually not in a person’s conscious awareness (Parkes & Weiss, 1983). When we speak of attachment in this context, we mean something more than a relational bond. Attachment relationships are linked to our primary, instinctual need to be close to significant others in order to feel safe and to feel a sense of “anchoring” in our world. In infants, the attachment system is formed around the primary caregiver who is present to meet the basic needs of the infant and who responds to the infant’s cries and beginning attempts at social interaction. Later, we form attachments to individuals who tend to be closest to us, or to whom there is significance identified for us. It is important to note that the presence of an attachment bond in a relationship is not necessarily dependent on the quality of the relationship or the personality or temperament of the individuals involved in the attachment bond. Attachment in humans was first described by John Bowlby, a psychoanalytically trained psychiatrist who worked with young children in postwar England. In his position at the Tavistock Clinic, he observed children who had been separated from their parents (their primary attachment figures), and he made note of some commonalities in the responses of these children, which he termed “separation distress.” Bowlby was also influenced by the work of Hinde (1992), who, like Harlow (1961), studied the effects of infant–mother bonding in rhesus monkeys. Bowlby noted that in the works of both researchers, there were comparable behaviors demonstrated by primates that were separated from their mothers and human infants who were separated from their human mothers. He termed these consistent behaviors “attachment behaviors” and suggested that their function was to ensure that the primary caregiver stayed within close proximity to the needy, helpless infant in both species (Cassidy, 1999). Bowlby later postulated that attachment between infants and their mothers is an ethologically based1 construct, which serves to ensure the protection and survival of the infant. Thus, attachment theory was initially born as a merging of the psychoanalytic school of thinking  Ethology is concerned with the adaptive, or survival, value of behavior and its evolutionary history. Ethology emphasizes the genetic and biological roots of development; thus, attachment is seen as an instinctual drive in humans and most mammals (Hinde, 1992). 1

30

I.  Theoretical Underpinnings

and ethology, the study of animal behavior. Attachment was defined as an instinctually mediated response of an infant to its mother, and this response is delineated in the infant’s developing mind through object representation and maintained through the attachment behaviors (Bretherton, 1992). Bowlby’s later work, which is now known as attachment theory, became an eclectic model that incorporated elements of psychoanalysis, ethology, experimental psychology, learning theory, and family systems to describe the psychological and emotional development of the child. Colin Murray Parkes, a psychiatrist based in London, United Kingdom, worked at the Tavistock Clinic with John Bowlby. He postulated that the attachment behaviors observed in infants upon separation from their mothers were the same behaviors that grieving individuals display upon the loss of a loved one through death (Parkes & Weiss, 1983). Parkes (1996) conducted extensive longitudinal research with older widows, documenting their behaviors, thoughts, and feelings after the death of their spouses. He found common behaviors between the separated infants in Bowlby’s research and the widows in his own studies. Examples of these common behaviors were searching, pining, and protest upon the disappearance/loss of the attachment figure. Weiss (1975) explored attachment behaviors in the situation of divorce and obtained similar findings. In addition to comparisons between the separation of infants from their mothers and the separation of adults from attachment figures through death, further studies examined the attachment behaviors of adults in various relationships (Ravitz, Maunder, Hunter, Sthankiya, & Lancee, 2010). The role of attachment in adult relationships has now been explored in longitudinal studies (Fraley, Roisman, Booth-LaForce, Owen, & Holland, 2013). Stable patterns of attachment behavior in children up to the age of 10 were documented by Sroufe, Egeland, and Kreutzer (1990). Clulow (2012) examined the identification of adult attachment styles with specific interactions in married couples, concluding that there are significant correlations between attachment security and marital quality. Simpson and Rholes (2012) explored the role of attachment style to adult intimate relationships. These authors stated that adults demonstrate the same types of attachment style in their current relationships that were originally present when they were much younger. Thus, their premise was that adult coping strategies and behaviors in intimate relationships are governed by attachment style, as determined by childhood attachment experiences. The “take home” messages for this discussion are understanding that: ■■

Grief is part of an instinctually mediated response that is based on our attachment system. Our attachment system typically exists outside of our conscious awareness unless it is threatened.

■■

The loss of an attachment figure will be experienced as a threat to most individuals.

■■

An attachment relationship is one that is significant, but the attachment bond itself is not necessarily dependent on the quality of the relationship. Infants form attachments to mothers who are not attentive; however, the quality of the attachment bond that is formed will most certainly be affected by the interaction between the infant and mother.



3.  Theories and Orientation to Bereavement

■■

31

Attachment relationships are present throughout life and do not only involve parental figures from early life and development. That being said, patterns of attachment style/orientation that are established early in life tend to continue in similar ways in close relationships through adulthood.

An additional perspective is to view grief as a wound to our attachment system; as a result, attachment plays a foundational part in our experience of grief. Perhaps this is why the presence of attuned support is such a pivotal aspect of how we grieve. Bowlby (2005) viewed bereavement as a time when attachment needs are intensified. As a result, the relationship that a client has with the counselor is particularly important. The therapeutic relationship is often seen as the most important element of the counseling process. Kosminsky and Jordan (2016) emphasize the necessity of flexible accommodation to the relational/attachment needs of the client for the client to be able to navigate through the grieving process. Attachment is described as the primary mediator in the capacity to tolerate intense emotions and the distress that often accompany the significant losses in our lives. In addition, the counseling relationship can provide a secure base from which clients can venture into emotionally laden territory that they might otherwise avoid (van Wielink, Wilhelm, & van Geelen-Merks, 2019). This anchoring may foster emotion regulation, distress tolerance, and a place of safety within a time when the client’s world has been shattered by loss.

THE DUAL PROCESS MODEL OF GRIEF Research by Stroebe (2002) and Stroebe, Schut, and Stroebe (2005) combined the work of all of the researchers in the area of attachment to acknowledge (a) the role of attachment in grief and bereavement, (b) the presence of consistency in adult attachment styles related to childhood attachment style, and (c) the specific coping strategies and appropriate expectations and interventions for grieving adults based on identified attachment patterns. These authors proposed the dual process model of bereavement, which allows for an understanding of diverse responses to separation and loss by examining the underlying attachment issues that are present in grieving individuals. The dual process model (Figure 3.1) posits that bereaved individuals will spend time in acute, active grief over the loss and its implications (loss orientation), and they also will spend time tending to their everyday life and returning to the world of the living that distracts them from their grief (restoration orientation). According to Stroebe et al. (2005), individuals identified as basically secure in their attachment style will demonstrate a more balanced approach to emotion regulation in grief and will tend to “oscillate” more evenly between loss orientation (overt grief) and restoration orientation (daily functionality and activities of daily living). Individuals who display avoidant attachment patterns will tend to focus more on restoration orientation and will restrict their expressions of distress and avoid seeking emotional support. Individuals whose attachment style is anxious–ambivalent will tend to focus more on loss orientation, and they are more likely to become preoccupied by their grief and will tend to ruminate more about the deceased individual. Individuals who display patterns of disorganized attachment tend to present in ways that are similar to individuals who have suffered from traumatic experiences

32

I.  Theoretical Underpinnings

Lossoriented

Everyday life experience

Restorationoriented

Grief work

Attending to life changes

Intrusion of grief

Doing new things

Relinquishingcontinuing-relocating bonds/ties

Distraction from grief Denial/avoidance of grief

Denial/avoidance of restoration changes

New roles/ identities/ relationships

Oscillation

FIGURE 3.1  The Dual Process Model of bereavement. Source: From Stroebe, M., Schut, H., & Stroebe, W. (2005). Attachment in coping with bereavement: A theoretical integration. Review of General Psychology, 9(1), 48–66. doi:10.1037/1089-2680.9.1.48

and have difficulty integrating their experiences into a relational context. The conclusion of these authors is that attachment style influences the course, intensity, and pattern of grieving after the death of an attachment figure (Table 3.1). The use of attachment theory with its terminology, background, and associated predictions offers some interesting possibilities. For instance, when the concept of attachment theory as an ethological construct is applied to the grieving process, there is an implication that the grieving process itself is an adaptive mechanism that also functions to ensure the survival of the individual after the loss of a significant attachment figure. Grief, as we know it, may thus be a response that is instinctually programmed into us as a result of natural selection. If this statement is true, then the grieving process itself must be allowed to unfold without hindrance for the assistance in adaptation to significant losses that grief may afford to the bereaved individual. The grieving response would also be seen as separate from the quality of the relationship to the deceased individual, and more of an extension of the attachment pattern of the remaining bereaved survivor, although certainly the quality of the relationship would likely have an impact on the grief process.

TWO-TRACK MODEL AND THE CONTINUING BONDS THEORY In research and clinical work with bereaved parents in Chicago, and later in Israel, Rubin, Malkinson, and Witztum (2012) proposed that the response to loss can be more effectively assessed when both the behavioral–psychological functioning of an individual and the internalized relationship to the deceased are considered. This model addresses grief



3.  Theories and Orientation to Bereavement

33

TABLE 3.1  Attachment Style and the Experience of Grief ATTACHMENT STYLE

EARLY EXPERIENCES

Secure

ADULT EXPERIENCES

GRIEF RESPONSE

Home life felt generally safe; needs were mostly met by parents or significant adults.

Able to create meaningful relationships that are reciprocal in nature; empathetic and able to set healthy boundaries.

Able to navigate through grief with supports and normal coping mechanisms.

Avoidant

Often experienced parent or significant adults as unavailable, dismissive, or rejecting. Learned to be self-sufficient and independent early.

Tends to avoid closeness or emotional connection; often comes across as critical, rigid, resistant, or intolerant. Compulsive self-reliance and somatization common.

Often uses distraction or busyness to cope and avoid emotional pain; may focus on analyzing details and gets stuck asking questions. Usually uncomfortable with feeling vocabulary.

Ambivalent

Parental figures or significant adults inconsistent or intrusive. Availability and attention mixed with periods of rejection or violation of normal boundaries.

Tends to be anxious and insecure; often ruminates about relationships and may become heavily dependent and “needy” of others.

Rumination about loss; loss experience takes over all aspects of life and ability to cope and function. Grief may continue unrelentingly.

Disorganized

History of trauma, abuse, or significant lack of safety in childhood. Parental figures/significant adults often are frightening to child.

Ongoing, chronic vulnerability present, often accompanied by personality, psychiatric, and substance abuse disorders; tend to dissociate or “go blank” when triggered by perceived threats.

Loss often triggers previous trauma and any psychiatric or substance abuse disorders; often “seesaw” between wanting support and needing distance.

through a multidimensional lens, exploring both (a) the bereaved individuals’ ability to function and navigate the world after a significant loss (track I) and (b) the tendency of bereaved individuals to continue in an ongoing and meaningful, but intangible, relationship with a deceased individual over long periods of time, and even indefinitely (track II; Rubin, Malkinson, & Witztum, 2011). Rubin and colleagues strongly urge clinicians working with bereaved individuals to identify which “track” appears to be more problematic or prominent for the bereaved person and to focus on that aspect of the grief in the support that is offered. For example, if a widow describes a great deal of stress as a result of the financial matters that were associated with her husband’s estate, the counselor would serve her more

34

I.  Theoretical Underpinnings

readily by focusing on these issues (track I) rather than engaging in therapeutic work that is focused more on the memories and feelings associated with her deceased husband at that time (track II). When first describing the two-track model of bereavement, Rubin emphasized that the relationship with the deceased person often remains a focal point for the rest of the lifetime of the bereaved individual. In tandem with this model, Klass, Silverman, and Nickman (1996) described what they termed the bereaved’s continuing bond with the deceased individual. It was clear from the data presented in these authors’ research that the bereaved maintains a link with the deceased that leads to the construction of a new relationship with him or her. This relationship continues and changes over time, typically providing the bereaved with comfort and solace. Most mourners struggle with their need to find a place for the deceased in their lives and are often embarrassed to talk about their ongoing relationship with a person who has died, afraid of being perceived as having something wrong with them. The idea of a continuing, ongoing relationship with a deceased individual was a very novel proposition after so much of popular thought (based on Freud’s writings) had been focused on the need to let go of the deceased loved one in order to move forward in life. The work of these researchers actually demonstrated that individuals who were more highly functional and had adapted better after a significant loss were those who were able to maintain a sense of connection (a continuing bond) with their deceased loved ones. Obviously, there will be some complications to this process, as when the relationship with the deceased was difficult or complicated (Field & Wogrin, 2011), or if the bereaved individual displays symptoms of prolonged grief disorder rather than developing an adaptive continuing bond with the deceased individual (Prigerson et al., 2009), which is discussed further in Chapter 10, When Grief Goes Awry. The Continuing Bonds Theory has very important implications for grief counselors. First is that bereaved individuals may be well served to find ways to reconnect to their deceased loved one in ways that are meaningful. In the course of clinical practice, you will hear a myriad of stories about how bereaved individuals “connect” with their deceased loved ones— through having conversations with them, journaling to them, dreaming about them, feeling a sense of guidance from them or a sense of their presence with them in an abiding way, or finding “signs” that they believe are from the deceased individual to them. We have had clients tell us about hearing significant songs on the radio at opportune times, birds appearing on their porch, seeing patterns in carpeting, electronic devices turning on by themselves, dream encounters and symbols seen in dreams, hearing a deceased loved one’s voice, feeling a brush of air, finding something that was lost a long time ago now being found in an obvious or significant place, and numerous other ways that are experienced by bereaved individuals as a form of connection with their deceased loved ones. The implication here is clear, as Morrie instructs Mitch in Tuesdays With Morrie: “Death may end a life, but not a relationship” (Albom, 1997, p. 174). It is very important as counselors to normalize this aspect of grief and to recognize its significance for the bereaved individual’s process. It would make sense that if a loss creates a wound to our attachment system, then the ability to reconnect with a deceased loved one in a real but intangible way might provide a form of healing to the wounded attachment system (Practice Example 3.1).



3.  Theories and Orientation to Bereavement

35

P R A C T I C E EXAM PLE 3 . 1 FOSTERING A CONTINUING BOND

John’s 14-year-old daughter was diagnosed with acute leukemia. She underwent aggressive treatment, which was unsuccessful, and she died within a few months of the diagnosis. John sought assistance with a grief counselor at the suggestion of his minister several months after his daughter died. In his first counseling session, John admitted that he felt ambivalent about wanting to feel better, as he saw his grief as a way to remain connected to his daughter. Many people had given him advice about learning to “let go” so that he could be more functional in his everyday life. The counselor gently suggested that just as John felt that part of him died when his daughter died, perhaps a part of his daughter continued to live with him. They then began to work on finding ways to “invite” his daughter back into his life through letters that he wrote to her, journaling, and sometimes in conversations that he would have with her at her gravesite. Gradually, John began to feel that his daughter was with him, sometimes as a presence, or a thought that would come to his mind, or an overall feeling that she knew how much he loved her. At one point, he had a powerful dream about her where she was happy and healthy, which was comforting to him. John told his counselor that it had never occurred to him that he didn’t have to “let her go” in order to continue living his life.

In our clinical practices, we often notice that bereaved individuals seek out support at a time when they have lost the physical and tangible presence of their loved one, and have not yet been able to establish a link to their deceased loved one in an intangible way. There are obviously many other factors that contribute to a decision to seek support after a significant loss, but this is one area where we actively work with clients to assure them of the normalcy of their experiences, and to let them know that in some way, they may need to find a way to “hold on” to their loved one in order to “move on.” This is a good time to bring up the controversy that surrounds what is known as the “grief work hypothesis.” This belief about grief was that it was necessary for bereaved individuals to talk about their loss and to express emotions in order to work through their grief, and that once painful emotions were worked through, grieving persons could resolve their feelings of grief (Stroebe et al., 2005). We now realize that not everyone grieves through feeling and expressing emotion, and, in fact, insisting that someone grieve in this way when it is not that person’s propensity may induce more harm than good. The grief work hypothesis also posited that the goal of grief work was to eventually let go of the deceased person and relinquish the relationship to that person in order to move forward in life. We now know from the previous discussion that this “letting go” is not supported as the way that many bereaved individuals typically move forward in their lives after losing a loved one.

36

I.  Theoretical Underpinnings

STAGES, PHASES, AND TASKS If you were to ask the average person in casual conversation about grief and what it looks like, you would most likely be quoted The Stages of Grief, as set out by Kübler-Ross (1969). This book was a seminal piece of work that openly addressed the needs and feelings of dying individuals in a society that had become increasingly death denying. In her book, KüblerRoss identified five stages in facing death and in being confronted with a significant loss: (a) denial, (b) anger, (c) bargaining, (d) depression, and (e) acceptance. Earlier proponents of this model suggested that the stages occurred in a more stepwise and linear fashion. However, Kübler-Ross later stated that these stages were more like descriptors rather than a prescription to follow, and an individual could fluctuate from one to another readily. Although these stages have been heartily embraced in popular (and academic) thinking, it is important to recognize the fact that the five stages were never actually empirically proven to occur in dying or bereaved individuals (Maciejewski, Zhang, Block, & Prigerson, 2007). The primary usefulness of this theory has been exactly what it did—promote a springboard for beginning discussions about this topic in a society that was generally avoidant and thus relatively uneducated about death and grief (Corr, Corr, & Doka, 2019). There are also many theories of bereavement that suggest bereaved individuals go through “phases” in the grieving process. Bowlby (1982) described the “processes of mourning,” in which he listed first yearning and searching, then disorganization and despair, followed by reorganization. Parkes (1996) later expanded on these phases by adding an additional phase of numbness at the beginning of grief. Sanders (1999) proposed her five phases of the grief process as (a) shock, (b) awareness of loss, (c) conservation/withdrawal, (d) healing, and (e) renewal. Rando (1993) put forth her description of the process of the “six Rs” of bereavement as (a) recognize the loss, (b) react to what has happened, (c) recollect and review memories associated with the loss, (d) relinquish the world as it once was, (e) readjust to life after the loss, and (f) reinvest and reenter the world. It is apparent that there are many ways of describing the grief process and many different perspectives from which these descriptions are drawn. Worden (1991, 2018) developed a task-based model of grief, in which the grieving process is compared to the developmental tasks that individuals must master in order to move forward in life. These tasks are as follows: 1. Acknowledge the reality of the loss. The mourner needs to cease denying that the

death has occurred and come to recognize that the loved person is truly dead and cannot return to life. The mourner needs to examine and assess the true nature of the loss and neither minimize nor exaggerate it.

2. Process the pain of grief. Sadness, despondency, anger, fatigue, and distress are all

normal responses to the death of a loved person; people should be encouraged to experience these feelings in appropriate and supported ways, so that they do not carry them throughout their lives.

3. Adjust to a world in which the deceased person is missing. A full awareness of the

loss of all of the roles performed by the deceased in the life of the mourner may



3.  Theories and Orientation to Bereavement

37

take some time to realize. Challenges to grow are presented to the bereaved as they assume new roles and begin to redefine themselves, often by learning new coping skills or by refocusing attention on other people and activities. 4. To find a way to remember the deceased while embarking on the rest of one’s jour-

ney through life. It is important for the bereaved individual to find an appropriate place for the deceased person to occupy in a spiritual or nontangible sense. This task involves creating and sustaining an appropriate relationship with the deceased based on an ongoing emotional connection and memory, so that the person will never be wholly lost to them. This task was revised by Worden (2018) over the earlier versions of his model, and it is now very similar to the process that is described in the Continuing Bonds Theory discussed earlier.

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

MEANING RECONSTRUCTION AND GROWTH The experience of a significant loss will often pose a strong challenge to an individual’s sense of equilibrium. Coping, healing, and accommodation after such experiences are part of a greater process that individuals undertake in an effort to “relearn” their world (Attig, 2011) in light of confrontation with a reality that does not match one’s expectations or assumptions. As we discussed in an earlier section, how we see the world (and our lives) as meaningful is based on the assumptions we have formulated about the world from our earlier life experiences and interactions. A significant loss can shatter the assumptions we have about how the world should be, and we can experience a high degree of distress when we cannot make sense of what has happened, or when we no longer feel a sense of safety or equilibrium in our lives. Challenges to one’s assumptive world are usually met through the process of assimilation (where events are interpreted through the lens of the assumptive world satisfactorily) or accommodation (where assumptions are gradually revised somewhat in order to explain a new set of experiences). However, there are times when something may happen that defies belief, or overwhelms one’s ability to integrate the experience with any known way of how the world should work. The phrase “loss of the assumptive world” is used when a negative life event has challenged one’s basic assumptions about the world in a way that these assumptions no longer make sense, and there is no acceptable alternate way of seeing the world that will reconcile previously held assumptions and beliefs with a new reality that does not

38

I.  Theoretical Underpinnings

fit these assumptions (Attig, 2011; Janoff-Bulman, 1992; Harris, in press (a); Parkes, 1971). Pre-existing assumptions that are no longer viable in describing the world and one’s inner working models or schemata must somehow be reworked in order for the person to feel safe in the world again, but this process can be very difficult. Janoff-Bulman (1992) uses the term “shattered assumptions” to describe when a negative life event overwhelms an individual’s core assumptions so completely that reconciliation of reality with one’s existing assumptive world is not possible. Tedeschi and Calhoun (2004) speak of “seismic life events” that “violate” an individual’s schemata about how the world should work. It is important to note in this discussion that the individual’s subjective appraisal process is very important. How one interprets and perceives an event determines the significance of its impact on the assumptive world. Meaning making is the focus of many authors who explore responses to trauma, loss, and negative life events. Making sense of an event involves a process of attempts to reconcile the occurrence of the event with one’s working models of the assumptive world (Davis & Nolen-Hoeksema, 2001; Harris, in press (a); Neimeyer & Krawchuk, in press). Frankl (1963), a concentration camp survivor and the developer of logotherapy, asserted that one can survive all forms of harm and harshness by finding meaning and purpose through what one has experienced. By choosing to reflect on the possibility of something positive occurring after a negative life event, individuals may be able to assign meaning to their experience, which helps to rebuild the foundation for one’s assumptive world that is once again relevant and coherent. Janoff-Bulman (2004) describes the existential issues that must also be addressed and assigned meaning after experiencing a critical event. Survivors are interested not only in why an event happened but also in why an event happened to them in particular. She cites Sartre (1966) in her discussion of existential issues, stating that individuals must create their own meanings through a deliberate choice in the face of meaninglessness. She concludes that we may not be able to prevent misfortune, but we have the ability to create lives of value in the wake of misfortune. Searching for meaning after significant loss appears to be an almost universal phenomenon and an important part of the grieving process (Davis, 2001; Gillies, Neimeyer, & Milman, 2014; Park, 2010). The trauma, shock, and anguish of a major loss assault an individual’s fundamental assumptions about the world. Meaning making can result from reinterpretation of negative events as opportunities to learn new lessons about one’s self or life in general, as a means of helping others, or contributing to society in some way that is related to the experience that occurred (such as the formation of an advocacy group or efforts to help others in similar situations). Perhaps this description offers an explanation as to why many bereaved individuals undertake the founding of trusts, advocacy organizations, and public awareness groups. Mothers Against Drunk Driving (MADD) is one example of how bereaved parents made meaning by educating the public and advocating for stricter enforcement of laws related to driving under the influence of substances after they experienced the loss of their children from accidents that involved drinking and driving (Practice Example 3.2). Neimeyer (2001) and Neimeyer et al. (2002) discuss the social constructivist view of meaning making through the use of narrative reframing in individuals who have experienced significant losses. In these writings, the description of the “master narrative,” which is an



3.  Theories and Orientation to Bereavement

39

P R A C T I C E EXAM PLE 3 . 2 VALIDATING GRIEF AND FINDING MEANING AFTER LOSS

Denesha and her husband were elated to find out that they were going to have a baby. They had been trying to conceive for over a year when the pregnancy test came back positive. Denesha’s pregnancy progressed normally without any concerns. However, just before the end of her first trimester, she began bleeding. Tests confirmed that she had miscarried. Denesha was crushed. She tried to talk with people about her loss, but most dismissed her grief because she never “held” her baby in her arms, and it was assumed that she could readily get pregnant again. Nobody seemed to understand how much she wanted this baby, and that she already felt that she knew this baby that had spent these past several months inside her body. Denesha began reading about miscarriage and pregnancy loss. She realized how many women go through this painful experience, and she knew that most would never have their grief validated by others. Through her doctor’s office, she connected with other women who had lost their babies and had indicated they wanted to speak with others about their experience. Together, they supported each other in their grief. Finally, they decided to start a project for women who never got to hold their babies in their arms. They created “in my heart forever” memory boxes for women who experienced miscarriages, where they could store ultrasound pictures, keepsakes, and write in a special journal to the baby that they lost. While Denesha continued to feel deep grief over the loss of her baby, she was comforted in knowing that other women who had a similar experience would have their grief validated rather than dismissed through the gift of the memory box project that she had created.

“understanding of one’s life and experiences, along with meanings attached to these” (p. 263), is very similar to earlier descriptions of the assumptive world by other writers. Neimeyer states that significant losses disrupt taken-for-granted narratives and strain the assumptions that once sustained them. Individuals must find ways to make meaning of the life events that have been disruptive through a “reweaving” process that incorporates the new experiences into the existing narrative of one’s life so that it is once again coherent and sustaining. Searching for meaning in what seems to be a meaningless event is how human beings attempt to re-establish a sense of order and security in the world and to minimize the high degree of vulnerability that occurs after basic assumptions are shattered. Davis, NolenHoeksema, and Larson (1998) focused on two aspects of meaning in their research: meaning as the ability to find a benefit in what had happened and meaning as a way of making sense of the loss. Attig (2001) further delineates the various conceptualizations of the search for meaning by distinguishing between meaning making and meaning finding. Meaning making refers to the conscious and active process of reinterpreting and bringing new meaning to one’s experiences, actions, and suffering, and meaning finding refers to becoming aware of and accepting meaning that arises spontaneously out of grief and suffering. These two processes mix together as one rebuilds the assumptive world after a significant loss.

40

I.  Theoretical Underpinnings

POSTTRAUMATIC GROWTH AND RESILIENCE Research published by Calhoun and Tedeschi (2014) suggests that there is potential for more than adjustment after exposure to “seismic” life events. These authors cite numerous instances in their research where individuals encountered tragic bereavement, catastrophic illness, violence, or political oppression, and their exposure to such events led to significant personal accounts of positive growth and development. These authors’ use of the term posttraumatic growth describes the potential that individuals may have for transformation after exposure to trauma, highly stressful events, and crises. Growth in this sense is not a direct result of exposure to these types of events, but rather from the struggle that an individual engages in with the new reality in the aftermath of these events. Posttraumatic growth may also coincide with ongoing distress related to the negative event, because it can be viewed as both a process and an outcome, but not necessarily an acceptance of the event. Resilience and hardiness, which are two related concepts, speak to a potential for a positive outcome after the experience of significant losses. Resilience tends to focus on an ability to go on with life after hardship and adversity (instead of being paralyzed or destroyed by it). Resilience represents more of a “return to baseline” in regard to functioning and views about life. Hardiness is a concept that describes certain individuals’ innate tendencies when confronted with challenge (Harris, in press (b); Maddi, 2008; Mathews & Servaty-Seib, 2007). “Hardy” people are those who tend to anticipate that life will bring challenges and they expect to be able to develop and become stronger as they rise to meet these challenges. Individuals who experience posttraumatic growth may or may not have these characteristics, although individuals who score high on hardiness would be very likely to experience posttraumatic growth after a significant loss. Perhaps most salient to this discussion are the aspects of posttraumatic growth, which reflect on personal strengths that are developed when some individuals face an assault on their deeply held assumptions about the world. Personal strength may include descriptions of greater self-reliance, fortitude, and self-respect. Janoff-Bulman (2004) gives an account of a client that survived a debilitating accident, who, after months of intense rehabilitation and therapy, stated, “I guess I really am strong . . . I never knew I had it in me” (p. 30). She also quotes a rape survivor who stated, “I feel stronger now. . . . I came through with my integrity—I got through those months of hell and I know myself as a strong person now” (p. 31). In these descriptions, survivors of traumatic loss events often recognize that they have gone through agony and that they have become stronger as a result of these experiences. In the backdrop of suffering, pain, and adversity, individuals may recognize the preciousness of life and be able to identify what is truly “most important” in their lives, which may not have been as easy before the experience.

CONCLUSION Through the work of bereavement researchers, clinicians, and academics, the present-day thinking about the grieving process has been extrapolated. It is generally thought that the grief process has evolved as part of our survival instinct to enable us to integrate the experience



3.  Theories and Orientation to Bereavement

41

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

GLOSSARY Continuing Bonds Theory  It states that bereaved individuals may be well served to reconnect to their deceased loved one in ways that are meaningful; often summed up in the statement that death ends a life, but not a relationship. Dual process model  A model of grief that posits that bereaved individuals will “oscillate” regularly between restoration orientation (e.g., activities of daily living, distractions, and focusing on life) and loss orientation (e.g., remembering the deceased individual, reminiscing about life before the loss, and feeling the pangs of grief). Grief  The normal and natural reaction to loss. Hardiness  Refers to a trait in individuals who tend to expect that life will bring challenges and that they can find personal development and growth in meeting these challenges. Loss  An experience where there is a change in circumstance, perception, or experience where it would be impossible to return to the way things were before, with the key element being the inability to return to some aspect of life that we have cherished or valued. Master narrative  Coherent overarching story and understanding of one’s life and experiences, along with the meanings that are attached to these experiences. Posttraumatic growth  The potential that individuals may have for transformation after exposure to trauma, highly stressful events, and crises. Resilience  The ability to go on with life after hardship and adversity (instead of being paralyzed or destroyed by it). Represents more of a “return to baseline” in regard to functioning and views about life. Two-track model of grief  Explores both the bereaved individual’s ability to function and navigate the world after a significant loss (track I) and the relational aspects of the grief that relate to maintaining a connection with the deceased individual over long periods of time, and even indefinitely (track II).

QUESTIONS FOR REFLECTION 1. Before you read this chapter, or before you had any exposure to the current

thinking about bereavement, what were your thoughts about grief and the grieving process? Can you think of what may have shaped your thinking before you began reading about grief and bereavement?

2. A client comes to seek your assistance for grief counseling after the death of her

abusive husband, who was an alcoholic and caused her a great deal of harm and

42

I.  Theoretical Underpinnings

terror. Since her husband’s death, she has experienced a great deal of anxiety, and she finds herself ruminating about their relationship. Most of her friends and family tell her that she should be relieved, and she does feel a relief from the exposure to his unpredictability and her feelings of powerlessness to control her family life. She tells you that, mostly, she feels “lost” and paralyzed. Based on the discussion in this chapter regarding attachment and grief, and some of the other theoretical models, can you suggest what is happening to her? 3. Think of a significant loss experience that you have had or that someone you know

has experienced. After reading this chapter and the various explanations of adjusting to loss, which of the theories of bereavement seems to best describe the process you went through after this loss occurred?

4. If you were to think of your life as a book, what would the title be? Describe some

of the chapters that would be part of the book. Can you think of how either previous chapters were rewritten or new chapters were created after you experienced significant losses in your life?

REFERENCES Albom, M. (1997). Tuesdays with Morrie. New York, NY: Doubleday. Attig, T. A. (2001). Relearning the world: Making and finding meanings. In R. A. Neimeyer (Ed.), Meaning reconstruction and the experience of loss (pp. 33–53). Washington, DC: American Psychological Association. Attig, T. A. (2011). How we grieve: Relearning the world (revised ed.). New York, NY: Oxford University Press. Bowlby, J. (1969). Attachment and loss: Attachment (Vol. 1). London, UK: Hogarth. Bowlby, J. (1973). Attachment and loss: Separation (Vol. 2). New York, NY: Basic Books. Bowlby, J. (1982). Loss: sadness and depression (attachment and loss). New York, NY: Basic Books. Bowlby, J. (2005). A secure base: Clinical applications of attachment theory. New York, NY: Taylor & Francis. Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759–775. doi:10.1037/0012-1649.28.5.759 Calhoun, L. G., & Tedeschi, R. G. (Eds.). (2014). Handbook of posttraumatic growth: Research and practice. New York, NY: Routledge. Cassidy, J. (1999). The nature of the child’s ties. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 3–20). New York, NY: Guilford. Clulow, C. (Ed.). (2012). Adult attachment and couple psychotherapy: The “secure base” in practice and research. New York, NY: Routledge. Corr, C., Corr, D., & Doka, K. (2019). Death and dying, life and living (8th ed.). Boston, MA: Cengage. Davis, C. G. (2001). The tormented and the transformed: Understanding responses to loss and trauma. In R. A. Neimeyer (Ed.), Meaning reconstruction and the experience of loss (pp. 137–155). Washington, DC: American Psychological Association. Davis, C. G., & Nolen-Hoeksema, S. (2001). Loss and meaning—how do people make sense of loss? American Behavioral Scientist, 44, 726–741. doi:10.1177/00027640121956467 Davis, C. G., Nolen-Hoeksema, S., & Larson, J. (1998). Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75(2), 561–574. doi:10.1177/00027640121956467 Field, N., & Wogrin, C. (2011). The changing bond in therapy for unresolved loss: An attachment theory perspective. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 37–46). New York, NY: Routledge.



3.  Theories and Orientation to Bereavement

43

Fraley, R. C., Roisman, G. I., Booth-LaForce, C., Owen, M. T., & Holland, A. S. (2013). Interpersonal and genetic origins of adult attachment styles: A longitudinal study from infancy to early adulthood. Journal of Personality and Social Psychology, 104(5), 817. doi:10.1037/a0031435 Frankl, V. E. (1963). Man’s search for meaning: An introduction to logotherapy. New York, NY: Washington Square Press. Gillies, J., Neimeyer, R. A., & Milman, E. (2014). The meaning of loss codebook: Construction of a system for analyzing meanings made in bereavement. Death Studies, 38(4), 207–216. doi:10.1080/07 481187.2013.829367 Harlow, H. F. (1961). The development of affectional patterns in infant monkeys. In B. M. Foss (Ed.), Determinants of infant behavior (pp. 75–97). New York, NY: Wiley. Harris, D. L. (in press, a). Non-death loss and grief: Context and clinical implications. New York, NY: Routledge. Harris, D. L. (in press, b). Compassion and resilience. In N. Thompson & G. Cox (Eds.), Promoting resilience. New York, NY: Routledge. Hinde, R. A. (1992). Developmental psychology in the context of other behavioral sciences. Developmental Psychology, 28(6), 1018–1029. doi:10.1037/0012-1649.28.6.1018 Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY: Free Press. Janoff-Bulman, R. (2004). Post-traumatic growth: Three explanatory models. Psychological Inquiry, 15, 30–24. Klass, D., Silverman, P, & Nickman, S. (1996). Continuing bonds: New understandings of grief. Washington, DC: Taylor & Francis. Kosminsky, P. S., & Jordan, J. R. (2016). Attachment-informed grief therapy. New York, NY: Routledge. Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan. Maciejewski, P, Zhang, B., Block, S., & Prigerson, H. (2007). An empirical examination of the stage theory of grief. Journal of the American Medical Association, 297(7), 716–723. doi:10.1001/jama.297.7.716 Maddi, S. R. (2008). The courage and strategies of hardiness as helpful in growing despite major, disruptive stresses. American Psychologist, 63(6), 563–564. doi:10.1037/0003-066X.63.6.563 Mathews, L. L., & Servaty-Seib, H. L. (2007). Hardiness and grief in a sample of bereaved college students. Death Studies, 31(3), 183–204. Neimeyer, R. A. (2001). The language of loss: Grief therapy as a process of meaning reconstruction. In R. A. Neimeyer (Ed.), Meaning reconstruction & and the experience of loss (pp. 261–292). Washington, DC: American Psychological Association. Neimeyer, R. A., Botella, L., Herrero, O., Pecheco, M., Figueras, S., & Werner-Wilder, L. A. (2002). The meaning of your absence. In J. Kauffman (Ed.), Loss of the assumptive world: A theory of traumatic loss (pp. 31–47). New York, NY: Routledge. Neimeyer, R. A., & Krawchuk, L. (in press). Meaning-making after non-death losses. In D. Harris (Ed.), Non-death loss and grief: Context and clinical implications. New York, NY: Routledge. Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257. doi:10.1037/ a0018301 Parkes, C. M. (1971). Psycho-social transitions: A field for study. Social Science & Medicine, 5, 101–115. Parkes, C. M. (1996). Bereavement: Stories of grief in adult life. London, UK: Routledge. Parkes, C. M., & Weiss, R. S. (1983). Recovery from bereavement. New York, NY: Basic Books. Prigerson, H., Horowitz, M., Jacobs, S., Parkes, C., Aslan, M., Goodkin, K., . . . Maciejewski, P. (2009). Prolonged grief disorder: Empiric validation of criteria proposed for the DSM-5 and the ICD-11. PLOS Medicine, 6(8). Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371/ journal.pmed.1000121 Rando, T. (1993). Treatment of complicated mourning. Champaign, IL: Research Press. Ravitz, P., Maunder, R., Hunter, J., Sthankiya, B., & Lancee, W. (2010). Adult attachment measures: A 25-year review. Journal of Psychosomatic Research, 69(4), 419–432. doi:10.1016/j.jpsychores.2009.08.006 Rubin, S., Malkinson, R., & Witztum, E. (2011). The two-track model of bereavement: The double helix of research and clinical practice. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 47–56). New York, NY: Routledge.

44

I.  Theoretical Underpinnings

Rubin, S., Malkinson, R., & Witztum, E. (2012). Working with the bereaved: Multiple lenses on loss and mourning. New York, NY: Routledge. Sanders, C. (1999). Grief: The mourning after: Dealing with adult bereavement (2nd ed.). New York, NY: Wiley. Sartre, J. P. (1966). Being and nothingness: A phenomenological study of ontology. New York, NY: Washington Square Press. Simpson, J. A., & Rholes, W. S. (2012). Adult attachment orientations, stress, and romantic relationships. Advances in experimental social psychology, 45, 279–322. doi:10.1016/B978-0-12-394286-9.00006-8 Sroufe, L. A., Egeland, B., & Kreutzer, T. (1990). The fate of early experience following developmental change: Longitudinal approaches to individual adaptation in childhood. Journal of Child Development, 61, 1363–1373. doi:10.2307/1130748 Stroebe, M. (2002). Paving the way: From early attachment theory to contemporary bereavement research. Mortality, 7(2), 127–138. doi:10.1080/13576270220136267 Stroebe, M., Schut, H., & Stroebe, W. (2005). Attachment in coping with bereavement: A theoretical integration. Review of General Psychology, 9(1), 48–66. doi:10.1037/1089-2680.9.1.48 Tedeschi, R. G., & Calhoun, L. G. (2004). Post-traumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1–18. Van Wielink, J., Wilhelm, L., & van Geelen-Merks (2019). Loss, grief, and attachment in life transitions: A clinician’s guide to secure base counseling. New York, NY: Routledge. Weiss, R. (1975). Marital separation. New York, NY: Basic Books. Worden, W., (1991). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York, NY: Springer Publishing Company. Worden, W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (5th ed.). New York, NY: Springer Publishing Company.

CHAPTER 

4

T HE SO C I AL C ON T E X T O F L O S S

LEARNING OBJECTIVES 1. Describe how the social context and spheres of interaction have an impact upon the grieving process. 2. Distinguish between micro, mezzo, and macro practice in the context of grief counseling. 3. Identify social norms and expectations as they apply to grief in Western-oriented industrialized societies. 4. Distinguish between cultural competence and cultural humility in relation to grief counseling. 5. List ways that grief counselors can acknowledge the social context in their work with clients.

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

46

I.  Theoretical Underpinnings

as either normal or abnormal, social norms and rules that affect bereaved individuals’ experiences, and access to potential sources of support and assistance.

SOCIAL SPHERES AND INDIVIDUAL EXPERIENCE Most of the models of grief that have been proposed originate in the psychological literature, which tends to focus on grief as an intrapsychic, individual experience. Although some of these models may include acknowledgment of the role of family, most tend to describe the experience of the individual, measuring levels of distress, possible problematic coping, and screening for mental disorders, such as depression, posttraumatic stress disorder, and generalized anxiety disorder. Grief is seen as an individual’s personal response to loss, and any treatment or support that is proposed is also directed at the individual level. Thompson (2010) proposes that this current dominant psychological model could be compared to soup that is poured into a bowl, where the soup exists within the bowl, but the soup and the bowl remain separate. The bowl simply serves as a container for the soup. Applied in our context, the implication is that the soup (representing an individual’s experience) is held by the bowl (society) but does not interact with it. In contrast, Thompson suggests that instead we look at a different analogy, such as coffee that has cream added to it, where the coffee (society) and the cream (individual) are inseparable and mix together in a way that each is changed and affected by the other. We truly are creatures that are meant to exist in social relationships with others, and the influences of our relationships, social norms, and existing social structures on our lives are impossible to ferret out from our ways of thinking, being, and acting. The experience of grief is a profound example of the interplay between individual and social factors. Most counselors focus on individual clients who come to them for help in dealing with difficulties that are being encountered in their lives. This form of help is often referred to as micro practice in the social work literature (Knight & Gitterman, 2018; Wronka, 2008). In micro practice, the focus is on the intrapsychic, individual aspects of the client’s experience and what is happening in his or her life, with interventions focused on the individual’s beliefs, perceptions, and feelings. In this practice setting, the professional helper also has the opportunity to “bear witness” to the client’s story, which can be a very powerful healing experience for the client. Mezzo practice focuses on work with small groups at a local level, such as employees of a specific workplace, members of an extended family system, or a support group that has formed around a specific issue or experience. In mezzo practice, the skills of active listening and reflection that are utilized in micro practice are enhanced by understanding and working with group dynamics as they occur in the interactions and communication among individuals who are present in the group setting. The focus in mezzo practice is on facilitation by the helper. Macro practice looks at larger systems, such as organizations, communities, and even political structures and governments. In macro practice, the focus is on the exploration of social norms and policies, with education and advocacy being the primary ways of addressing organizational, social, and political policies that may have a negative effect on the individuals who are part of these larger groups (Krawczyk et al., 2019). Looking at these levels of intervention is very important, because the strict focus on the individual in isolation (or an atomistic focus; Thompson, 2012) will not address the profound



4.  The Social Context of Loss

47

social influences under which an individual must live and function. The emphasis on micro practice can also be problematic because it tends to individualize social problems rather than correctly identify that problematic social norms may actually be at the root of some of the difficulties that individuals experience. As with the image of the cream in the coffee, individual experiences of grief are molded and often profoundly influenced by social messages and norms that have usually been internalized by the grieving individual. This chapter looks at these internalized messages with a “macro lens,” exposing the underlying social norms and rules that may have been adopted into our client’s (and our own) values and self-judgments. It has often been said that grief is related to our innate tendency to form attachments. This propensity toward attachment identifies human beings as primarily social in nature, needing the acceptance of and affiliation with others in order to feel safe and secure. Thus, the social messages and beliefs held by the dominant group into which an individual belongs will have a powerful influence on how that individual perceives and interprets events and whether individual experiences will be either validated or invalidated socially. If we need to feel connected to others in order to feel safe in the world, then experiences that cause us to feel disconnected from our affiliated “group” will be highly disruptive to our sense of safety and security at a very basic level. Feeling isolated or marginalized from our social group increases anxiety, and this anxiety will often motivate us to align ourselves more closely with the values of the group, sometimes even at the expense of our individual feelings and needs (Eisenberger, 2015; Harris, 2016).

WHAT IS NORMAL? Stop and think about what you consider to be normal, everyday food. What is your typical breakfast? What foods do you think of as comforting? What foods would elicit a strong aversion (negative) reaction from you? And yet, people from other cultures may think the foods that you love are detestable and perhaps even disgusting! The point here is that what we think of as “normal” is socially and culturally mediated, and it is also internalized into our personal point of view. It is impossible to separate out what we might view as a tasty dinner from what we were taught was “tasty” as determined by the social and cultural norms of our family, physical location, and cultural views about food. Likewise with grief, what we may consider as a “normal” and acceptable response to loss is largely determined by the social/ cultural values and messages that have shaped our thinking. A society that places a high value on productivity and functionality may see emotional expression as a potential threat to these values. After all, people who are emotionally distraught or deeply engaged in their emotions might not be very productive or functional. If loss of productivity is viewed as a challenge to the valued “way of life,” then there would be a great deal of social pressure to minimize or suppress any experience that interferes with one’s ability to be fully functional. One example of the interplay of individual and social factors in grief is who decides what is normal and abnormal grief. How does the concept of “normal” vary from one society to another? In some societies, the grieving process involves the expectation that mourners will loudly wail and may even physically fling themselves onto the casket or the deceased person at the funeral in a show of profound grief and despair after a death. In other societies, people

48

I.  Theoretical Underpinnings

who remain stoic and hold in their emotions are commended for being “strong” and for “holding up so well” (Despelder & Strickland, 2015). The point here is that definitions of what is normal and abnormal are going to vary and are determined largely by what is valued by the most dominant group in that society (Exhibit 4.1). For example, the values in most Western industrialized societies are based on the capitalist focus on productivity, efficiency, and the market economy. These values narrowly shape what is “normal” grief with an emphasis on being strong and functional, returning to work as soon as possible (with limited leave after a loss), and viewing emotional expression as a very private and inconvenient aspect of grief (Harris, 2016).

EXHIBIT 4.1 COMPARISON OF INDIVIDUALISTIC VERSUS SOCIALLY CONSTRUCTED VIEWS OF DISORDERED GRIEF*

Proposed Criteria for Diagnosing Persistent Complex Bereavement Disorder (DSM-5) A: The individual has experienced the death of someone [in].. a close relationship B: Since the death, experienced at least one of the following symptoms…for at least 12 months after the death

Criteria for Diagnosing a Society That Unnecessarily Complicates Grief/Disables Grieving People A: The individual has experienced the death of someone [in]…a close relationship B: Experienced at least one of the following symptoms, for at least a generation

1. Persistent yearning/longing for the deceased 2. Intense sorrow and emotional pain in response to the death 3. Preoccupation with the deceased 4. Preoccupation with the circumstances of the death

1. Persistent assumptions throughout society that there is one way to grieve 2. Intense cultural beliefs that grief has an end point 3. Preoccupation among clinicians and the general public with rigid and outdated models of grief 4. Preoccupation in society with the idea that grief is an individual, psychological problem C: Experienced at least six of the following symptoms, persisting for at least a generation:

C: Since the death, experienced at least six of the following symptoms…on more days than not and to a clinically significant degree, and persisting for at least 12 months after the death Reactive distress to the death 1. Marked difficulty accepting the person has died (e.g., preparing meals for them)

Reactive distress to bereaved people 1. Marked difficulty accepting that people die 2. Disbelief that bereaved people are experts in their own experience (continued )



4.  The Social Context of Loss

49

EXHIBIT 4.1 (continued) Proposed Criteria for Diagnosing Criteria for Diagnosing a Society That Persistent Complex Bereavement Unnecessarily Complicates Grief/Disables Disorder (DSM-5) Grieving People 2. …disbelief or emotional numbness over 3. Difficulty in allowing people to reminisce – the loss positively and negatively – about the person 3. Difficulty in positive reminiscing over who died 4. Anger or disappointment if bereaved people the deceased 4. Bitterness or anger related to the loss react in a long-term or unexpected way 5. Maladaptive appraisals about oneself... 5. Maladaptive appraisals of the significance of [re] the deceased or the death (e.g., cultural and structural factors in complicatshame) ing grief 6. Excessive avoidance of reminders 6. Excessive avoidance of reminders of the pain of the loss (…individuals, places, or of bereaved people situations) Social/identity disruption 7. A desire to die in order to be with the deceased 8. Difficulty trusting individuals since the death 9. Feeling alone or detached from others 10. Feeling life is meaningless or empty without the deceased, or…one cannot function… 11. Confusion over one’s role in life, or a diminished sense of one’s identity (e.g., feeling that part of oneself died with the deceased) 12. Difficulty or reluctance to pursue interests…or to plan for the future D: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning E: The bereavement reaction is out of proportion to…the cultural, religious or age-appropriate norms

Social/identity disruption 7. A desire to define normal and abnormal grief 8. Difficulty trusting that friends and family can support bereaved people 9. Feelings of loneliness and detachment widespread in communities 10. Feelings that people are of less value if they are not productive members of society, even temporarily 11. Confusion over the role of death and bereavement in the school curriculum and professional development 12. Difficulty or reluctance to pursue policy goals that would improve the economic situation of bereaved people D: The social and cultural response to bereaved people causes them real distress and impairment in social, occupational, or other important areas of functioning E: Social and cultural norms are out of proportion to the actual lived experience of grief

*This chart was developed as part of a workshop and has been reproduced with the permission of the author who wishes to remain anonymous.

50

I.  Theoretical Underpinnings

CASE STUDY I (D.L.H.) began to explore the social influences on grief shortly after I started working with bereaved clients in my clinical therapy practice. I noticed that many of my clients would censor and judge their experiences if they were not aligned with the unspoken social norms and rules related to grief. Most of these norms/rules served to encourage the suppression of grief, which tended to stunt many of my clients’ abilities to grieve in the ways they really needed in order to integrate the loss into the fabric of their ongoing lives. I was curious about the role of shame in grief because many of my clients expressed feelings of self-deprecation and loathing because they could not “get over” the grief in a “timely” manner (Harris, 2010). Let us explore a case study to illustrate this discussion: Jerry was a 57-year-old man whose wife of 35 years (Peggy) had died after a 3-year ordeal with cancer. They were very close, and they did everything together. They loved to travel, planned and cooked gourmet meals together, and were patrons of their local art gallery. They did not have children. Jerry had taken leave from his work in order to be Peggy’s caregiver for the last 6 months of her life. When she died, he was devastated. The house they shared was painfully empty. The friends with whom they had socialized together were kind and attentive, but he felt out of place because they had socialized as a couple. He hated cooking because it was another reminder of Peggy’s absence. Jerry’s boss began to pressure him about returning to work, suggesting that he would be at risk of losing his position if he did not return soon. He told Jerry that “getting back to work will help you to be busy and distracted.” However, Jerry felt unfocused and was concerned about his ability to function in the workplace. He came for counseling 6 months after Peggy’s death, concerned that he was “wallowing” in self-pity and needed help to “just get a grip on life” and go back to work. The pressure from his boss and some of the comments from a few of his friends suggested to him that he just needed to “get on with it” and that perhaps he was not progressing the way he should. In our initial session, I suggested that perhaps his response (what he termed as “wallowing”) was very appropriate for the significance of the loss of Peggy, and we explored how the loss of his lifelong soul mate affected every area of his life. Much of the work in his sessions involved normalizing his feelings and experiences rather than trying to assist him to find ways to “buck up” and be strong. Interestingly, what seemed to help him the most with his grief was an invitation from Peggy’s friends to join them for coffee one week. When there, they all shared memories about Peggy and how much they missed her. They had set up a foundation in her name with a local art gallery, and they asked Jerry to join them for the first exposition that was sponsored by Peggy’s foundation. Jerry’s sense of isolation and devastation began to lift as he regularly joined these women for coffee and to assist with the work of the foundation. He began to feel more energetic, and he set up a plan to gradually ease back into his workplace.

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



4.  The Social Context of Loss

51

What does this mean for individuals who grieve after the experience of profound losses? We are urged to silence our grief or ignore our feelings about our loss experiences. We also feel the pressure to carry on with our lives and our routines as before, being praised for “being strong” in the face of adversity. As a result, individuals who experience profound losses may turn inward, perhaps being able to share their thoughts and feelings with a select few, but still expected to maintain their functionality in the public sphere. We know that raw grief can be temporarily crippling to many individuals, affecting their ability to focus and function, and affecting their interest and engagement in the world around them. Thus, it is apparent that the expectations and values of a product-driven society can painfully collide with the individual experience and expression of disabling grief. Social pressures to remain functional, stoic, and strong may not make much sense when your life is decimated by the loss of a loved one or a deeply held part of yourself. In this instance, what is normal? If we go back to the example of Jerry from the case study, we can see that Jerry felt a great deal of pressure to function and ignore his pain, and he had also internalized these social norms to the point that he felt shame at not being able to return to work and “get on with it” after Peggy’s death. In the context of grief counseling, it is important for the counselor to help clients to separate out the social expectations of how they are supposed to respond to loss (i.e., how they should respond) from the actual reality of their loss experience (how they actually need to respond) and to normalize grief as a potentially adaptive, but socially uncomfortable and often stigmatized process. Gender socialization and stereotyping are also strong social forces that shape the expectations of how individuals should grieve. For example, men who are sensitive or who express vulnerable emotions publicly are often stigmatized as “weak” or effeminate. The fact that Jerry needed to talk about Peggy and that his grief affected his ability to focus would be doubly stigmatizing to him as a man, because in Western-oriented societies, men are expected to stay in control and to function proficiently, even in the face of extreme adversity (Creighton, Oliffe, Matthews, & Saewyc, 2016). Similarly, women who do not cry or express vulnerable emotions outwardly are often labeled as “frigid” or insensitive (Doka & Martin, 2010). Strong emotions of any type are usually stigmatized, and bereaved individuals may express embarrassment for “losing control” of their emotions in front of others (think about how people will say they are sorry when they cry in public places). Pressure to view grief in purely individualistic terms, overlaid with the values of strongly capitalistically oriented thinking, twists our fundamentally human experience of loss into pathology, making it into a worse (more disabling, more disempowering) experience than it could have been if adequate support and understanding were available. The problem is not with grief, which can help us to adapt and integrate the losses that occur in our lives. Rather, the problem we often find in our clinical work is that grief causes far more pain and difficulty for our clients when it is rigidly defined and socially controlled through suppression of the normal and healthy ways that it can be experienced.

IMPACT OF SOCIAL RULES AND NORMS In the previous section, we explored how social values can have an impact on the experience of the bereaved individual. Social norms govern appropriate ways of behaving, thinking, and feeling in a particular situation. Norms also may be internalized and thus be considered the

52

I.  Theoretical Underpinnings

“normal” way of behaving, thinking, and feeling by individuals (Harris, 2016). We continue the discussion to look at the various social “rules” of grief and how they may be applied to bereaved individuals. As grief counselors, we urge you to always bear these issues in mind when you work with clients. In many cases, clients are “stuck” in their grief because they do not have permission to fully enter into their grief in the way that is congruent with their experience of loss. Making these social norms and rules explicit and talking about the ways that grief can be stunted by adherence to expectations that suppress grief rather than support it will often create the very space that your grieving clients need in order to address their grief in an open and healing way. Keep in mind that because most people internalize the social norms of the society in which they identify, the “pressure” is often felt within the individual client, even though the issue is rooted in socially mediated values and expectations. A key component of socially mediated norms in this context is Doka’s (1989, 2002) concept of disenfranchised grief, which states that an individual may have a very significant reaction to a loss, but the loss and the grief are not recognized or validated socially. The implication is that there are norms that provide both social acceptance (and support) or social rejection of a member or group, depending on specific criteria that are identified either overtly (clearly delineated) or covertly (implied). There are several different ways by which the grieving individual is disenfranchised and thus excluded from social support (Doka, 2002): ■■

The relationship that was lost was not considered valid, socially acceptable, or important

■■

The loss itself is not recognized or viewed as significant

■■

The grieving individual is exempted from rituals that might give meaning to the loss or is not seen as capable of grieving for the loss

■■

Some aspects of the death or loss are stigmatizing, embarrassing, or unacceptable

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

How long grief should last (we now know that grief may never really end)

■■

What the narrowly accepted expressions of grief are for specific members of society, usually delineated along gender lines and social acceptability (e.g., men who grieve through their emotions and women who grieve instrumentally through action are often the most socially wounded in their grief)

■■

Who is valued and worth grieving versus who/what is not (think of the loss of pets, loss of friends, miscarriage, significant nondeath losses, as well as intangible losses, such as loss of hope, dreams, and innocence)

■■

Who may have an exemption from socially expected roles and who may not (bereaved parents and widows often have some leeway after their losses, but you can think about typical workplace policies about funeral leave, family pressures around holiday times, and who is included/excluded from funerals and memorials as examples here)



4.  The Social Context of Loss

53

These social rules can cause a great deal of difficulty for individuals whose grief does not “meet” the socially sanctioned criteria in some way. As we stated earlier in this chapter, we are social creatures and the need to attach and feel a sense of belonging is a core part of what it means to be human. When grief is disenfranchised, or the griever is socially isolated, the process is made much more painful: In order to become more socially acceptable, and to counteract the potential for social isolation or exclusion due to lack of conformity to expectations, grieving individuals may try to “mask” their grief in stoicism or find covert ways to grieve that keep their experience out of the public eye (Creighton et al., 2016). By so doing, bereaved individuals internalize the oppressive forces that are enforced through the social rules of acceptability after a loss occurs. Death and grief signify vulnerability, which is interpreted as a sign of weakness. In a social system that is based on competition and acquisition, weakness is not tolerable, and so grief goes underground (Harris, 2016). An emerging area of concern relates to bereavement in groups that fall outside of the mainstream. These groups may be disadvantaged during times of bereavement if their loss is not given the social recognition it deserves, or if the supports that are available are not informed or sensitive to their unique needs and issues. Common groups that are marginalized might be members of the gay and lesbian communities, transgender individuals, people of color, persons with disabilities, and minority ethnic and racial groups in given societies. How one experiences bereavement and loss is affected by multiple factors, including gender, culture, ethnicity, class, age, able-bodied-ness, and sexual orientation. Some of these factors will complicate the process of bereavement further and may make individuals in these groups more vulnerable to experiences such as loneliness, isolation, and depression following bereavement (Fenge, 2014; Practice Example 4.1). There is very little research and literature exploring same-sex bereavement or end-of-life experiences of lesbian and gay individuals. Even less is known about the experiences of transgender or intersex individuals as they get older and face the loss of their partners. There is

P R A C T I C E EXAM PLE 4 . 1 ACKNOWLEDGING GRIEF AND VULNERABILITY

Alex was referred to a grief counselor by his family doctor after his mother died. Alex had been in treatment for depression for several years, requiring inpatient treatment twice when he had expressed suicidal ideation. In his initial session with Serena, a grief counselor, Alex sat down in the chair in her office and immediately said, “I have been diagnosed with bipolar disorder and I am borderline as well.” Serena put down her pen and paper, looked at Alex, and asked, “Alex, what has all of this been like for you?” Alex stopped, put his head in his hands, and said very quietly, “Nobody has ever asked me that.”

54

I.  Theoretical Underpinnings

virtually no literature available on the concept of intersectionality1 and bereavement. For these individuals, the social context of how their loss is viewed by wider society may result in the pain and significance of their loss being overlooked. Many people from these communities potentially face discrimination from health and social care providers when they are dying, and it is likely that this will also have implications for the support their partners might receive during bereavement (Germany, Pederson, & Bridges, in press). The experience of disenfranchisement may increase exponentially if individuals are members of more than one marginalized group, such as a person of color who is also transgender. Fear of discrimination at the hands of health and social care providers is often the result of a lifetime experience of marginalization, oppression, and discrimination, and these individuals will require support that is consistent and sensitive to begin to trust professionals with their emotional needs during end-of-life care and bereavement (Hughes, 2009). Most Western-oriented industrialized countries have enacted legislation that protects the rights of individuals who may not be part of the mainstream in regard to race, gender, ethnicity, and class; however, legislation cannot change attitudes of private citizens, who may feel threatened and perpetuate discrimination at a personal level against those who are seen as “other” in some way to themselves. As counselors, it is important to be informed, sensitive, and open to the experiences of individuals who reside outside of the mainstream norms, and to offer support that incorporates the vulnerable place that raw grief engenders while advocating for clients whose identity and social position have often been disregarded and dismissed.

CULTURAL CONSIDERATIONS Most of this chapter so far has been devoted to the experience of grief in Western-oriented industrialized societies. However, most of the countries that would fit into this description typically include a diverse range of different cultural, racial, and ethnic communities. Many people who immigrate from other countries have not been steeped in the mainstream values of capitalism, and their experiences of grief may differ greatly from what has been described so far in this book. While this topic could provide the content of an entire book unto itself, there are some important concepts that might inform culturally sensitive practice in grief counseling. It is important to keep in mind that the purpose of exploring diverse ways of looking at grief is to appreciate the many different ways that people with various identities and backgrounds understand and approach loss and grief so that you can more readily walk alongside them without interfering with their grieving process. Denial or ignorance of cultural differences does not foster positive interactions. While it may sound quite expansive to say that we are all the same and that differences don’t matter, this statement is quite naïve and could actually cause harm, especially to individuals who live on the outskirts of the mainstream of the society in which they reside. There are real differences in people, their backgrounds, cultural perspectives, and views of the world. Expanding your awareness of your background and beliefs will serve you well, so that you don’t accidentally impose  Intersectionality illustrates the interplay between any kind of discrimination, whether it is based on gender, race, age, class, socioeconomic status, physical or mental ability, gender or sexual identity, religion, or ethnicity. 1



4.  The Social Context of Loss

55

your cultural norms and expectations onto someone who does not share these, erroneously assuming that what is normal for you is the norm for everyone. Discussions such as this can quickly turn into a view of differences rather than appreciation of diversity. So, here are a few basic guidelines: ■■

There is more to acknowledging diversity than highlighting differences between groups. To really appreciate diverse ways of knowing and experiencing, you need to be open to ways of being that might be outside of your own comfort zone. It is important to know when you are being stretched and to acknowledge when this happens, while at the same time maintaining an open mind (and heart) toward those who have been raised with different attitudes and beliefs than your own. This attitude is commonly referred to as “cultural competence.” Recently, the term, “cultural humility” has been offered in deference to our awareness that we can never really be fully competent in a culture with which we don’t primarily identify (Rosenblatt, 2016).

■■

The best stance is one of wanting to learn from others rather than focusing on differences. Rather than focusing on how others are “different,” allow yourself to be openly curious about how others approach issues and topics that are more difficult or that are controversial. Rather than trying to defend your position, take the stance of learning what you can from someone who may be able to enrich your own life.

■■

Threat and anxiety lead to rigid thinking and intolerance. Be aware if there are certain types of individuals or groups or people where you feel intimidated, uneasy, or where you may have experienced wounding, as you want to be cautious not to let your personal feelings and background interfere with your ability to be fully present to a client who may represent these individuals or groups to you. Know the places where you have some anxiety or where you may be more rigid or closed in your thinking. Recognize these areas as sites of potential growth within yourself and allow yourself to feel this anxiety even while you try to remain open. Be aware that you, too, may represent an individual or group that is associated with threat or harm to your client as well.

■■

Allow yourself to be genuine and curious. Your energy should be devoted to learning to listen well, with an appreciation of the shared human experience of loss and grief, while honoring the diverse ways that loss may be defined and grief may be expressed.

■■

Every human encounter is a cross-cultural experience. We may look similar, been raised in similar circumstances within similar cultural beliefs and values, but we can’t just assume that sharing these things means we are exactly the same. Approach every encounter with an openness to learn, share, appreciate, and understand…without assumptions (Practice Example 4.2).

Many people have immigrated to a new country to escape terrible conditions and have experienced significant trauma as a result. They have learned to live in a protective stance,

56

I.  Theoretical Underpinnings

P R A C T I C E EXAM PLE 4 . 2 HONORING CULTURAL BACKGROUNDS AND PERSPECTIVES

Mindy was the social worker for a palliative care unit in a large medical center. She was aware of a young mother on the unit who had metastatic cancer, and she knew that the family had recently immigrated from a Middle-Eastern country where they had been subjected to brutal treatment by the regime that came into power. From the doctor’s admission note, Mindy knew the couple had two young boys and that the family did not have any close relatives in the country. When Mindy walked into their room to speak with Hassan, the husband and father, he seemed very uncomfortable and did not readily respond back to her queries, despite being quite fluent in English. Mindy wasn’t sure what to think about his reaction to her. When she mentioned the awkward interaction to the spiritual care provider for the unit, he suggested that perhaps Hassan was uncomfortable speaking about private matters with a woman. At first, Mindy felt offended that Hassan would not recognize her role and training. But, as she thought about all that the family had gone through, she realized her forthrightness when approaching Hassan had probably just added more stress to the situation. Mindy asked a male social worker from another unit to check in with Hassan the next day. When she walked by the room, she saw the two men talking, with Hassan fully engaged in the discussion. She realized that what had happened when she walked into the room was not a personal affront to her; rather, it was Hassan’s cultural background that needed to be acknowledged and honored.

and to not trust readily in order to survive. Even within countries where there is relative peace and prosperity, there will be individuals who have experienced marginalization, oppression, and significant threat and trauma in their lives, resulting in the adoption of attitudes and behaviors that you may not be able to understand completely. As a counselor, you may end up working with people who have come from situations where their safety and security have been at risk. It is important to tread lightly, follow their lead, and listen to what they share as most important to them (Box 4.1). Always remember: Your clients are the experts of their lives and experiences.

IMPLICATIONS FOR GRIEF COUNSELORS As counselors, social influences can have an impact on our ability to offer support to grieving individuals. Most counselors are not in a situation in which public funding is readily available to clients to cover the costs of counseling. Thus, our services may be limited by the lack of recognition by insurers and public policies that not only limit how grief should be experienced and expressed but also limit many bereaved individuals’ ability to access supports that may be needed. A cycle of social exclusion, pressure to conform, and difficulty accessing resources occurs because mental healthcare and counseling tend to be socially stigmatized



4.  The Social Context of Loss

57

BOX 4.1 FIVE AS OF CULTURALLY CONSCIENTIOUS PRACTICE

Acknowledge—Recognize the dynamics of the relationship, including the presence of privilege and power dynamics. Ask—Don’t assume you understand or know about what is most important to the individual; instead, ask if you are hearing accurately and understanding correctly what has been shared with you. Accept—Receive what is shared with you and recognize that the lens of the person sharing with you is based upon their social location and life experiences. This includes accepting the notion of “not knowing” or being able to fully understand another’s position. Align—Choose to journey alongside those who are in your care in the way that they offer and request. Sometimes, your best stance might be as someone who bears witness to their story and feelings; at other times, you may be an advocate and ally in a situation where their grief is being exacerbated by social and structural factors. Apologize—Recognize that it is human to make errors; however, it is humane to apologize if you have made a mistake or made an erroneous assumption. Let cultural humility be your stance and guide. Source: Adapted from Bordere, T. C. (2016). “Not gonna be laid out to dry”: Cultural mistrust in end of life care and strategies for trust-building. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 75–84). New York, NY: Routledge.

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

Application of Diagnostic Criteria to the Grieving Process In Chapter 10, When Grief Goes Awry, we will explore times when the loss and the grieving process completely overwhelm and consume someone. We caution counselors to keep in

58

I.  Theoretical Underpinnings

mind that jumping in to intervene may be experienced very negatively by clients. Do not be afraid to question how your work may be informed by unhealthy and unrealistic social messages and pressures that reinforce an unrealistic idea of “normal” grief. Keep in mind that most professional training programs tend to emphasize intervention and treatment models, many of which can be problematic and heavy-handed for individuals whose grief is intense and difficult, but not disordered.

Cultivate Self-Awareness Bordere (2016) emphasizes the need for clinicians to cultivate personal awareness of how they have been and are influenced by social and political forces, in order to be able to identify and disentangle the potential detrimental impact of these forces on their engagement with their clients. Learn to monitor your internal reactions and self-talk to identify your own biases, opinions, and expectations, and consider their impact on how you interact in your everyday world and with your clients. In order to effectively do this work with clients, you need to be congruent with the values and ideals that you espouse. For example, if you suppress or deny your experiences of grief due to social constraints, how can you realistically bear witness to and facilitate the full expression and experience of grief with your clients?

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

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



4.  The Social Context of Loss

59

However, commonly used words in psychological descriptions, such as dysfunctional, disordered, impaired, pathological, or identifying a person with a diagnosis may reinforce the social vulnerability that an individual experiences after a life-altering loss event (Granek, 2016). Given the tendency for diagnoses to be utilized as a dividing line between those who are “healthy” and those who are mentally ill, great care must be taken when associating a client’s distress and pain with a reified set of criteria in a diagnosis code. There is often a conflict created for clinicians in this issue because insurance companies often require a diagnostic code to be assigned in order for reimbursement of services. Using language that opens possibilities helps to encourage people to identify their ability to adapt and create meaning within change. Individuals feel empowered when the focus is on their strengths and resilience rather than on their perceived dysfunction. Focusing on the innate strengths in a client can provide a powerful catalyst for growth in contrast to the paralyzing effects of oppressive social expectations. For some clients, there may be initial resistance to the identification of their strengths and attempts to cope with adversity due to the presence of internalized negative beliefs and attributions toward themselves. In clinical practice, we can gently explore how these negative beliefs began and are reinforced in clients’ daily lives. We often explicitly identify the social rules and expectations that augment these negative self-perceptions, giving clients the opportunity to differentiate their actual experiences and responses from unrealistic social expectations that are intended to serve the purposes of a materialistic culture. By naming these rules and acknowledging their influence on daily life, clients have the opportunity to see their strengths more clearly and identify where they have actively engaged in coping and surviving in the context of situations that have made them feel powerless and helpless.

Validate and Support Subjective Experiences It is important to be able to enter the reality that is experienced by the client—as the client feels it, understands it, and participates in it—in order to fully appreciate the client’s world (Larson, 2014). The process of validation occurs through an ongoing dialogue, in which the counselor actively listens to the client’s descriptions and feelings and acknowledges the impact of these experiences on the client’s world. The client’s descriptions and experiences are what matter the most and are the most important part of the process. This aspect of the therapeutic relationship is of primary importance, as we have already discussed how disenfranchisement robs people of the ability to experience their grief as it needs to unfold, pressuring conformity with social norms and expectations that often deny and stigmatize their experiences. It is important to name and validate losses for the significance in which clients actually experience them—not because they are expected to do so by the social rules surrounding the loss experience. In this process, it is important to identify where clients’ experiences have been invalidated, pathologized, or marginalized by social rules and where oppressive factors have robbed the person of their subjective expertise and agency.

Cultivate Compassionate Awareness The phrase “we’re all in this together” may sound trite, but it does speak to the deeper reality that we all experience grief and losses as we go through life, and nobody is immune to pain and

60

I.  Theoretical Underpinnings

suffering at some point. Within the boundary of a professional relationship, clinicians must be able to work from a framework that emphasizes bearing witness to the experience of another human being rather than adopting a role of authority over the client’s experiences. In professional training programs, we are often taught about empowerment and the role of the therapeutic alliance. Rarely do we have discussions about suffering and compassion, and yet it is our ability to acknowledge this pain and suffering, bear witness to it without turning away, and offer ourselves as instruments to relieve this suffering that forms the foundation of healing during these very difficult times. Loss and pain are a part of life, not experiences to be suppressed and hidden away because they highlight our vulnerability. As a grief counselor, you will regularly be reminded of the commonality of human frailty, vulnerability, and fragility that we all share. Allowing yourself to be open to these experiences in yourself and others is an act of healing.

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

GLOSSARY Atomistic view  Assumes that each individual in a society stands alone as an independent, self-sufficient unit. The individual is seen as the “atom” of society and therefore the only true object of concern and analysis. Disenfranchised grief  Refers to situations in which the loss is not recognized as valid, the griever is not recognized as a valid person to mourn a loss, the grief response of the individual falls outside of social norms, or in which the loss itself has a social stigma attached to it. Macro practice  Focuses on systemic issues at the social/political level. Emphasis is on the role of social norms and policies, with education and advocacy being the primary ways of addressing organizational, social, and political policies. Mezzo practice  Focuses on work with small groups at a local level; may include group therapy, self-help groups, or neighborhood community associations. Attention is usually placed on the group dynamic, goals, and/or problem-solving at the local level. Micro practice  Focusing on personal interactions with attention to individual beliefs, perceptions, and feelings. Social norms  Rules and expectations about how members of a certain society should behave, think, and believe, and identification of what is considered acceptable behavior within a social group.

QUESTIONS FOR REFLECTION 1. Think of a significant loss (death or nondeath) that either you or someone close

to you experienced. Identify the social messages that you (or this other person)



4.  The Social Context of Loss

61

received in relation to the loss and the experience of grief afterward. How did these messages affect your/the other person’s response to this loss? 2. Identify at least three situations in which grief might be disenfranchised. In what

ways does the disenfranchisement of grief in these situations reflect the existing social norms about grief?

3. Many public/social policies reflect the norms of the dominant culture. Identify

some of the (social/community/workplace/institutional) policies related to grief and discuss the purpose they serve in relation to social norms and rules (e.g., most large companies allow 3 days of paid funeral leave for direct members of family, most insurance companies will provide limited payment for counseling services provided there is a diagnosis code and the provider has the credentials that are specified).

4. Many professionals think that a category of complicated grief should be included

as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) in order to allow individuals the opportunity to receive support and professional help when needed. Others in the field express concern that providing a diagnosis attached to grief (which is seen as a normal and adaptive process) contributes to the pathologization and medicalization of a normal human experience. What do you think?

REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Bordere, T. C. (2016). “Not gonna be laid out to dry”: Cultural mistrust in end of life care and strategies for trust-building. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 75–84). New York, NY: Routledge. Creighton, G., Oliffe, J., Matthews, J., & Saewyc, E. (2016). “Dulling the edges”: Young men’s use of alcohol to deal with grief following the death of a male friend. Health Education & Behavior, 43(1), 54–60. doi:10.1177/1090198115596164 Despelder, L. A., & Strickland, A. L. (2015). The last dance: Encountering death and dying (10th ed.). New York, NY: McGraw-Hill. Doka, K. J. (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington, MA: Lexington Books. Doka, K. J. (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press. Doka, K. J., & Martin, T. L. (2010). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Routledge. Eisenberger, N. I. (2015). Social pain and the brain: Controversies, questions, and where to go from here. Annual Review of Psychology, 66(1), 601–629. doi:10.1146/annurev-psych-010213-115146 Fenge, L. A. (2014). Developing understanding of same-sex partner bereavement for older lesbian and gay people: Implications for social work practice. Journal of gerontological social work, 57(2–4), 288– 304. doi:10.1080/01634372.2013.825360 Granek, L. (2016). Medicalizing grief. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 111–124). New York, NY: Routledge. Harris, D. L. (2010). Healing the narcissistic injury of death in the context of Western society. In J. Kauffman (Ed.), The shame of death, grief, and trauma (pp. 75–86). New York, NY: Routledge. Harris, D. L. (2016). Social expectations of the bereaved. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 165–176). New York, NY: Routledge.

62

I.  Theoretical Underpinnings

Hughes, M. (2009). Lesbian and gay people’s concerns about ageing and accessing services. Australian Social Work, 62(2), 186–201. doi:10.1080/03124070902748878 Knight, C., & Gitterman, A. (2018). Merging micro and macro intervention: Social work practice with groups in the community. Journal of Social Work Education, 54(1), 3–17. doi:10.1080/10437797.201 7.1404521 Krawczyk, M., Sawatzky, R., Schick-Makaroff, K., Stajduhar, K., Öhlen, J., Reimer-Kirkham, S., . . . & Cohen, R. (2019). Micro-meso-macro practice tensions in using patient-reported outcome and experience measures in hospital palliative care. Qualitative Health Research, 29(4), 510–521. doi:10.1177/1049732318761366 Larson, D. (2014). Getting grief working: A guide for the new grief therapist. New Therapist, 90, 25–29. Rosenblatt, P. C. (2016). Cultural competence and humility. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 67–74). New York, NY: Routledge. Thompson, N. (2010). Theorizing social work practice. Basingstoke, UK:Palgrave Macmillan. Thompson, N. (2012). Grief and its challenges. Basingstoke, UK: Palgrave Macmillan. Wronka, J. (2008). Human rights and social justice. Thousand Oaks, CA: Sage.

PART II PRACTICE AND PROCESS

CHAPTER 

5

T HE PR AC T I C E OF P R E S E N C E

LEARNING OBJECTIVES 1. Define what is meant by the term therapeutic presence. 2. Describe the components that form the foundation of therapeutic presence. 3. Explain the relationship between contemplative practice and therapeutic presence. 4. Discuss the role of compassion and self-compassion in the counselor’s ability to be fully present to clients who are experiencing pain and suffering. 5. Demonstrate exercises that may assist counselors to enhance self-awareness, self-reflection, and the cultivation of a sense of presence.

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

66

II.  Practice and Process

I walked into Ella’s room; she was asleep on her side, facing away from the door. Her breakfast tray was untouched. When I went up to her and said her name, she smiled a little weakly and then nodded back off again. Not knowing what else to do, I completed Ella’s bath and changed her sheets as usual. That took a very short amount of time because Ella kept her eyes closed and did not answer me when I spoke to her. When I finished with her personal care, I had a lot of time to spare, because in the past our conversation usually filled in the time that I was allotted to spend with her. Not knowing what else to do, I proceeded to water the plants at the window. I then straightened and organized her personal items in the bathroom, which had not been used in a good while. I cleaned off her bedside table and filled her water pitcher with fresh ice water, knowing very well that she would never drink it. I began monitoring the doorway, concerned that my clinical instructor would walk by and see that I was not busy and think that I was not doing what I was supposed to do. I added a blanket to Ella’s bed, and I was in the midst of adding another pillow when Ella reached out and grabbed my arm, opened her eyes, and said simply, “SIT.” So I sat on the edge of a chair next to her while she rested, her hand gripping my arm . . . and I watched the doorway, concerned that I would be reprimanded for sitting down while “on the job.” When I directed my focus on to Ella, she seemed to be sleeping and unaware of my presence. However, whenever I tried to move away, her grip would tighten on my arm. Ella could not engage with me verbally, and she did not want me to be scurrying around her in a lot of busyness, but she obviously wanted my presence with her. Many years later, when I entered my graduate training program in counseling psychology, I recalled this experience. It was my first lesson in the gift of presence. I now will sometimes do a parody with my students about the lesson I learned from Ella that day: Don’t just do something; sit there! In my reading about this topic, I came across the concept of presence. Being present is described as something that is multilayered—that in addition to offering our physical presence, there are deeper forms of “being with” someone. For example, being psychologically and emotionally present and attentive with someone involves good listening, empathy, being nonjudgmental, and fully accepting of that person and his or her experience. A further expansion of this concept, described as therapeutic presence by McDonough-Means, Kreitzer, and Bell (2004), described this kind of presence with another as a “spirit-to-spirit connection,” requiring “that the caregiver have skills of centering, intentionality, intuitive knowing, at-one-ment, imagery, and connecting” (p. 25). Geller and Greenberg (2014) describe therapeutic presence as: The state of having one’s whole self in the encounter with a client by being completely in the moment on a multiplicity of levels—physically, emotionally, cognitively, and spiritually. Therapeutic presence involves being in contact with one’s integrated and healthy self, while being open and receptive to what is poignant in the moment and immersed in it, with a larger sense of spaciousness and expansion of awareness and perception. This grounded, immersed, and expanded awareness occurs with the intention of being with and for the client, in the service of his or her healing process. (p. 7) We live in a world that values individuals for their productivity and efficiency. People tend to lead very busy lives, and if you are not busy, there is an implicit assumption that something



5.  The Practice of Presence

67

must be wrong with you. When at a social gathering, one of the first things people will ask is, “What do you do?” Our lives and mentality are built around doing, producing, and consuming. However, one of the most important skills required of a counselor is the ability to “be with” someone and not what to “do to” someone. Learning theory and acquiring skills for interventions with clients are both important for being a good counselor. However, interventions and book knowledge are not going to be enough when you have a client sitting in front of you who is experiencing intense emotional pain. Most training for counselors focuses on the content of the therapeutic encounter, emphasizing the development of communication skills and possible approaches and interventions to specific client issues (Riggall, 2016). Very little training explores the counselor’s quality of “being with” the client, and yet there is a good amount of research indicating that what fosters the most growth and change in therapy springs from the relationship that clients form with their counselor and the awareness of their counselor’s ability to journey alongside them, rather than the specific techniques that were utilized and the theoretical orientation of the counselor (Flückiger, Del Re, Wampold, & Horvath, 2018; Geller & Greenberg, 2014; Kottler & Carlson, 2014; Yalom, 2009). In short, the relationship with the counselor and the sense of the counselor’s attentive, engaged presence provide the foundation from which much of the work of the therapeutic encounter extends.

“BEING WITH” When you are starting out in the work of grief counseling, you might find that you get “stuck” in the process because you might not know what to say to a client or you may not know what to “do” when a client shares something that is deeply painful. You may be afraid of saying the wrong thing and making the client feel worse or of not saying enough and thus falling short of the desire to assist your client. Often, it happens that a great deal of time in the session is spent with the budding counselor nervously trying to decide what to say and how to respond to a client, experiencing a great deal of anxiety about what should be said and done, when it might be much more productive and meaningful to learn how to simply be with a client before uttering a single word. We would like to use this chapter as an opportunity to address some of these concerns from the standpoint that sometimes less is really not just more—but best. Beginning counselors often find themselves unsure about what to say, and they often feel pressured to say and/or do something that will make a difference to their client. However, if you really stop and think about it, there is nothing that you can say that will make a bereaved individual feel better, because you cannot bring back the lost person and you cannot return someone’s world back to the way it was before the loss occurred. The main issue, which is the significant loss of a loved one or of an aspect of the self that has been profoundly altered, is not something that can be fixed, changed, or reversed. There are no “a-ha” moments that will make a bereaved person all of a sudden look up and tell you that they are now “better.” Nothing you can say or do will change the amount of pain that person is experiencing from the loss they have experienced (Practice Example 5.1). In their everyday lives, most bereaved individuals are aware of a fair degree of social distancing by others who are afraid of saying the wrong thing or who do not want to make them

68

II.  Practice and Process

P R A C T I C E EXAM PLE 5 . 1 RECOGNIZING A PATIENT’S NEEDS AND BEING FULLY PRESENT

As a social worker for a busy inpatient hospice unit, Paul would often have the opportunity to get to know the patients on the unit and their families quite well. While checking on a few of the patients, Paul went into the room of Mr. Greene, who had end-stage lung disease. He had been told that Mr. Greene’s condition was deteriorating, and the family had been with him constantly for the past 2 days. When Paul entered the room, he noticed the family members all looked exhausted and stressed. Mr. Greene’s breathing was labored, and he was not responding to Paul’s voice. Paul asked the family if they would like to leave for a bit to get something to eat and take care of their own needs while he stayed with Mr. Greene. They were relieved for this opportunity, not wanting to leave Mr. Greene alone, but greatly needing a break. When the family left the room, Paul sat next to Mr. Greene and told him that he would stay with him. He sensed that Mr. Greene knew he was there, although he did not verbally acknowledge his presence. Paul focused on breathing with Mr. Greene and placed a hand on Mr. Greene’s hand. As he sat with Mr. Greene, he said to himself, “May you feel peace. May you know you are loved. May you rest.” As he did this, Mr. Greene’s breathing changed and became more regular. Paul stayed with Mr. Greene in this way until his family returned. As he left the room, he felt that the work he was able to do in the hospice unit was truly a privilege.

feel worse by what they say—so the tendency is to avoid the person and the discomfort that is aroused by the uncertainty (Harris, 2016). It is very important that grief counselors do not perpetuate this scenario. A helpful stance in working with bereaved individuals might be an understanding that you may not be able to help the bereaved individual to feel better; however, you can still make a tremendous difference by remaining fully present to that person and his or her experience as it is shared. With the advent of modern medicine’s focus on cure and fixing what is broken as the goal of professional helping, the emphasis on outcome and recovery has permeated our thinking about other aspects of life that may not fit very well into such a model. Healing, in this context, is more about care and process than about cure and outcome. Thinking “I cannot take this pain away from this person, but I can ensure that they will not have to go through this pain alone” may help to reframe some of the expectations around the role of the grief counselor. As we discussed earlier, grief is not a pathological state but an adaptive process that allows us to adjust and accommodate to significant loss events in our lives. In light of this understanding, one of the main goals of grief counseling would be to allow the adaptive aspects of grief to unfold without hindrance so that the bereaved individual can integrate the loss experience into his or her life. Thus, as a grief counselor, it is important to learn to “sit with” grief, even though it can be a very difficult and intense process at times. This “sitting with” someone involves cultivating a sense of presence that is open, engaged, and compassionate. We now attempt to describe what is meant by the term “therapeutic presence” and how to cultivate the practice of presence with oneself and with clients.



5.  The Practice of Presence

69

CULTIVATING PRESENCE Perhaps the best way to establish a strong therapeutic relationship with a client is to begin with your relationship to yourself. It has been said by many wise individuals that we cannot offer to others what we are not offering to ourselves. Indeed, the concept of the “wounded healer” (Nouwen, 1972) implies that we allow the painful life experiences that we have endured to sensitize us to the pain of others when they are in similar dark places. Much has been written in the counseling literature about the counselor’s use of self as a source of healing in the therapeutic relationship (Aponte & Kissil, 2016; Geller, Greenberg, & Watson, 2010; Wosket, 2017; Yalom, 2009). In this section, we look at important ways of thinking and being that will be of benefit when supporting others who are experiencing difficult and painful losses.

Safety Inside/Safety Outside This phrase does not have to do with locking windows and doors, but of taking stock of what it is like to feel emotionally comfortable and safe with ourselves and others. If you think about those who are closest to you and whom you trust, consider what allows you to trust them, and to feel safe sharing some of your deepest thoughts and feelings with them. When you know that someone will be honest with you, but will also show respect and regard for you, there is a sense of feeling safe with that person. Rogers (1995) stated that human beings crave unconditional love and regard, and this is not a narcissistic tendency, but a real need to feel safe and deeply appreciated. When we speak of “safety inside,” we are referring to your inner world—your thoughts, feelings, and reactions to yourself. For example, an individual who is continually driven to perfectionism and strives constantly to achieve may have an inner world filled with negative thoughts about not “measuring up,” or needing to prove their worth, or that they are lacking in some way. It is not unusual to hear someone say out loud, “I am so stupid!” These reactions can be comedic, and they are often not taken seriously—but it is important to listen deeply to the thoughts you tell yourself on a regular basis about how you perceive yourself and how you respond to life situations. Cultivating a feeling of being safe with yourself means that you are careful with yourself just as you would be careful with the words you share with someone whom you love—and you are no different from someone else who deserves your love and respect. Bluth and Neff (2018) discuss the importance of talking to ourselves as if we are our own best friend. Shame, the sense that something is deeply wrong with us, is a very painful experience, and the debilitating effects of feeling shamed by someone else can have a profound effect upon us. Shame differs from guilt in that when there is guilt, it is usually over something that we have done, which can hopefully be corrected or amends can be made. On the other hand, shame implies that there is something wrong with who we are, and we are paralyzed in our attempts to address it because there is no specific source or action—just a deep-seated sense of being inferior, feeling worthless, or being like damaged goods (Harris, 2010). Shame in this sense leaves us unable to connect with others in a meaningful way because we cannot move beyond the need to avoid the pain of it, while we are inescapably drawn to try to alleviate the ineffable source of the shame at the same time (Harris, 2010).

70

II.  Practice and Process

Checking in with the dialogue that occurs inside your mind is often referred to as listening to your “self-talk,” and it can be a very important place to start when you want to be a counselor. If you are in the habit of respecting yourself and being kind with yourself, while you are also honest in your self-appraisals, you can “sit” with yourself in calm and patient awareness. If not, “sitting with” yourself or with someone else will be much harder because you really are not safe in the silence; these times of quiet can become the moments when your mind can be permeated by negativity, self-loathing, and insecurity, and nobody would want to remain in that place very long (Warren, Smeets, & Neff, 2016).

Self-Awareness and Reflection Presence begins with the therapist’s self-reflective abilities and personal work as preparation for being with another person who is seeking the therapeutic encounter. Being able to understand yourself and what makes you “tick” may be very important when you are with clients whose experiences may be similar to yours or with individuals who may “trigger” some of your painful past experiences and associations. In our classes, we often give students an assignment that requires them to complete an inventory of the loss experiences of their lives, from birth to the present (see the Loss Line Exercise later in this chapter). These loss experiences may or may not involve the death of someone close; rather, they are experiences where life took a turn that was unplanned, unexpected, and required a period of adjustment and grief. Often, students will identify moving from one place to another, the loss of friends through changes in life situations, the ending of romantic relationships, and lost hopes and dreams alongside losses that have occurred after the death of someone significant. The purpose in assigning this exercise is to allow for an opportunity to reflect upon how these losses have shaped their lives and to see places where there may be some lingering vulnerability, enabling the ability to separate feelings and experiences from those of a client who may share a similar experience and feelings. In the development of greater self-awareness and open reflection on one’s life and experiences, there is an invitation to self-correct when necessary. The ability to respond to a situation by choice after reflection rather than to react quickly without much thought is certainly much more conducive to living in a way that is in line with your true intentions and values. This way of being will certainly give you a greater capacity to listen with openness to others who need to know that you will listen to and reflect on what they share with you rather than jumping in with quick advice and conclusions. Geller and Greenberg (2014) offer several suggestions for counselors to prepare for their time with a client. They suggest the following practice before the start of a session with a client: ■■

Before meeting your next client, take a moment just to be still. Whether seated or standing, feel your feet firmly placed on the ground.

■■

Begin to pay attention to your breath. Place your hand on your abdomen and feel your belly expand with a full inhalation and contract with a full exhalation. Pay attention to the rise and fall of your belly breath.

■■

Start to visualize your next client. Be open to the energy of this person, connecting to his or her human-ness.



5.  The Practice of Presence

■■

71

Open your eyes and walk to the door to greet this person, while connecting to the ground, to your breath, and to the intention for presence. (p. 236)

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

■■

■■

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

Geller and Greenberg (2002) state: Therapists’ presence is understood as the ultimate state of moment-by-moment receptivity and deep relational contact. It involves a being with the client rather than a doing to the client. It is a state of being open and receiving the client’s experience in a gentle, non-judgmental and compassionate way . . . being willing to be impacted and moved by the client’s experience, while still being grounded and responsive to the client’s needs and experience. (p. 85) Presence is one of the most difficult concepts for individuals in Western society to grasp, as the opening scenario of this chapter with Ella describes, because the main focus in helping professions is typically on “doing something” rather than “being with” someone. Our ability to offer our full attention and empathetic presence to another human being is one of the greatest gifts that we have. Learning how to be fully present to others begins with learning how to be fully present to ourselves and our experiences (Practice Example 5.2). A relatively new area of exploration is the intersection of Eastern philosophy with Western psychology, more specifically in the application of mindfulness to the therapeutic venue. Several authors describe the value of regular contemplative practice or the development of mindfulness practice for the therapist as a means to learn how to be fully present on a daily basis in one’s life and to apply this same practice of presence to being fully present to clients as they seek counseling (Epstein, 2007; Geller & Greenberg, 2014). Contemplative practices are designed to quiet the mind in the midst of the stress and distraction of everyday life in order to cultivate a personal capacity for deep concentration and insights. Examples of contemplative practice include not only sitting in silence, but also many forms of single-minded concentration, such as meditation, contemplative prayer, mindful walking, focused experiences in nature, yoga, and other contemplative physical or artistic practices. Various kinds of ritual and ceremony designed to create sacred space and increase insights and awareness are also considered examples of contemplative practice.

72

II.  Practice and Process

P R A C T I C E EXAM PLE 5 . 2 “BEING WITH” THE GRIEF COUNSELING CLIENT

Athena was completing her internship for her graduate training in counseling psychology. She had chosen to specialize in grief counseling, and the intake coordinator for the counseling center where she was an intern usually assigned clients with issues pertaining to loss and grief to Athena. One day, Athena was working with a young woman whose fiancé had been killed in a horrific accident. The client was distraught, caught up in the terrible events that led to the death of her fiancé. She was speaking rapidly, barely breathing, and her body was tense, with her eyes wide as she recalled what had happened. Athena froze. She could feel the anxiety emanating from her client and it made her feel anxious as well. In her head, she was rapidly trying to think of what she should say or do to help her client. At that point, she remembered the emphasis in her training on being present to the client. She took a deep breath and realized that her client was breathing very fast and shallow. So, she suggested that they stop for a moment and just focus on breathing and being in the room together. This simple suggestion seemed to help her client to settle a bit and it also helped Athena to focus on and stay present with her client during an intense time in their session.

Contemplative practice has the potential to bring different aspects of oneself into focus, to help develop compassion, and to awaken an awareness of the interconnectedness of all life. Some modalities draw directly or indirectly from these same practices to assist clients in developing ways of being and thinking in their lives that will foster re-entry into life after a significant loss event (Kabat-Zinn, 2005; Kumar, 2009). These same practices assist with distress tolerance and affect regulation, both of which are necessary when deep pain, suffering, and traumatic imagery come forth on a regular basis (Jacobs, 2015). The key aspect of any type of contemplative practice involves the development of a philosophy that allows for letting go of expectations and outcomes, as well as learning to live from moment to moment in the present, while cultivating greater tolerance of ambiguity and increased awareness and presence with one’s self and others (Halifax, 2013). We discuss the use of contemplative practices further in Chapter 13, “Caregiver Issues for Grief Counselors.”

Cultivation of Compassion Compassion is described as “. . . a multidimensional process comprised of four key components: (a) an awareness of suffering (cognitive/empathic awareness), (b) sympathetic concern related to being emotionally moved by suffering (affective component), (c) a wish to see the relief of that suffering (intention), and (d) a responsiveness or readiness to help relieve that suffering (motivational)” (Jazaieri et al., 2013, pp. 1117–1118). Halifax’s (2013) descriptions of compassion are very closely aligned with this description as well, adding the dimension of insights and discernment to recognize situations where relief of the suffering



5.  The Practice of Presence

73

may not be possible, but human presence and comfort may still provide a positive benefit. Neff, Kirkpatrick, and Rude (2007) define compassion as the ability to demonstrate kindness, understanding, and nonjudgmental awareness toward human responses, especially those that involve suffering, inadequacy, or perceived failure of some sort. Halifax (2011) states that compassion is a capacity that allows us to be attentive to the experience of others, to be able to wish the best for others, and to sense what will deeply serve others. These authors state that compassion serves as a buffer against anxiety and leads to enhanced psychological well-being. Compassionate responses take into account the awareness that we all share common human experiences and traits. Nobody is perfect, nobody is immune from painful life experiences, and nobody is spared from some kind of suffering at some point in time. Individuals who gravitate toward the helping professions typically have a great deal of empathy for others, but they often have difficulty feeling compassion toward themselves. To deny compassion for ourselves can be highly detrimental, because to separate ourselves out from the compassion we may extend to others means that we will be left looking to others to prove that we are valuable and worthy because we are unable to do this for ourselves. It can be dangerous to have this kind of mentality and to be working with vulnerable individuals, because without a strong sense of self-compassion, the helper will need clients to bolster their weak sense of self, and in the process may inadvertently use clients for their own needs, thus violating the objective of the therapeutic relationship to place the client’s needs as primary. Stop and think for a minute about how you define compassion. If you were to describe someone who is compassionate, what would their attributes be? People who are identified as compassionate are those who see the suffering of others and are moved to address this suffering in some way. Cultivating compassion involves a willingness to see the pain of others, to allow yourself to be exposed to others’ suffering, and to choose to be an instrument of relief to that suffering in ways that are possible. Because we cannot remove many of the causes of suffering, such as death and significant losses, we resonate with those who suffer by bearing witness to their pain, journeying alongside those who are grieving, and being present and nonjudgmental to those who suffer. Far from being a passive process, demonstrating compassion requires us to actively and decisively “be with” another individual when others may leave quickly or get frustrated because they cannot “fix” what has happened. Being compassionate requires a great deal of inner strength and awareness, and it takes time and practice to cultivate the ability to remain grounded, focused, and fully present in such an engaged and open way (Vachon & Harris, 2016). The Being with Dying Program, developed by Roshi Joan Halifax and offered through the Upaya Zen Center in Santa Fe, New Mexico, for healthcare professionals working in end-oflife care, is based on the development of mindfulness, receptive attention, and cultivation of presence through contemplative practice. The premise of the training is that cultivating stability of mind and affect (emotions) enables clinicians to respond to others and themselves with full presence and compassion (Halifax, 2012, 2013). The program provides skills, fosters reflection on attitudes and behaviors, and offers tools that change how caregivers work with the dying and bereaved. Halifax and her colleagues developed the GRACE model to help

74

II.  Practice and Process

clinicians to focus on compassionate responses in their interactions. The acronym GRACE stands for: G—Gather your attention R—Recall your intention A—Attune by checking in with yourself, then the patient/client C—Consider what will really serve by being truly present in the moment E—Engage, enact ethically, and then end the interaction The practice offers a simple and effective way to open to the experience of the suffering of others, while remaining centered and connected to your own deepest intentions, and in so doing, fosters the capacity to respond with compassion in all types of situations (Halifax, 2013). We discuss this model further when we address caregiver issues in Chapter 13, “Caregiver Issues for Grief Counselors.” Many forms of therapeutic training require student counselors to be in counseling themselves as part of their training. There is certainly merit to this approach, because one of the best ways to develop empathy for clients in the therapeutic setting is by being a client yourself. Being a client is also an excellent way to see the process modeled through your encounter with a trained counselor and also a good start to developing skills for self-awareness and reflection. There is perhaps no better way to learn than by doing!

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

Loss Line Exercise A personal loss is any loss that results in a significant change to our lives. Personal losses may include the death of a significant person, relationship loss, job loss, pet loss, loss of dreams, divorce, immigration, loss of health, or loss of self. Losses can be tangible (such as loss of employment) or intangible (such as loss of hopes or dreams). 1. Create a list in chronological order of all of your personal losses. Include only the

year and who or what was lost. For visual impact, it is helpful to diagram these losses on a timeline on a sheet of paper.

2. Look over this “loss line” that you have made. Think about each loss that you have

indicated on the sheet of paper and its impact on your life. Make note of developmental or maturational differences at each stage of life that is highlighted in the loss history. How have your losses shaped you as a person now? What losses still feel “raw” or continue to overshadow your life at this point in time? How would the way you have handled your losses affect how you will work with a client who has encountered similar losses to yours?



5.  The Practice of Presence

75

Presence Exercise (You Will Need a Partner for This Exercise)1 Ideally, partners should not be too familiar with one another, although this might be unavoidable. It might be helpful to have a third person read this exercise aloud for the two partners who are participating in it. Part One

Please sit facing your partner, at a comfortable distance apart but close enough that you could lean forward and whisper to one another. Begin by closing your eyes and settling into your body. Try to recall a time when you opened your eyes on the world in innocence and wonder. If you cannot recall such a time, simply visualize that you now have those eyes that are about to open on the world, as if for the first time. Take a few moments to try to discover this inner sense of wonder and innocence. Now, open your eyes, keep your gaze lowered, and try to maintain a soft, slightly unfocused seeing, as opposed to staring or glaring. . . . You will be looking in the area of your partner’s knees or lap. Please open your eyes softly now. You become aware of the presence of another. In your visual field, there is something that all of your senses tell you is not simply an inanimate object. Even just looking into this area of the person before you, your innate knowing tells you that this is a living being, just like you. Even at this stage you may sense the movement of breath in the other. And now very slightly and gently raise your field of vision to include the lower abdomen of your partner—focusing on the area below the rib cage. Now you clearly become aware of the breathing of another. It may happen that the rhythms of your in-and-out breaths begin to harmonize. Do not strive to consciously make this happen—just gently observe whether this synchronicity arises naturally. Calmly and silently stay with this awareness for a few moments. Next, raise your vision very slightly, keeping this field soft and unfocused, from the shoulders down to the lap, so that you are gently taking in the whole upper torso of the person before you. You become aware in looking at this other and feeling your own breath that breathing involves the entire upper body—not just the nostrils, not just the lungs. Now you can more fully sense the presence of this person in front of you. Now, slowly, gently, and with compassion for both yourself and the other, please look into the face of your partner. . . . You behold a face completely unique in the world and, yet, fundamentally not so different from yours. . . . You can see in this face, as if looking in a mirror . . . this face that has known countless moments of loss and grief of all degrees . . . this face that has yearned for the same joys as you . . . this face that has been thrilled with love and acceptance . . . and torn by rejection and shame . . . this face that expresses the whole history of the heart . . . this person who longs for the same peace and happiness you do . . . this universal longing for the end of suffering. . . . Just gently allow yourself to look into the eyes and face before you for a few more moments. . . . At this point, sometimes some giddiness or reluctance arises because doing this part of the exercise can be uncomfortable, and you may feel self-conscious. If this occurs, try to raise 1

This exercise is used with permission from Brad Hunter.

76

II.  Practice and Process

your sight one last time and simply look innocently and deeply into the face of your partner. When you follow this instruction, please do not avert your gaze. If it feels too intense for an instant, just close your eyes and locate that innocent, nonjudgmental vision again. Part Two

At this point, you will need to think of a true story of personal loss. How current and how profound the loss is completely up to you. But obviously, the more profoundly you share, the more powerful this experience will be. Just take a second to decide who is going to share first. . . . The listener who is bearing witness to the story of loss just listens. It is vitally important that there should be no cross-talking. Please hold back your impulse to reach out and touch or comfort the person for now. You do not have to sit poker faced—your body language and facial expressions are going to naturally respond to the story, but please do not speak. Allow about 3 to 5 minutes for telling the story. When the first partner has completed telling his or her story, then signal that the second partner can begin to share his or her story. When the second partner has completed telling his or her story, allow a few moments to close your eyes and be with your partner. Then, share with each other what it was like to do this exercise. What was it like to listen without being able to “do” or say something? How did it feel to share in this context? This exercise is often a poignant demonstration of how difficult it is to simply be fully present to someone else without “doing” something. It gives an idea of how to engage with someone by offering presence without interfering with the other person’s flow or process.

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

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



5.  The Practice of Presence

77

GLOSSARY Compassion  Sensitivity to the suffering of one’s self and others with the desire to relive that suffering; the ability to demonstrate kindness, understanding, and nonjudgmental awareness toward human responses, especially those that involve suffering, inadequacy, or perceived failure of some sort. Presence  The act and intention of “being with” another individual, with full attention and engagement. Therapeutic presence  Involves the counselor engaging the skills of centering, intentionality, intuitive knowing, at-one-ment, imagery, and connecting with the client. Wounded healer  Implies that we allow the painful life experiences that we have endured to sensitize us to the pain of others when they are in similar dark places.

QUESTIONS FOR REFLECTION 1. In your own experience, what might hinder your ability to be fully present to

another person as described in this chapter? How does presence in this chapter concur with or diverge from how you have viewed being a helper to those who are in painful circumstances?

2. Complete the two exercises described in the chapter with someone whom you

trust. What was the experience like for you? How about for the person who completed the exercises with you?

3. We are often conditioned to think of healing to be the same as cure or being

relieved of a painful situation. Based on the concepts in this chapter, how can healing include times when it is not possible to change someone’s circumstances or relieve their pain?

4. Think of times when you have been uncomfortable because you did not know

what to say or do. Can you think of other ways to remain in these situations, using the concepts about presence that were presented in this chapter?

REFERENCES Aponte, H. J., & Kissil, K. (Eds.). (2016). The person of the therapist training model: Mastering the use of self. New York, NY: Routledge. Bluth, K., & Neff, K. D. (2018). New frontiers in understanding the benefits of self-compassion. Self and Identity, 17(6), 605–608. doi:10.1080/15298868.2018.1508494 Epstein, M. (2007). Psychotherapy without the self. New Haven, CT: Yale University Press. Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy 55(4), 316–340. doi:10.1037/pst0000172 Geller, S. M., & Greenberg, L. (2002). Therapeutic presence: Therapist’s experience of presence in the psychotherapy encounter. Person-Centered and Experiential Psychotherapies, 1(1–2), 71–86. doi:10.1 080/14779757.2002.9688279 Geller, S. M., & Greenberg, L. S. (2014). Therapeutic presence: A mindful approach to effective therapy. Washington, DC: American Psychological Association. Geller, S. M., Greenberg, L. S., & Watson, J. C. (2010). Therapist and client perceptions of therapeutic presence: The development of a measure. Psychotherapy Research, 20(5), 599–610. doi:10.1080/1050 3307.2010.495957 Halifax, J. (2011). The precious necessity of compassion. Journal of Pain and Symptom Management, 41(1), 146–153. doi:10.1016/j.jpainsymman.2010.08.010

78

II.  Practice and Process

Halifax, J. (2012). A heuristic model of enactive compassion. Current Opinion in Supportive and Palliative Care, 2(6), 228–235. doi:10.1097/spc.0b013e3283530fbe Halifax, J. (2013). Being with dying: Experiences in end-of-life-care. In T. Singer & M. Bolz (Eds.), Compassion: Bridging practice and science [ebook] (pp. 108–120). Munich, Germany: Max Planck Society. Harris, D. L. (2010). Healing the narcissistic injury of death in the context of Western society. In J. Kauffman (Ed.), The shame of death, grief, and trauma (Vol. 1, pp. 75–87). New York, NY: Routledge. Harris, D. L. (2016). Social expectations of the bereaved. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 165–176). New York, NY: Routledge. Jacobs, C. (2015). Contemplative spaces in social work practice. Journal of Pain and Symptom Management, 49(1), 150–154. doi:10.1016/j.jpainsymman.2014.10.004 Jazaieri, H., Jinpa, G. T., McGonigal, K., Rosenberg, E. L., Finkelstein, J., Simon-Thomas, E., . . . & Goldin, P. R. (2013). Enhancing compassion: A randomized controlled trial of a compassion cultivation training program. Journal of Happiness Studies, 14(4), 1113–1126. doi:10.1007/s10902-012-9373-z Kabat-Zinn, J. (2005). Full catastrophe living. New York, NY: Bantam. Kottler, J. A., & Carlson, J. C. (2014). On being a master therapist: Practicing what you preach. Hoboken, NJ: Wiley. Kumar, S. M. (2009). The mindful path through worry and rumination. Oakland, CA: New Harbinger. McDonough-Means, S. I., Kreitzer, M. J., & Bell, I. R. (2004). Fostering a healing presence and investigating its mediators. The Journal of Alternative and Complementary Medicine, 10(1), 25–41. doi:10.1089/1075553042245890 Neff, K. D., Kirkpatrick, K. L., & Rude, S. S. (2007). Self-compassion and adaptive psychological functioning. Journal of Research in Personality, 41(1), 139–154. doi:10.1016/j.jrp.2006.03.004 Nouwen, H. J. (1972). The wounded healer: Ministry in contemporary society. New York, NY: Doubleday. Riggall, S. (2016). The sustainability of Egan’s Skilled Helper Model in students’ social work practice. Journal of Social Work Practice, 30(1), 81–93. doi:10.1080/02650533.2015.1082465 Rogers, C. (1995). On becoming a person. New York, NY: Houghton Mifflin. Vachon, M. L., & Harris, D. L. (2016). The liberating capacity of compassion, In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 265– 281). New York, NY: Routledge. Warren, R., Smeets, E., & Neff, K. (2016). Self-criticism and self-compassion: Risk and resilience: Being compassionate to oneself is associated with emotional resilience and psychological well-being. Current Psychiatry, 15(12), 18–28. Wosket, V. (2017). The therapeutic use of self: Counselling practice, research, and supervision. New York, NY: Routledge. Yalom, I. (2009). The gift of therapy. New York, NY: HarperCollins.

CHAPTER 

6

T HE BA S I C S OF C OU N S E L I N G P RA CTIC E

LEARNING OBJECTIVES 1. Describe common attending skills and their importance in the counseling relationship. 2. Identify ways that the counselor can verbally track the client’s story. 3. Explain the purposes of both open and closed questions in counseling and provide examples of each. 4. Define what is meant by empathy and advanced empathy in the therapeutic alliance, and why empathy is so important in counseling. 5. List the three types of self-disclosure and discuss when counselor self-disclosure is appropriate.

INTRODUCTION Although we firmly believe that counseling practice is rooted in the personhood of the counselor and the relationship that is formed between the counselor and the client, there are some therapeutic techniques and responses that you might find helpful to “give words” to your intentions with clients. Counselors who are newer to the field will often say that they are concerned they will say something that will make the bereaved person feel worse, will say something that is inappropriate, or will not say anything and will feel foolish because they are tongue-tied. Hopefully, this chapter provides some ideas for responding sensitively to

80

II.  Practice and Process

bereaved individuals, and perhaps provides more. We start with some basic skills to incorporate into your regular, everyday practice and then discuss how to get started with a client. We then go to some “trickier” areas that you might want to consider as you begin working with clients.

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

ATTENDING SKILLS Attending skills are very basic things to which you need to “attend,” both in yourself and in your client. When you are attending to your client, you are focused on what your client is sharing, on your client’s body language, and on your own inner responses and body language. It is important to keep in mind that much of our communication with others is nonverbal, even when someone is talking. So, we listen to someone’s words, but we also perceive their body language to identify what may be “underneath” the words—and clients do the same with you as well. So it is important that your body language and your focus be congruent with your intentions and the words, thoughts, and feelings that you share with the client. Here are some basic thoughts about attending: 1. Eye contact—Involves looking at clients in a culturally appropriate way. This does

not mean maintaining an unrelenting gaze, but rather looking into their eyes from time to time, especially when they are speaking, so that they are connected with you and they know you are focused on them. It is very important to remember that not all cultures interpret eye contact as comfortable or appropriate. If you notice that your client seems uncomfortable with maintaining eye contact with you, you may want to modify your gaze to looking just to their side or occasionally looking down from their eyes for brief periods of time. If the eye contact discomfort seems obvious, it is a good opportunity to check in with your client about comfort and expectations around this issue. Another reason that clients may feel uncomfortable with eye contact is that some people are unaccustomed to being the intense focus of another person’s attention in the way that a counselor may focus on a client in a session. These feelings and issues provide a chance to deepen the trust and respect in the encounter if they are approached in a sensitive and respectful way.



6.  The Basics of Counseling Practice

81

2. Vocal qualities—You need to think about your rate of speech, the volume of your

speech, and your tone when speaking with clients. We tend to speak very quickly because we are accustomed to quick responses and sharing a lot of information in short snippets of time either through technological means or in short encounters with others. It is important in the counseling session to consciously slow things down, to take the time to focus not only on what is being said, but also on how it is being said. You should think about how you speak so that you are easy to hear— not too high, too low, or monotonous. Ask a trusted friend for feedback on your verbal quality or listen to yourself on a recording device—the voice is an instrument that can be fine-tuned, if need be.

3. Verbal tracking—Involves active listening on your part, where you follow the

client’s story, asking relevant questions that permit deeper understanding. Do not interject your own ideas, unless they would be helpful to the client, and conduct the session such that the client does most of the talking. You cannot follow every detail of the client’s narrative, and some clients are confused and scrambled in their account, but search for the main threads and themes that make a complete whole. Another related aspect of verbal tracking is sometimes referred to as “intuitive tracking,” which focuses not as much on the details as on the implicit feelings and meanings that a client shares with you. This may take some time to develop, and it may be a skill that is easier for some more than others to practice.

4. Attentive body language—Your positioning and physical presence can send a

powerful signal to clients that you are tuned in to them. The same can be said for when your body language might demonstrate disinterest, impatience, tiredness, or distraction. Think about the bodily clues that indicate to you that someone is listening to you and engaged with you. We usually suggest that you should be sitting about 4 feet from the client, and often not directly facing the client, but turned to the side a little. When listening, you may wish to lean slightly in the direction of your client and not be afraid to use hand gestures and facial expressions that help to convey your thoughts. When watching videotaped sessions of clients and counselors, it is common to see that the counselor begins to unconsciously mimic the client’s body language, facial expressions, and gestures. This synergy between the counselor and the client is common, and it often indicates that there is a comfort and sense that the counselor and the client are “in tune” together.

Clients tend to feel uncomfortable if you are too close or your body language

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

82

II.  Practice and Process

A related issue is whether or not to take notes during a session. We feel this

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

5. The SOLER model—One of the easiest algorithms to remember about attending

skills with clients is described by Egan and Reese (2019) in their work titled The Skilled Helper. In the SOLER model, we keep in mind the following:



S—Squarely face the client or be at 45°. Do not have a desk or table between you.



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



L—Lean toward the client slightly, bending toward the client to invite conversation.



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



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

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



6.  The Basics of Counseling Practice

83

see it occur when the client and the counselor are deeply engaged in the session (Lakens & Stel, 2011). Verbal tracking is used by the counselor to more closely follow the client’s story or how a client tends to share an experience. In verbal tracking, the counselor tends to “pick out” things that point to a deeper level of a client’s experience or awareness. Clients tend to illustrate their life themes by underlining words with significant meanings. When clients use words that indicate strong feeling states or have an intense association or connotation, it is important for the counselor to take note and not miss these cues. Examples of these types of words might be hopeless, helpless, at a dead end, overwhelmed, paralyzed, and lost. These words often carry a great deal of significance for how the client perceives what has happened or where the client’s “crux” issue may reside. One important point to make when discussing this aspect of verbal tracking is to be aware that counselors may have their own selective attention—meaning that we might tend to focus on what we think is important and, in so doing, we could miss what the client feels is important. Awareness about our own biases and areas in which we are more comfortable in a dialogue may help to prevent us from tracking clients in a way that is more suitable to our interests and needs than to what a client may need. Another form of tracking is to follow the use of language that the client uses. For example, some clients tend to be very concrete in their thinking, and literal in how they share their experiences. These clients may be uncomfortable or feel confused if the counselor uses metaphors and abstract interpretations in their discussions together, and they may be more comfortable discussing things in a more concrete and behaviorally oriented way. Other clients may readily want to discuss patterns in their lives and seek to understand their underlying feelings and motivations. Matching a client’s style may help the client to be more comfortable, especially in the beginning of the counseling relationship. With time, clients may experience more growth and expand their awareness of themselves and others if they are challenged to think in ways that might, at first, seem a little “out of the box,” but this type of challenge is usually not helpful until the therapeutic alliance is well established. When clients make statements such as “I think . . .,” or “I feel . . .,” or “I believe . . .,” they are making “I” statements. These statements are important indicators of the inner world of the client and need to be attended by the counselor. Many clients have a great deal of difficulty making these kinds of statements because they are not accustomed to being heard or valued; if this is the situation, the counselor might have to encourage the client to make these statements in the sessions in order to try out their use in conversation. One final aspect of verbal tracking is paying attention to the client’s verbal style. Most people demonstrate a clear preference in verbal styles, and if you listen carefully to the words that a client chooses in his or her descriptions, you can “match” your client’s style more readily, and the client may feel more comfortable sharing. In addition, matching a client’s verbal style invites rich descriptions and explorations of the client’s world and feelings, which can be very helpful in the counseling process. When a counselor attends to this aspect of the client’s sharing, the client often feels deeply understood and quite comfortable in the exchange. Examples of verbal styles might be as follows: ■■

Visual—Ihe client uses words that speak about seeing, imagining, visualizing, providing details.

84

II.  Practice and Process

■■

■■

Auditory—The client uses words that focus on what is heard and may say things that incorporate words and phrases like hearing, sounds like, harmony, noisy, dissonant. Kinesthetic—The client focuses on movement, action, doing, feeling, touching, warmth, sharpness.

APPROPRIATE USE OF QUESTIONS Questions are typically the way we elicit information from others. Certainly, in some of the humorous skits that are done of a counseling scenario, the counselor asks the client a question, and then writes something down on a notepad, sometimes with a scratch of the chin and a comment like, “Hmmm . . . that’s very interesting. . . .” There are some important things to remember about asking questions of clients. First, asking a question puts the counselor in charge of the session, and if you recall from our earlier discussion, we want to empower the client to take the lead in the counseling session; by asking a question, you are requesting a response with a specific answer and taking the session in a direction that may be different from where the client may have initially wanted to go. Asking too many questions in a row can cause clients to feel more like they are being interrogated rather than being heard. In addition, it is important to be careful not to use asking questions as a means to “fill” silence in a session because you are uncomfortable with it. Silence and pauses in the session may be important times for the client to be able to sort through some of his or her thoughts and feelings without interruption. Beginning counselors often report that they experience pauses, silence, and breaks in the conversation as awkward and uncomfortable. If there is a pause in the session, stop and take a breath before you speak. Allow yourself to wait for a minute or two—follow your client’s lead—and see if this poignant time gives your client a chance to gather his or her thoughts a little and to go deeper with the material rather than being immediately sidetracked by having to answer a question that you have interjected (Practice Example 6.1). There are basically two types of questions, and each can serve a good purpose. Closed questions are those that can be answered with a “yes” or a “no,” or often with a single word. Closed questions often provide the facts, such as address, age, and length of time since an event, and often begin with “where,” “is,” “are,” and “do.” Closed questions are helpful for asking for specific information, such as demographics, and questions that are pertinent to counseling but are not necessarily part of the process. Examples might be, “Have you seen a counselor before?” or “Do you have a regular medical doctor?” Of course, many clients will often answer a closed question as if it were an open one because of their need to talk. Sometimes, an entire session will open with a simple question that is asked of the client, and the client chooses to elaborate on the answer because they feel it is something that is important. Open-ended questions often begin with “what,” “how,” “why,” and “could” and allow clients to respond according to their needs. These types of questions invite clients to



6.  The Basics of Counseling Practice

85

P R A C T I C E EX AM PLE 6 . 1 ALLOWING ROOM FOR SILENCE

Rashida was a counselor who had been seeing Barbara, a woman in her 60s who had been struggling with many different loss-related issues in her family. Barbara typically came into the sessions and talked nonstop, with Rashida doing her best to try to keep up with her. One day, Barbara came into Rashida’s office and began talking even before she was sitting down. She was very upset, as her beloved dog had died 2 days prior. She continued talking rapidly until she got to the part when she first adopted her dog as a puppy. Tears began to trickle down her cheeks, and she looked to the floor in front of her and stopped talking. Rashida was surprised that Barbara was not talking. She was about to interject her condolences about Barbara’s dog, but something told her to just sit with Barbara at this time. It was a long time. Rashida looked at the clock on the mantle above Barbara’s head, and it had been 7 minutes of silence, which was unheard of for Barbara’s sessions. She began wondering if she should say something, wanting to know what Barbara was thinking or feeling, and if she was okay, but decided to wait. Barbara was deep in thought, with tears continuing to trickle down her cheeks. Rashida tried to breathe and share this silence with Barbara. She was not sure what was more difficult—trying to keep up with Barbara’s ongoing rapid-fire talking, or this long, protracted silence. It was hard. Finally, Barbara looked up at Rashida and said, “I really needed that. I have no other place to go where I know someone won’t dismiss how much I loved that dog.”

elaborate on their story and add the details as they wish (Box 6.1). Open questions usually cannot be answered briefly, and they often require some thought or expression of feeling. Questions that start with “who,” “what,” “how,” “when,” “why,” and “where” might be open or closed, but in beginning a sentence with one of these words, you are asking  for  an answer. The word you use to open a sentence determines the focus of the answer: ■■

Who—people

■■

What—facts

■■

How—feelings and reactions

■■

When—temporal aspects

■■

Why—reasons (use sparingly)

■■

Where—environment and setting

■■

Could—might be the most open and productive of all questions

86

II.  Practice and Process

BOX 6.1 OPEN-ENDED QUESTIONS FOR GRIEF COUNSELING SESSIONS

Open-ended questions are used for the following purposes at specific times: 1. To begin the session, or to move the client forward in a story, indicating that you are listen-

ing and wanting more detail: “Can you share with me a little about what brought you to counseling?” “What are your thoughts about what is happening in your life right now?” “After the death, what were things like among the other family members?” 2. To move the client more deeply into his or her world or experience:

“Could you tell me more about that?” “What has this experience been like for you?” 3. To clarify specific information about what the client has shared:

“Can you give me an example of what you mean?” “How have you managed to get through this time?” 4. To assess aspects of the client’s situation and supports:

“Who has been there to support you the most?” “What is your typical day like right now?”

Here are some guidelines to keep in mind in regard to the use of questions: 1. Use questions consciously and selectively when you need the information and can

“go for it” when needed.

2. Think of how you can incorporate awareness-expanding questions into your

sessions:



“Can you describe your ideal . . .?”



“What might your life look like if this were changed?”



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

3. All questions and probes need to be grounded in empathy—understanding that

there are valid reasons why a client has made choices and an appreciation of what that person has gone through before getting here.

4. Build in an internal alarm that goes off if you ask two or more questions in a row

and look at why you are asking these questions. Asking too many questions stops the flow, tends to keep the client in his or her head, and leads the client too much.

5. Base questions on the context of the session and what the client is bringing up. 6. You must ask questions if a person seems suicidal.



6.  The Basics of Counseling Practice

87

7. Avoid using questions when you want to show empathy—use a statement instead.

For example, you can say, “This must be a very hard time right now,” instead of asking, “How difficult is this for you right now?”

8. Avoid closed questions as much as possible when you are in the midst of a session. 9. Try to avoid using the word “why” when asking a question, because it may tend

to appear judgmental or accusatory to a client and doing so can place the client in a defensive posture with you, which is counter to your intention of establishing a safe place in the counseling venue.

EMPATHY Empathy is perhaps one of the most essential components of counseling practice. The ability to join empathetically with a client involves your ability to essentially “get into the client’s shoes” and see and experience things as if you were the client. Empathy is not just imagining how you might feel in the place of another. It is imagining and trying to understand what the other person feels. The difference between thinking about yourself in another’s situation and thinking about the other person in that situation is simple but profound, requiring well-­developed, differentiated mental abilities. Empathy is other-focused, not self-focused. Someone with sociopathic tendencies can “read” other people well and understand their emotions. But a sociopathic person reads others in order to manipulate or take advantage of that person. It is not empathy (Segal, 2018). Rogers (1959), the founder of person-centered therapy, described empathy as the counselor’s ability . . . to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the “as if ” condition. Thus, it means to sense the hurt or the pleasure of another as he [or she] senses it and to perceive the causes thereof as he [or she] perceives them, but without ever losing the recognition that it is as if I were hurt or pleased and so forth. (p. 185) Responding to a client with empathy means you intentionally move into your client’s frame of reference—how things seem and feel to your client, trying to experience the world as your client does, while maintaining your awareness that this frame of reference and experience is not yours. All good counseling practices aim to increase our empathetic understanding of our clients with the understanding that joining with clients in this way helps them to feel deeply understood and accepted. You have probably heard the phrase “walk a mile in my shoes.” Empathetic joining is your attempt to do just that—to walk in your clients' shoes, see through their eyes, and think about how the world is experienced by them. When we are empathetic in our stance, we share a valued sense of resonance with our clients, and this experience can be very powerful for them. Sometimes, in the process of trying to experience the world as your client does in empathetic joining, you may get an intuition about something that the client may not have stated openly but seems to be apparent once you begin to join more with that client. This occurrence

88

II.  Practice and Process

is sometimes referred to as advanced empathy (Egan & Reese, 2019). It is important to note that you might actually be aware of something that the client is experiencing, which may not necessarily be in the client’s conscious awareness, but is there—the client is generating it and you perceive it. When you listen empathetically to clients, you are often not just listening to their words and using the attending skills described previously, but rather may be engaging in a deeper form of listening that involves your intuition and your own responses to the client’s material. Yalom (2009) spoke of using the “rabbit ears” of the therapist—picking up on often understated but very significant aspects of the client’s story and experiences. Wong (2004), the president of the International Network on Personal Meaning, describes what is meant by advanced empathy: Advanced empathy requires the listener to go beyond verbal and nonverbal expressions, to develop an insightful awareness and understanding of another person’s intentions, desires and unspoken concerns. It requires the skill to listen with the sixth sense, to feel the pulse of the innermost being, and to make explicit what is hidden beneath consciousness. It involves the insightful construing of meaning and significance from a variety of seemingly trivial clues. It tests hypothesis about the missing pieces of the puzzle and anticipates solutions. (para. 25) Whenever you think you are “tuning in” to your client in this deeper way, and you believe that you have an insight for the client as a result, it is important to check your perceptions with your client. You can let the client know that you have a “hunch” about something and want to know his or her thoughts about it. Using advanced empathy in this way is not an interpretation or even a “brilliant figuring out” of the client’s material, but an opportunity to share in your client’s world in a deeper way. When you experience advanced empathy, you may sense a pattern emerging and you really “get it”—the connections become apparent between the client’s story, experiences, feelings, and thoughts, and there is a certain clarity that you then reflect back to the client. Remember to offer your hunch as a possibility—invite the client to look at it, and if the client pulls away or does not agree, immediately move on to something else and do not dwell on it (Practice Example 6.2). Empathy is more than a set of skills, and for many counselors it is an innate quality. Learning what empathy is and how to enhance your ability to enter your client’s world in this way is of paramount importance to the development of the therapeutic alliance, where clients feel safe to share their thoughts and feelings and engage with you in a meaningful way. For empathy to be effective, the therapist needs to develop the attitude or mindset of empathy. In other words, empathy works only when it comes from a person who really cares about people and who truly has a compassionate heart. Knowing that the counselor truly cares about the client and values the client is far more important in this process than intellectual understanding and knowledge of details. This type of caring about your clients will “cover” a lot of counselor errors in timing, misunderstandings, and inadvertent miscommunication. A counselor can come across to a client as patronizing, judging, or condescending in the absence of an empathetic connection.



6.  The Basics of Counseling Practice

89

P R A C T I C E EX AM PLE 6 . 2 USE OF ADVANCED EMPATHY IN THE GRIEF COUNSELING SESSION

Sarah was a social worker in a family health unit. Janet, a young widow, had been referred to her by one of the nurses on the unit after Janet had an angry outburst when the nurse expressed concern that Janet needed to be looking after herself more. In the first session, Janet expressed anger at how unfair it was that her husband Ron had died young, leaving she and their two young sons alone and in financial straits. In the second session, Janet described the financial problems she was having to handle from her husband’s business, becoming aware that he had a great deal of debt from the business startup. She railed about how unfair life was, and her anger was palpable. As Sarah listened to Janet’s anger, she tried to imagine what it would be like if she was in Janet’s position. What she began hearing underneath Janet’s anger was deep hurt that Ron had not talked with her about his business decisions and he had not purchased life insurance, even though they had agreed that he would do this when he left his corporate job to start his business. At one point when Janet paused in the session, Sarah gently stated, “It sounds like it is really hard for you to reconcile the Ron who said he loved you with the Ron who neglected to talk with you about this debt and who also didn’t buy the life insurance he said he would. This must feel very hurtful to you.” Janet paused, her lips trembling, and her eyes filled with tears. “Yes … I can’t believe that he didn’t put us first.”

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

■■

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

90

II.  Practice and Process

based on what you think the client’s verbal style is, and then condense the material in your own words to check with the client for accuracy:

Sight—“As I see things . . .”



Sound—“As I hear you speak . . .”



Movement—“You appear moved by this . . .”



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

■■

Summarizing—Similar to paraphrasing, a summary will cover a longer timeframe and more information. Summarizing can be used to begin the session, for example, “Last time we were together, we talked about. . . . What has happened since?” In the middle of the session, summarization may help to wrap up one part of the session, before going on to something else: “Up until now, we have talked about how it was at the funeral. You have mentioned what happened that day, some of the issues with your family that arose, and how you felt just before the funeral . . . so, I wonder now what took place in the weeks following his death?” A good summary is often very useful at the end of the session to review what has taken place during the session. Use the sentence stem, a summary of important events and the feelings and key descriptors connected with them, and end with a check for accuracy. For example, “As I see the situation, you have been distraught over the death of your sister, partly because it was accidental, and you had no time to prepare. You have had to be the strong one in the family and support your parents and siblings in their grief. It is possible that you have not taken the time to feel your own grief in the face of all that you have had to do, and now you are overwhelmed and seem ready to collapse. It sounds like there is a lot on your plate, and perhaps we can start with these issues at our next session.”



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



6.  The Basics of Counseling Practice

91

It is important to remember that timing is crucial when you decide to draw attention to something that you experience with the client in the session. Immediacy is a bit of a “dance” between self-disclosure and feedback, because you choose to share something that you experience with the client in the here and now. Because this type of feedback is uncommon in most people’s lives, clients may not know exactly how to handle you sharing your experience of them during sessions so forthrightly and some clients may feel that you are challenging them or that you are criticizing them. Using immediacy requires skillful communication and perception of both the self and the client by the counselor. We are taught socially not to address issues in this way, so it involves a relearning process. Using immediacy means we are naming what is going on and bringing it up into the conscious awareness in the room. You are noticing what you are seeing and talking about it openly. Yalom (2009) gives an example of how he might use immediacy with a client who casually makes a statement before repeating an oft-told story to him during a session: “I know you’ve heard this story before but . . .” (and the patient proceeded to tell a long story). “I’m struck by how often you say that I’ve heard the story before and then proceed to tell it. What’s your hunch about how I feel listening to the same story over again?” “Must be tedious. You probably want the hour to end—you’re probably checking the clock.” “Is there a question in there for me?” “Well, do you?” “I am impatient hearing the same story again. I feel it gets interposed between the two of us, as though you’re really not talking to me. You were right about my checking the clock. I did—but it was with the hope that when your story ended, we would still have time to make contact before the end of the session.” (pp. 24–25) Keep in mind that clients may not be used to this type of interaction, and they may interpret it as judgment, shaming, or “calling them on the carpet” when that is not your intention. Therefore, it is very important that you ground any feedback like this in ­empathy and that you are careful and considerate when you first begin to incorporate its use in your work with a client. Some other examples of immediacy might be like the following: “I noticed you sighed just now. I wonder what that’s about . . .” “Your face grimaced as you talked about that . . .” “I am feeling this right now . . . how about you?” “I find it difficult that you are smiling right now, but your story is very troubling. Can you tell me a little about that?”

92

II.  Practice and Process

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

Helps to normalize the client’s experiences

■■

Helps to give realistic expectations

■■

Models self-disclosure for the client, especially if the client has difficulty disclosing information about self

■■

Communicates to clients that they are not alone

■■

Can be helpful if you are sensing/feeling that you need to be more visible as a real person or that there is a need to try to equalize the power in the therapeutic relationship.

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

Boundaries are not set or are problematic (e.g., the client may use the personal material you have disclosed in order to gain access to your personal life; the client has difficulty with maintaining close relationships because of dependency needs or inappropriate behaviors).

■■

You are triggered and want to share something for your own release during the session.

■■

You sense that disclosing something personal with a client might change the relationship dynamic in an unhealthy or unproductive way.

■■

Your self-disclosure leads the client to try to focus on you instead of them; the client may want to talk about you and your experience more as a defense or the client has a habit of wanting to take care of others incessantly or to “rescue” others repeatedly.

■■

The client does not tolerate intimacy well. Your sharing something personal could backfire with a client who has difficulty being close to others, because they may not be able to handle having personal knowledge of you, or may feel overwhelmed by the information.

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



6.  The Basics of Counseling Practice

93

■■

Be conscious—know why you are doing it.

■■

Be brief—one or two sentences maximum; keep the focus of the session on the client and not on you.

■■

Consider whose need it is serving—if you are feeling a lot of emotional energy around sharing something with a client, stop and reflect upon your purpose in sharing this information with your client.

■■

Limit the frequency—if you are doing this a lot, explore why. Are you being set up as an avoidance? Are you frustrated because the client is not sharing deeply in the sessions?

■■

Use your intuition whether or not this is right for this client. If you have any uneasiness about it, wait to disclose until you can give it more time and thought.

■■

Use your common sense.

■■

Be aware of timing; in the beginning of counseling, the focus should be more on hearing the client and “getting” the story. As you go on in time, and the focus of the sessions begins to move toward growth and the future, self-disclosure may be a very valuable tool.

■■

If you have any hesitation about whether to self-disclose or not, err on the side of not disclosing. Remember, once you have disclosed something to a client, you cannot take it back!

■■

Keep in mind that clients are not bound by the same adherence to confidentiality as a counselor is. Whatever you may share with a client can potentially be shared with many other individuals in the client’s interactions with others outside of the session.

Clients vary enormously with the appropriateness of this technique, so be very aware and follow the client’s response as a guide. There is no one “right” way to approach this issue with all of your clients, so you would need to gauge your disclosure on a case-by-case basis. Self-disclosure certainly has its place in the therapeutic alliance. Counselors tend to vary widely in how they choose to disclose or not to disclose details of their personal lives with clients. Many counselors feel that the benefits of disclosure in regard to their transparency and shared humanity with clients are profound. What is most important to this discussion is that you are able to think about this topic and your comfort with self-disclosure so that you feel reconciled with whatever choices you make about this issue.

HONORING RESISTANCE Even though a client freely chooses to begin counseling sessions, there may be times when you get the feeling that a client is holding back in the session with you or that a client demonstrates behaviors that indicate to you that something may be awry in the therapeutic alliance. If you have this experience, you may be facing resistance from the client, and it is important to reflect upon what is happening. Keep in mind that for many individuals, the counseling process may be associated with stigma or with identification by others of being “weak.”

94

II.  Practice and Process

Counseling can also be expensive for clients, especially if they have very little or no insurance coverage to assist with the costs of sessions. In addition, the venue itself might seem pretty daunting—unsure of what to expect, clients are asked to enter into a relationship with a virtual stranger and share personal experiences and feelings that they might not have shared previously with even their closest friends and family. For some clients, the choice to seek counseling help might not have been their own. They may have been coerced into counseling by a well-meaning family member, friend, minister, or healthcare professional, and as a result, they are not willing to fully commit themselves to the process. Given the unique dimensions of the process, it is only natural that some clients will feel a sense of resistance toward counseling. It is important for a counselor to know how to recognize resistance and how to best respond to its presence within a client. Keep in mind that when someone is feeling resistant, he or she is often feeling highly vulnerable and wanting to protect that vulnerability by putting up a barrier. Often, resistance stems from the client feeling coerced, outmaneuvered, or intimidated, even though these are the last things that a counselor would want to convey. In fact, the resistance may not have anything to do with the counselor at all but could be more of a reflection upon the client’s anxiety, difficulty trusting, feeling shame, finding the interactions too intense, or the need to stay in the familiar and to be identified with what is known (Box 6.2). Resistance is a normal response and it needs to be honored as such. It is imperative that you give the client space when this is happening and not push. In being resistant, the client is able to say “no,” which can be a good thing. It is a natural response to get frustrated with a resistant client—however, it is a normal process and it is important to see it as an opportunity to learn more about the client’s feelings and world view.

BOX 6.2 RESISTANCE IN THE GRIEF COUNSELING RELATIONSHIP

Common reasons for why resistance may occur: ■■

The counselor is leading too much.

■■

The client does not feel that the counselor understands him or her.

■■

The session or process may be too intense.

■■

The counselor is not listening well enough or engaged enough with the client.

■■

The counselor is too challenging for the client.

■■

The counselor’s body language may be misinterpreted by the client.

■■

The client feels that the counselor is judgmental or advice giving.

■■

There is transference on the part of the client that is interfering with his or her relationship with the therapist (e.g., the therapist reminds the client of someone who has been abusive, negative, or highly critical to him or her in the past).



6.  The Basics of Counseling Practice

95

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

Remember that it is normal and normalize it—“It’s okay.”

■■

Accept where the client is and be respectful; remember that resistance has a purpose.

■■

Understand that resistance and reluctance are fear based and are often related to feeling a loss of control, fear of the unknown, fear of change, and so on.

■■

Examine your own fear/resistance—what is your part? (As a counselor, are you afraid of failing, afraid of not working well with the client, or the client not doing well after seeing you?)

■■

Examine your interventions—especially any hidden agendas or current “hot issues” for you: Are you pushing too hard? Could the client be feeling any subtle coercion or expectations?

■■

Go with the resistance and allow it to produce change. You can befriend the resistance—“I can sense you don’t want to talk about that and it’s okay.”

■■

Be realistic, fair, and flexible. Do not be afraid to stretch. Maybe you are expecting too much. Allow the client to have control.

■■

Resistance is often felt as a challenge to you, but it may not be about you. Be willing to be open, be honest, look for solutions, and be as honest with yourself as you can be in your work with clients.

GETTING STARTED—THE FIRST SESSION As we have stated earlier, many people come to counseling without having a clear idea of what it is really about. Clients come to counseling for a variety of reasons, but most initiate counseling in order to feel better, to learn how to cope more effectively with the experiences they have had, or to feel that they are not alone in their situation. So, with these thoughts in mind, let us think about our objectives for the first session that we see a client: 1. Begin to build a trusting relationship. We have discussed much of the groundwork

involved in setting up the therapeutic alliance in previous chapters and in this one as well. This is now the time when you begin to orient the client to your way of being with him or her, and the client begins to have a good idea of your values and way of working therapeutically. Safety in the therapeutic relationship is built upon

96

II.  Practice and Process

trust, and you need to be able to share with the client how you will keep his or her disclosures safe and private and how you will begin the work. So, in addition to the intentional offering of your full presence, you will use the skills that we described in this chapter to lay the foundation for your future interactions. In addition, you will need to share with your client about the confidential nature of counseling, and any limits on that confidentiality that may be present. 2. Teach the client about the gradual, unfolding nature of the counseling process. Ask

the client for their expectations and to share ideas about how they expect the counseling process to work. You can also share a little bit about your philosophy of counseling and how you like to work with clients. However, it is also a very good idea to ask your client to identify what he or she might find most helpful as a starting point for this work together. You want to use this first session as a time to let the client know that you wish to follow his or her lead, not the other way around.

3. Ask the client about his or her concerns and desired outcome from counseling. Do

not be afraid to ask the client to indicate to you what he or she hopes will happen as a result of coming to a counselor. It is also important at this time to engage in a dialogue about what the counseling process is and what it is not. For example, some clients will indicate that they want you to tell them what to do. You may then have to explain that you do not tell people what to do, but rather you try to help them to figure out what they feel is best to do after exploring all of the possibilities that are available.

4. Discuss the collaborative nature of counseling. Ask the client about how you can

best support him or her in this journey. Do not be afraid to ask if they have seen a counselor in the past and to describe what that experience was like—and if you need to adjust your way of working with to better accommodate their needs and expectations. Remind clients that you will frequently “check in” with them during the sessions for their feedback and that you will also provide honest feedback to them, if they wish.

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

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



6.  The Basics of Counseling Practice

97

GLOSSARY Advanced empathy  Moments when the counselor is deeply attuned to the client and has an intuitive knowing about something that the client may not have stated openly but seems to be apparent in the session. Attending skills  Include things to which the counselor needs to “attend,” both in himself or herself and in the client. Include body language, eye contact, tone and volume of voice, use of language, and nonverbal cues. Closed questions  Questions that can be answered with a “yes” or “no,” or often with a single word. Closed questions often provide the facts, such as address, age, and length of time since an event, and often begin with “where,” “is,” “are,” and “do.” Empathy  Involves the counselor intentionally moving into the client’s frame of reference—attempting to experience how things seem and feel to the client, trying to experience the world as the client does, while at the same time maintaining the awareness that this frame of reference and experience is of the client and not of the counselor. Immediacy  The ability of the counselor to use the immediate situation within the session to invite the client to look at what is going on between them in the relationship. Observation skills  The ability to ascertain information about the client through careful observation on the part of the counselor. Observational skills assist in reading nonverbal cues and filling in details about the client’s story and situation. Open questions Cannot be answered briefly, and they often require some thought or expression of feeling. Open questions often begin with “what,” “how,” “why,” and “could” and allow clients to respond according to their needs. These types of questions invite clients to elaborate on their story and add the details as they wish. Resistance  The situation in which a client withholds disclosure or engagement in the therapeutic relationship or session, often due to the client feeling threatened or uncomfortable for some reason. Resistance may or may not be conscious on the part of the client. Self-disclosure  Involves the counselor sharing his or her own story and own personhood at appropriate times in the process. Three kinds of counselor self-disclosure are: (a) the mechanism of therapy, (b) feelings that are present in the here and now, and (c) sharing from the therapist’s personal life and experiences. Verbal tracking  Used by the counselor to more closely follow the client’s story or how a client tends to share about an experience. In verbal tracking, the counselor tends to “pick out” things that point to a deeper level of a client’s experience or awareness.

QUESTIONS FOR REFLECTION 1. Practice your own skills of empathy and listening to others in social settings. For

instance, when you are listening to someone, describe an experience or his or her feelings about something, try to “tune in” by listening to what they are saying, and their feelings about the experience without asking questions, and without interjecting your opinions. What happens when you do this?

2. Ask someone you know to describe an event or an experience he or she has had.

As that person is speaking, you can engage with that person, as long as you do not ask any questions. You may use statements, but not questions. What is it like to do this exercise? What can this exercise tell you about how you would interact with different kinds of clients?

98

II.  Practice and Process

3. Think of a “script” that you might use for your initial sessions with clients. Write

out what you would say in the beginning of the first session to set the tone for the counseling, and how you would describe your way of working with clients to a new client. You can practice your “script” with a friend or colleague to fine tune it before you use it with clients.

4. What are some reasons why a bereaved client might feel some resistance to sharing

something with a counselor? How might you address resistance with bereaved individuals in the counseling process?

5. Practice listening to people as they share their stories and experiences with you.

Do you find that you tend to remember details of the story more easily or that you tend to “tune in” to the tone of the person who is speaking, noticing his or her feelings and reactions more than the details of his or her story? What might this tell you about the way that you will work with clients?

REFERENCES Egan, G., & Reese, R. (2019). The skilled helper: A problem management and opportunity development approach to helping (11th ed.). Boston, MA: Cengage. Lakens, D., & Stel, M. (2011). If they move in sync, they must feel in sync: Movement synchrony leads to attributions of rapport and entitativity. Social Cognition, 29(1), 1–14. doi:10.1521/soco.2011.29.1.1 Rogers, C. R. (1959). A theory of therapy, personality and interpersonal relationships, as developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of science, (Vol. 3, pp. 184–256). New York, NY: McGraw-Hill. Segal, E. (2018). Social empathy: The art of understanding others. New York, NY: Columbia University Press. Wong, P. (2004). Creating a kinder and gentler world: The positive psychology of empathy. Retrieved from http://www.meaning.ca/archives/presidents_columns/pres_col_mar_2004_empathy.htm Yalom, I. R. (2009). The gift of therapy. New York, NY: Harper Collins.

CHAPTER 

7

WO RKI N G W I T H B ER E AV E D INDI VI D UAL S

LEARNING OBJECTIVES 1. Describe the various ways that grief can manifest in individuals. 2. Define and describe diverse ways of grieving in different individuals and groups. 3. Describe some of the developmental implications that are relevant to the experience of loss and grief. 4. Identify practical suggestions for supporting grieving individuals.

INTRODUCTION Many people are afraid to approach newly bereaved individuals, feeling concerned that they may say the wrong thing or that they may actually make the bereaved person feel worse by saying something that is inadvertently insensitive or that provokes pain. In this chapter, we explain some practical ideas about how to sensitively approach someone who is bereaved and to offer the best form of support that might be possible to that person. We have already mentioned in a previous chapter that most bereaved individuals do not require professional support or therapy to cope with their losses and their grief. In this chapter, we are not going to focus so much on what professionals may or may not do, but on what might be helpful to a bereaved person whether you are a friend, colleague, or counselor. Some people seek grief counseling not because their grief is complicated or because deeper unresolved issues in their lives have been triggered by the loss, but because they need a safe

100

II.  Practice and Process

place to explore their grief in a healthy way with someone who can offer them unconditional support. We first explore some of the common expressions of the grief experience and then we discuss some practical suggestions for how to be most helpful to a bereaved individual.

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

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

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



7.  Working With Bereaved Individuals

101

is important to remember that emotions do serve a valuable purpose when they are present, and the listener’s role is not to talk the bereaved person out of these emotions or to try to make them feel better, but to listen and support the sharing of these emotions so that the bereaved individual can benefit from the purpose the emotions are serving. We discuss more about working with strong emotions in Chapter 9, “Working With Emotions—Yours and Theirs.” ■■

■■

■■

Cognitively—It is common for bereaved individuals to complain that they just cannot focus well or that their minds seem to wander a lot. Many people describe difficulties remembering, organizing, and keeping track of things. Time may seem to warp as well; a day may seem like forever, or it may seem like a brief period of time. Days and nights can get switched around too. Many of our bereaved clients describe their minds as “constantly busy,” but not productively so. One client reported that she accidentally forgot to pick up her 2-year-old son from daycare. She stated that she had a nagging feeling that something was amiss, and when she got home, she realized that she had not picked up her son at the usual time of 4 p.m. (and it was now almost 6 p.m.)! This aspect of grief may be very hard if you work, as most people have limited time off work after the death of a loved one, and when they return to work, concentration and focus can be very difficult. Physically—Our bodies often “carry” the weight of our grief through physical symptoms. Many bereaved individuals will share that they often have symptoms that mimic those of their loved ones before they died. One client shared that she had gone to the emergency department three times with chest pain and shortness of breath that had never been present before her husband died suddenly of a heart attack. One very common description from clients is something that we term “restless exhaustion,” in which bereaved individuals may feel continually busy or agitated in their minds but exhausted physically. When they try to lie down or rest, their minds become even busier; however, when they try to get something done or try to complete a task, they are overwhelmed by feelings of exhaustion and lethargy. Headache, bodily ache and pain, difficulty sleeping, weight loss and weight gain, digestive problems, and accidents like falling, tripping, and knocking over things are also commonly described (Hensley & Clayton, 2008; Luekin, 2008; Stroebe, Schut, & Stroebe, 2007; Worden, 2018). It is interesting to note that there is research linking certain types of bereavement to lowered immune function and to higher rates of morbidity and mortality in survivors (Buckley et al., 2012; Jones, Bartrop, Forcier, & Penny, 2010; Khanfer, Lord, & Phillips, 2011). Investigations of health problems confirm the broad range of difficult reactions associated with bereavement that can result in increased use of medication, visits to doctors (although paradoxically, those most vulnerable may be the least inclined to seek help), and hospital admissions (Parkes & Prigerson, 2013). Spiritually—We have already discussed how a significant loss event can shake up an individual’s assumptive world, and the spiritual effects of a major loss often leave people questioning their beliefs about God or wondering if there is indeed

102

II.  Practice and Process

any higher order or purpose in life. Over time, many bereaved individuals will often say that their loss experience deepened their faith or caused them to re-examine beliefs that they had taken for granted before. On a more practical level, clients will often share how their faith communities are sources of support and also, at times, sources of discomfort or disappointment. Although there are studies that examine the effects of spiritual beliefs on bereavement outcome, most do not conclusively demonstrate that religion or systems of faith have a direct impact on the course of bereavement (Sawyer & Brewster, 2019). However, it is often thought that many individuals benefit from the sense of structure and ritual that a faith tradition may provide for them after a significant loss, such as the funeral liturgy, mourning rituals, and a sense of belonging to a community at a time when they may otherwise be isolated (Park & Halifax, 2011). Balk (1999) states that three things must be present for a life crisis to initiate spiritual change in a person: (a) the situation must create a feeling of destabilization that resists restabilization readily, (b) there must be time to reflect upon what has occurred, and (c) the crisis must be something that will be indelibly etched into the life story of the person who experiences it. Balk further states:



Bereavement contains all the necessary ingredients needed to trigger spiritual change. It is a dangerous opportunity, producing extreme psychological imbalance, and possessing sufficient intensity and duration to allow for serious reflection. Its effects color a person’s life forever. (p. 488) Fowler (1981) mentions that the times in our lives when we end up questioning our beliefs and searching for meaning can produce what he calls a transformed faith consciousness, which allows for greater meaning and understanding in our lives. Thus, a significant loss event carries the possibility of spiritual destabilization, but it may also hold the potential for increased depth and personal meaning in life later on.



■■

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





7.  Working With Bereaved Individuals

103

their lives have been filled with such deep grief and profound questioning of life and themselves. Many of these individuals have a difficult time fitting neatly in a social context—they may no longer be able to identify with the role that was associated with the deceased person—for example, a widow is no longer a wife; a parent to a deceased child is still a parent, but the child is missing (Juth, Smyth, Carey, & Lepore, 2015). In addition, many bereaved individuals sense the discomfort of others around them, as people struggle finding the “right” words to speak or avoid them to prevent the discomfort of an awkward social exchange. ■■

Economically—We often do not ask our clients about this particular issue in bereavement, but it is an area that can be of immense concern to bereaved individuals. Two of the younger widows that I (D.L.H.) have seen in my practice had to declare bankruptcy after their husbands died because there was no life insurance to cover the debts in their husbands’ businesses and they could not deal with bill collectors and harassing phone calls and letters on top of their paralyzing grief. If bereaved individuals take time off work to be the caregiver to a terminally ill loved one, they may not only face lost income, but their job may have been given to someone else in their absence. In addition, those individuals who take a leave from their work after the death of a loved one may do so out of necessity to take care of the estate issues and to look after themselves emotionally and physically, but this time may be unpaid leave from work, with the result being increased financial strain layered on top of the grief. If the bereaved individual is the executor of the deceased person’s estate, there are often time-consuming responsibilities associated with this role, and there may be conflict with surviving relatives about the distribution of the estate, all of which will land in the lap of the grief-laden executor (van den Berg, Lundborg, & Vikström, 2017). Some clients have difficulties accepting insurance monies and proceeds from an estate, citing feelings of guilt that the death of the person they loved has now somehow benefited them financially.



■■

Behaviorally—Some of the behaviors in which bereaved individuals may engage can be quite subtle, but they may be very common. For instance, many bereaved individuals will describe feeling like they are searching for their lost loved one in a crowd, or they will automatically scan situations for familiar things that are associated with their loved ones—a car that is similar to the one that your son drove before he died pulls up next to you and you realize that you are staring at the driver, looking for your son in the seat. Or you find yourself going to places that your loved one would go, even if it is not a place that you went together beforehand. Some individuals find engaging in an activity that their loved ones used to enjoy to be comforting—gardening, playing certain music that their loved ones enjoyed, feeding birds, collecting stamps, shopping, watching certain sports events and teams, eating at certain restaurants, or ordering certain types of food that their loved one liked are all frequently described by bereaved individuals, and the common thread is often an identification with the deceased person and an attempt to reconnect with that person in these activities (Worden, 2018). Pilling, Thege,

104

II.  Practice and Process

Demetrovics, and Kopp (2012) describe attempts to cope by the increased use of alcohol, tranquilizers, hypnotics, and cigarettes often reported in bereaved individuals. Many bereaved individuals describe a sense of “going through the motions,” or of being on “autopilot” for a long period of time after they experience a significant loss. One client described this experience as “showing up for work but leaving my brain at home asleep.”

Extraordinary Experiences Extraordinary experiences (EEs) as they are defined within the context of bereavement are experiences that occur at the time of, or after the death of someone that are assumed to be some type of contact with the deceased individual. These experiences are sometimes also referred to as anomalous experiences, as they are uncommon and/or believed to deviate from our ordinary experiences of life or from the usually accepted explanations of reality. Bereaved individuals commonly describe feeling that their loved ones have connected with them through a sign, a dream, a vision, a hallucination, or a sense of presence (Parker, 2005; Steffen & Coyle, 2017). We have had clients give descriptions of radios getting tuned in to the favorite station of their loved ones without them recalling changing the tuner themselves, a bird landing on a windowsill that they believe represents a visit from the deceased person, a “sense” of something brushing against their skin, finding a book open to a page where there is a message for them, flickering of lights, butterflies appearing from nowhere, or hearing the voice of their loved ones speaking to them either silently or audibly. The “visitation dreams” that clients describe are often very vivid and totally engaging, often with the deceased person telling them that they are okay, and sometimes the feeling that there was physical contact with the deceased in the dream. Some of the dreams are not comforting and may involve looking frantically for their loved ones, getting lost and unable to find their way out of a place, or of a sense of unease associated with their loved ones or the circumstances around their death (Cooper, Roe, & Mitchell, 2015; Practice Example 7.1)

P R A C T I C E EXAM PLE 7 . 1 EXTRAORDINARY EXPERIENCES

Andrea’s father died several months ago. She has been seeing Carole, a grief counselor, to talk about her relationship with her father and the grief that has overwhelmed her. As Andrea came into her office, Carole noticed that she was visibly lighter than she had been in her previous sessions. Carole sat down and said, “I have something really amazing to tell you.” She then proceeded to explain that one day when she got into her car after work, the radio came on, blaring a station that she never played. She immediately recognized the song as a favorite of her Dad. She did not remember changing the station on the radio before she went into her workplace, and she would never have changed it to THIS station. Then, it clicked … it had to be her Dad causing this to somehow happen so that she would know he was O.K. and thinking about her.



7.  Working With Bereaved Individuals

105

Many clients share that they have regular “conversations” with their deceased loved ones, most commonly described as silent discussions that occur in their thoughts, but sometimes in audible dialogue as well. These conversations most often happen at the graveside or in a place that was most frequented by the deceased person, such as his or her office, the car, a favorite recreation spot, or a special place that they shared together. Most bereaved individuals describe these experiences as comforting and helpful, which is also supported by research on the topic (Black, Belicki, & Emberley-Ralph, 2019; Parker, 2005). What is important to note about these experiences is that they are common among bereaved individuals and they also tend to have a functional role in the grieving process rather than a pathological or unhealthy influence. These experiences are not breaks in reality that would occur in someone with a psychotic or delusional disorder, as the bereaved are aware that the experience is extraordinary when it occurs, and their interpretation of the event is often kept very private to avoid social stigma surrounding the experience or their mental state.

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

Diversity in Grief Early research in bereavement was focused mostly upon middle-class widows whose husbands of many years had died. With the burgeoning increase in bereavement research

106

II.  Practice and Process

of many different representative groups, we now know that there are many diverse ways that people experience and express grief. Doka and Martin (2010) extrapolate on different patterns of the expression of grief in their descriptions of adaptive grieving styles. These authors describe three main grieving styles on a continuum, with intuitive grievers at one end and instrumental grievers at the other, and a more blended grieving style between them. Intuitive grievers tend to express feelings and wish to talk about their experience with others. Instrumental grievers tend to grieve more cognitively and behaviorally and are more likely to express their grief in terms of thoughts, analysis, and actions. Individuals who have a blended grieving style may combine elements of both intuitive and instrumental grieving styles, but they usually have a predominant tendency toward one or the other styles. This exploration of grief emphasizes that there is no “right” way to grieve; however, bereaved individuals are often expected to grieve in certain ways based on gender socialization, and if they do not express grief in a way that is expected by others, their experience may be labeled as problematic or even pathological (Creighton, Oliffe, Matthews, & Saewyc, 2016). There have been times when a client or a family member of a bereaved individual will assume that a person has not “grieved well” unless they have expressed emotions about the loss. As we stated earlier, not all bereaved individuals will grieve through their emotions or will need to share their feelings and talk about their loss. Expressions of grief typically are congruent with an individual’s existing personality, temperament, and preferences. For example, one of our colleagues recently lost his wife. They were extremely close, and her illness and subsequent death occurred over a few short months. He was back to work within a few weeks after the funeral. Many individuals in our workplace assumed that he was avoiding his grief and attempting to bury himself in his work, and they expressed concern that he was “hiding” from his grief. However, during speaking briefly with him, it was very apparent that he needed the structure of work to help him through his daily life, and he is by nature, a more cognitively oriented individual, who tends to process his experiences through his intellect and analytical thinking. His grief was very real to him, as was his profound loss, and his choice in going back to work and focusing on everyday tasks was congruent with his personality and previous ways of coping during times of stress. For a long time, the goal of grief counseling seemed to be to get the client to emote and to “clear” the grief by having emotional catharsis. However, it seems much more appropriate (and humane) to think of grief counseling not with this type of goal in mind, but to support the bereaved individual in working out the process of grief in ways that are aligned with that person’s values, view of themselves, personality, and temperament. Although emotional expression is now not seen as an imperative in the way it once was, social support to bereaved individuals can be very important in assisting bereaved individuals, no matter what style of grieving they employ. What is very important to remember about social support is that individuals will vary widely in what is seen as supportive and what is not. For instance, if we go back to the example of our widowed colleague, I doubt he would find it helpful if one of us showed up to his office, sat down, and asked him to talk about his feelings. Support to him has come in the form of snippets, which allow him to know that his colleagues are thinking of him and care about him, but not placing an expectation upon him



7.  Working With Bereaved Individuals

107

to talk about his feelings at length. He also seems to greatly appreciate the ability to talk about his teenage children as they cope with the loss of their mother, and he has often requested information about specific aspects of teen grief and the loss of a parent.

Mediators of Mourning The most important aspect of grief counseling is attending to the story and needs of bereaved individuals as they describe them. In this form of active listening, you might also “tune in” to the aspects of the grief experience that are unique to each individual’s experience, and how these unique modifiers shape the landscape of grief for this person. Worden (2018) refers to these unique factors as the mediators of mourning, which include (a) identifying the relationship of the deceased person to the bereaved individual, (b) the nature of the attachment to the deceased person, (c) how the person died, (d) the bereaved individual’s history of previous losses and stresses, (e) personality style and how the person has coped in the past with stressful situations, (f) perceived social support that is available, and (g) the presence of concurrent changes and crises that may be occurring at the same time. Worden cautions that in identifying these variables, the focus is on the multidimensional aspects of grief and the many variables that may have an impact on the bereaved individual and not an attempt to oversimplify grief and its antecedents.

DEVELOPMENTAL CONSIDERATIONS The scope of this book focuses on the experience of and supporting adults who are grieving. However, grief in adults harkens back to childhood and adolescence with the way that grief is experienced as an adult related to attachment patterns that were established in the early years. In addition, adult grief can be influenced by significant losses that were experienced during the formative years in childhood and adolescence. There is also a sense of timing as to when losses occur. For example, a parent whose child dies experiences the tragedy of losing a precious loved one who was expected to outlive the parent. On the other hand, with life expectancy increasing and adults often living well into their 90s, there is an extended period of time that is shared between a parent and an adult child, grandchildren, and even great grandchildren. With increasing life expectancy also comes many changes in how families respond to the presence of multiple generations that require care, assistance, and support all at the same time. We will briefly touch upon these issues here.

Children and Youth For children and young people, it is important to consider many different variables other than age as the primary determinant for relating to a young person when there is a significant loss. Corr, Corr, and Doka (2018) describe four variables that need to be considered when considering a young person’s response to death: ■■

Development—not just cognitive understanding, but also maturity in various aspects of life, including physical, psychological, social, and spiritual dimensions.

108

II.  Practice and Process

■■

■■

■■

Life experiences—related to other types of loss experiences that may have occurred, including their impact on the child and how they addressed by the significant adults in the child’s life. Individual personality/temperament—some children are more curious than others; some are also more demonstrative, whereas others may be more inwardly focused. Communication and support—some children wish to talk about what has happened, whereas others may not want to do so. It is important for children to have a safe adult available to listen and to answer questions that the child asks in a direct and sensitive way.

Speece and Brent (1996) indicate that comprehending death (and the resulting experience of grief) involves mainly understandings that may vary between children. These understandings relate to concepts of universality (all living things will eventually die), irreversibility (once someone dies, they cannot come back to life again), nonfunctionality (final cessation of all functional capacities and ability to feel), causality (a realistic understanding of how/why things die, such as through something happening in the body versus magical thinking), and noncorporeal continuation (articulating thoughts about a continuing life without the physical body). While these researchers stated that they believed most children understand each of these components by age 7, they also cautioned that this understanding is highly variable and must be assessed individually without making assumptions beforehand. Below are some general guidelines for supporting grieving children: ■■

Let children know grieving is natural and that sadness and crying are acceptable. Also, let them know that they will not always feel so sad and hurt.

■■

Let children observe adult’s grieving behaviors, crying, and sadness. Adults sometimes conceal their emotions believing that they have to protect and reassure children by appearing to be strong and in control; doing so can be confusing to children.

■■

Talk to children about death and grief using simple, direct, truthful terms. Do not keep knowledge of the death from the child. Do not use euphemisms or substitute words for death.

■■

Do not tell them lies, such as the dead person has gone away on a long trip, thinking that you are sparing them sorrow and pain.

■■

Listen to them and answer their questions. Do not be afraid to ask if they have questions about what has happened or how they are feeling.

■■

Allow them to talk about the death and the dead person.

■■

Allow them to talk about their feelings and let them know that you respect their feelings.

■■

Do not tell them clichés like, “God wanted someone to take to heaven.” Remarks like that can frighten children and make them worry that God will take them too.



7.  Working With Bereaved Individuals

109

Adolescence is a time of being betwixt and between, as being in this age group means you are no longer a child with undeveloped cognitive understanding and maturity; however, you are also not quite yet an adult, with the full independence and autonomy that is understood in adulthood. Adolescence is often divided up into three maturational phases, where early adolescence involves learning to separate oneself from parents, middle adolescence, which is a time of increasing independence to forge a distinct identity, and late adolescence, which is a time of increasing maturity, associated with the formation of stable, intimate relationships, and achieving a relatively stable character and self-identity (Corr, Corr, & Doka, 2018). In the past decade, the use of technology, including cell phones and tablets, has grown exponentially. It is estimated that roughly 90% of teens between the ages of 13 and 18 have a digital phone, with the majority of these being smartphones (Sofka, 2018). It is not uncommon for teens to find out about the death of someone they know through a social media site before being told by an adult in person. In addition, teens often use social media to grieve together. Social networking sites of deceased friends are often turned into memorial or commemorative pages, where groups of friends can post their memories, feelings, and offer support to each other. Adults who wish to offer support to bereaved adolescents need to understand and appreciate the importance of social media to the social systems and supports that surround young people. A caveat may exist here for teens who lose a loved one or friend by suicide, as the intensity of the grief and the complicated feelings that surround the death can be overwhelming. There may be a tendency to romanticize the death or the choice to end one’s life, along with a sense of idealism about the person who died. The popular Netflix series 13 Reasons Why was created as a form of adolescent entertainment, but became worrisome as teens binge watched the series, completely immersed into the story and thoughts about suicide. Ayers, Althouse, Leas, Dredze, and Allem (2017) found that suicide-related Internet searches increased following the release of this program, with increases in specific query terms suggesting that the series had both a positive effect of elevated suicide awareness as well as a deleterious effect of increased suicide ideation. It is impossible to know whether the searches on “how to kill yourself ” were made out of idle curiosity or by suicidal individuals contemplating an attempt, but there are significant concerns about this level of exposure to adolescents, whose brains are still developing the ability to inhibit certain emotions, desires, and actions. According to Arnold (2018), who we are and how we approach grieving youth is much more important than what we actually do. The following are guidelines for adult communications with bereaved youth: ■■

Be present, available, and open. This is often a time of great sensitivity and vulnerability, so the focus should be on open-ended support offered without any conditions. Parents especially may feel their own anxiety and sadness over the loss, and these feelings should be acknowledged, but the focus needs to be on the young person’s needs.

■■

Listen deeply, paying special attention to the underlying feelings below the words that are being said.

110

II.  Practice and Process

■■

Do not attempt to problem-solve or intervene if the young person does not ask you to do so.

■■

Some adolescents may feel uncomfortable talking with parents, counselors, or other adults and may find it easier to address their feelings and concerns in a support group with peers. If you are a counselor providing service to families, be familiar with potential resources like this in your community.

■■

Respect the valued connections that social media may provide to young people. Be aware of potentially useful sites that may offer good information and online support to grieving young people. It is important to locate Internet sites that have accurate information, are updated frequently, and are monitored regularly if there is an interactive component.

A few additional thoughts may be useful in addressing the grief of young people. First is the concept of re-grieving that can occur later in life. For example, a child may lose a parent at 5 years of age. Specific/significant milestones, such as graduations, birthdays, and weddings later in life, may trigger grief to the surface in a new way and with a greater depth because of the increased capacity for understanding and awareness of the meaning of the loss to that child (Koehler, 2010; Slyter, 2012). This resurgence of grief may be present in adults who seek grief counseling after being triggered by a more recent loss or event. Next is the notion that because adolescents tend to seek support in their peer groups, they do not need or want support from the adults in their lives. Bereaved teens often feel caught between their desire to act like an adult versus feeling deep vulnerability that may lend itself to caregiving and comfort from the significant adults in their lives. Do not be afraid to offer support; if you are aware of special ways the teen receives comfort, make these readily available. Finally, there are some crucial times and types of losses for young people. In young children, the loss of a primary attachment figure, most often their mother, can be incredibly difficult. The remaining parent or adults in the child’s life will be crucial lifelines for safety and security while the child continues to grow and develop. While adolescence involves differentiating oneself from the role of parental involvement, the loss of the same-sex parent can be very difficult during this time due to the increasing awareness of gender, sex, and identify formation (Slyter, 2012). It might be helpful to have an adult of the same sex of the parent who died to serve as a positive role model and to be available to spend time with the young person. In addition, adolescence is a time when young people want to feel a sense of belonging to their peer group and they are often self-conscious about standing out amidst their peers. When a significant loss occurs, especially one that is stigmatized, such as a death by suicide or lifestyle choices, the affected young person will often struggle to not be seen as an outlier or as different from their friends, sometimes denying real feelings and concerns in order to fit into the desired group of peers (Vigil & Clements, 2003).

Changing Demographics and Adult Grief Current social trends indicate that the role, composition, and expectations within families in Western-oriented industrialized nations have radically changed in the last 25 years. Most women now work outside the home. Women also now attend post-secondary education and



7.  Working With Bereaved Individuals

111

plan for careers in the way that only men would in their parent’s generation. As a result of the push for higher education and pursuit of a career, many women delay childbirth until much later than their mothers. Life expectancies are now well into the 80s for most developed countries, with a marked increase in the number of nonagenarians and centenarians.1 The following issues are associated with these changes: ■■

Many illnesses that were once considered terminal are now chronic conditions. We are living longer but living longer with more complex medical issues and increasing need for assistance as we age.

■■

Women who delayed childbearing until after they were established in their careers now face a very difficult split in their family responsibilities, with many routinely offering care and assistance to aging parents while still being responsible for children at home—all while they are typically still engaged in the workforce. This is also a time when many are peaking in their careers.

■■

The increased need for supports being provided to aging adults is accompanied by increases in expenses required to pay for these services. As a result, adult children now often provide emotional, physical, and financial support to their aging parents. On another note, a very common scenario is that the elderly parents refuse “outside” help, even if they can afford it. Instead, there is a tendency to rely on their adult children, who are often struggling with the mounting pressures and responsibilities that are accruing as a result of juggling their existing family and work commitments.

■■

Adult children may, at times, step in and undermine parental independence and autonomy in situations where there is a perceived crisis, a time of relatively high degree of parental need, when there are concerns about safety, and/or if a decision needed to be made expeditiously at a time when the parent is not in a position to do so (Funk, 2010). If the parent’s situation then stabilizes, there may be conflicts between the adult child and the aging parent that center around issues of independence, autonomy, and responsibility for both parties (Practice Example 7.2).

■■

An issue that often arises when a parent’s needs for care increase is the intensification of the relational dynamic that was present prior to the parent’s need for assistance. Increased caregiving needs of elderly parents usually results in more time being devoted to their care by their middle-aged children, who have lived independently and have their own routines, values, and ideas about many aspects of life that may not be congruent with their elderly parents’ views. Both the adult children and the elderly parent can become stressed as they try to navigate this new relational pattern. In the past, disagreements and stresses that may have occurred over time could usually be set aside because there was time and space in between contact. Increased dependency by the parent, coupled with the mounting pressures and responsibilities on the adult child can lead to resentment, with prior differences becoming flashpoints of pain and hurt for both.

A nonagenarian is an individual between the age of 90 and 99; A centenarian is an individual over 100 years of age. 1

112

II.  Practice and Process

P R A C T I C E EX AM PLE 7 . 2 TRYING TO FIND A BALANCE BETWEEN PARENTAL INDEPENDENCE AND SAFETY

Jan’s 92-year-old father had been gradually declining over the past year. Although he had managed to remain in his home, living alone since her mother died, he was now having issues with dizziness and his balance that predisposed him to falling. Jan tried to convince her dad to wear a lifeline device that would notify her if he had fallen, but he had refused it. She was concerned about his driving as well. She shuddered to think about what could happen if he became dizzy when driving his car. Early one morning, Jan’s father called her to tell her that he had fallen in his bathroom and could not get himself back up. Jan and her husband rushed across town to his home and found him lodged between the bathtub and toilet. There were pools of blood from where he had hit his head and there was a large gash on his forehead that was still bleeding. They called for an ambulance to help lift him up and he was taken to the hospital. After 2 days, the doctors told Jan that her father could return home. She and her husband decided that the situation at home was unsafe for her dad and they told him that he had no choice but to move on to a senior’s residence where he would have a monitor and his cleaning, laundry, and meals would be covered. They also took the keys to his car to ensure he did not try to drive. Her dad became angry, stating “You’re treating me like a child. I can’t believe you would rob me of my independence. You have no idea what it’s like to be told what to do by my own child.” Jan went home and cried, not sure if it was better to worry about her dad at home alone where he was not safe, or to hear how hurt and angry he was at her for forcing the decision about his home and driving. It felt like there was just no way to do the right thing.

In my (D.L.H.) practice, I am increasingly working with middle-aged adults who are tending to their aging parents. There are no easy solutions. It is a place of ambiguity for many, not knowing what might happen next, and also feeling a sense of responsibility that is coupled with emotional and physical exhaustion. When the parent(s) die, the grief afterward can be very difficult due to the changes in the relationship that occurred during the time when the adult child became the parent’s primary caregiver. Feelings of relief that they are no longer being torn apart by increasing demands and concerns for their parent are accompanied by feelings of guilt; loving memories can be tainted by the conflict and perceived self-centeredness of a parent who may have previously been loving and giving by nature. Below are suggested approaches for counselors who may be involved in situations where there has been extensive dependence by an elderly parent onto their mid-life child: ■■

Remember the grief begins before the death of the parent. The loss of the relationship as it once was as well as the loss of control experienced by both the parent and the child are important to recognize. There would be many tangible and intangible losses experienced by both parties along the way, and the stress of coping with all of these losses would be significant. As you begin to name and validate these nondeath losses, remind your client that the main problem was with a situation that



7.  Working With Bereaved Individuals

113

presented both the parent and the child with an unsolvable problem that created stress and grief for them both during that time. ■■

Acknowledge and normalize ambivalent feelings. Adult children will often express a multitude of feelings about the needs and care of their elderly parents. Sometimes, there is significant anger at siblings who did not contribute to the care or support the primary person in the family who acted as the main caregiver to the elderly parents. Relief over the ending of an impossible situation is met with feelings of guilt that they did not take more time with their parent or that they should have done something different.

■■

Support re-membering of the parent through the entire lifespan, taking into account the period of dependency in the whole arc of the parent’s life. While not all parent–child relationships were positive before the parent became dependent, there is usually a semblance of equilibrium around the relationship by the time the adult child is in mid-life. Looking through photo books and other memorabilia such as recipe cards, letters and cards that may have been sent, and keepsakes may assist in honoring the grief over the loss of the parent that was once known, as well as the loss of a significant attachment relationship for the adult child.

Foster rituals that acknowledge the grief of both the adult child and the older parent. The experience of caring for an aging parent typically occurs in the backdrop of a very busy time in life for many adult children. Often, there is the sense that addressing the needs of the parent can be like putting out fires in between rushing to meet other pressing family and work commitments and responsibilities. Typically, there is very little time to recognize the losses that occurred along the way. Counselors may be able to assist clients to “count their losses” through the creation of rituals and meaning-oriented reminders of their relationship. One idea might be to suggest the creation of overlapping life lines with the parent and child to acknowledge the presence and experiences of the parent through the life of the child from birth to present day. Other ideas might be to create a collage of pictures that depict the parent and child at different times in life, or through journal or letter writing to the deceased parent. One client found all of her father’s military medals in a drawer after he died. She had the medals mounted, along with a brief description of when they were awarded and what they represented. The window box that held the medals was then mounted on a wall next to a picture of them together when she graduated from university, a time when he told her how proud he was of her.

WHAT MAY HELP—PRACTICAL SUGGESTIONS It is apparent in this chapter that grief takes many different shapes and forms, occurring across age groups, and through many different aspects of life. If we return to the general premise that grief is a healthy and adaptive response to loss, our role as grief counselors is to provide a safe place where grief can unfold in the way that needs to occur for our clients. In the following section are some suggestions for supporting grieving individuals in ways that might facilitate the adaptive work after losses occur.

114

II.  Practice and Process

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

Know Yourself If you have any unresolved or “raw” grief issues, be aware that you are very likely to be triggered by working with grieving clients. If you have not worked through some of your own loss experiences, chances are that you will inadvertently shut your client down emotionally to protect yourself or you will use your client in order to complete your own grief work, which violates the therapeutic alliance. Self-awareness is one of the most important responsibilities of being a grief counselor. Loss issues, as we all know, do not always pertain just to death. We address counselor issues in more depth in Chapter 13, “Caregiver Issues for Grief Counselors”; suffice it to say that grief is a universal experience, and we all experience losses throughout our lives. It is important that counselors be aware of how their loss experiences have shaped and influenced their lives and often, their responses to clients. If we remain open to our own experiences, and address them with compassionate awareness, we can more readily maintain our focus on our clients’ processes and needs (Practice Example 7.3).

Re-Membering Although not everyone needs to talk and to share feelings about their loss, many who seek grief counseling are likely to self-select toward this way of coping. Much of grief counseling involves “bearing witness” to your client’s story of loss—who they were before the loss, the relationship to the person who died if the loss was a death, the nature of the loss and its meaning, and what life has been since the loss occurred. If the loss is the death of a loved one,



7.  Working With Bereaved Individuals

115

P R A C T I C E EX AM PLE 7 . 3 COUNSELOR SELF-AWARENESS

Vanessa was a social worker who saw clients in her private counseling practice. She had just returned to her practice after a year during which she and her husband had undergone treatment for infertility. The treatments were incredibly expensive and emotionally exhausting. They had finally decided to discontinue the treatments and were engaged in the home study process with hopes of adopting a child. In her first week back, Vanessa saw a new client who asked to come for counseling related to “family issues.” In the intake, the client began to share about her involvement in the same infertility clinic where Vanessa had received treatment. Hearing what the client said about the treatments made Vanessa feel anxious. Ideas about treatment plans and advice readily came to Vanessa, as she doubled onto her client’s descriptions. She managed to hold all of these thoughts in check in order to focus on what the client’s concerns were, but it was incredibly hard. The next day, Vanessa called her community supervisor and scheduled a session to talk about her feelings that arose with this client, hoping that in speaking with her supervisor she would be able to explore her feelings to keep them from interfering with her ability to focus on the expressed feelings and needs of her client.

we often suggest that the client bring pictures of the person at different times in their life, with and without the client in these pictures. You can ask the client to “introduce” you to the deceased person, and in that process, you will learn much about the story of the person who is now gone, and also about their relationship. You can also invite the client to bring “linking objects” to the sessions. These may be special items that serve as reminders of the loved one— pieces of clothing, jewelry, books, samples of the person’s handwriting, cookbooks and recipe cards, and many other things—that invite memories and rich descriptions of the deceased person and the relationship that they shared together. We call this process “re-membering,” as you are putting the shattered parts (members) back together as the story of the person and the relationship come together through the sharing. Many clients welcome the opportunity to speak freely and to share openly about their loss, their feelings, and their process since the loss. This type of sharing may also serve to remind the client of the times that were good or happy, especially if there has been a period of lengthy caregiving, difficulties, or pain before the loss. It is often helpful to use the name of the deceased person in the conversation and to try to use language that is similar in tone, words, and style to the client in responding to the sharing of the story. Bearing witness to a client’s grief occurs when you listen intently and when you are fully present to the client as the story unfolds. In your listening and responding, you are also acknowledging the significance of the relationship as well as the painful loss and deprivation that are now part of the client’s daily existence, and you are journeying alongside your client as they experience the aftereffects of the loss.

116

II.  Practice and Process

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

Rituals and Legacies As we discussed earlier, much of the “work” of grief is the need to find meaning after a significant loss event. The initiation of rituals associated with the loss, or of establishing legacies to commemorate a loss, may be helpful in attaching meaning to what has occurred and to the life of the bereaved individual in the wake of a significant loss event. Although there are very few prescribed mourning rituals in current Western society, clients may find their own personal rituals that give meaning to their experience. Some people may wear the clothing of the deceased ones in efforts to remain close in some tangible way (Practice Example 7.4). Some may write in a journal to their loved ones, light a candle, play a specific piece of music, or a certain type of music that has meaning to them or their loved one. Queen Victoria, after the death of her beloved husband Albert, continued to have his clothing laid out every day for ensuing years (Lewis & Hoy, 2011). We explore this aspect of working with bereaved

P R A C T I C E EXAM PLE 7 . 4 FINDING PRESENCE THROUGH RITUAL

Judy’s husband died 2 years ago. His body had been cremated, and Judy had asked for some of his ashes to be placed into a locket that she wore as a necklace. Judy found it comforting to think that a physical aspect of her husband resided in the locket that was close to her heart. She would sometimes find herself holding the locket or rubbing her fingers over it; doing so made her feel like he was there with her in some way.



7.  Working With Bereaved Individuals

117

individuals in more detail in Chapter 11, “The Clinician’s Toolbox: Therapeutic Modalities and Techniques in the Context of Grief.” Suffice it here to say that there is no limit to the creativity and ingenuity of ritualized acts as a response to human need born from loss and grief.

When to Refer for Additional Help and Assessment for Complicated Grief Although normal grief usually abates in intensity over time, and most bereaved individuals do not require professional help in order to adapt to their loss, there are some instances where additional help from individuals with specialized training is indicated. This type of difficult, complicated grief is explored in greater detail in Chapter 10, “When Grief Goes Awry.”

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

GLOSSARY Extraordinary experiences  These experiences are assumed to be some type of contact or connection with deceased loved ones through a sign, a dream, a vision, a hallucination, or a sense of presence. Instrumental grievers  Individuals who tend to grieve more cognitively and behaviorally, and who generally express their grief in terms of thoughts, analysis, and actions. Intuitive grievers  Individuals who tend to express feelings and wish to talk about their experience with others. Linking objects  Special items that serve as reminders to clients of a deceased loved one. These items often invite memories and rich descriptions of the deceased person and the relationship that they shared together. Mediators of mourning  Unique modifiers that help to shape the grieving process for a given individual. STUG reactions  Acronym for sudden temporary upsurges of grief; these occur in situations in which the realization of the loss and its magnitude are brought into the active awareness of the bereaved individual, sometimes many years later. Transformed faith consciousness  Difficult times in people’s lives that lead to greater questioning of beliefs and searching for meaning, with the result being a deeper appreciation of life and one’s beliefs.

QUESTIONS FOR REFLECTION 1. Much of the experience of grief involves feeling out of control. Bereaved individ-

uals have no control over the loss of their loved ones or over the changes in their lives that have occurred as a result of a major loss. One exercise to explore loss of

118

II.  Practice and Process

control involves having a blindfold placed over your eyes. Have a partner choose different foods—tastes, textures, spices, and temperatures—and your partner chooses which foods to feed you without your knowing what you will be fed. After you complete this exercise, talk with your partner about what it was like to not be able to make your own choices about what you were going to eat, or to know what was going to be fed to you. (Be sure to disclose any food allergies or major food aversions in advance!) 2. Think of a significant loss that either you or someone close to you has experienced.

Look at the mediators of mourning written by Worden (2018), as discussed in this chapter, and describe how each mediator played a role in how you or the other person dealt with the loss experience.

3. In this chapter, we briefly discussed the possibility of assisting a bereaved individ-

ual to “change the channel” at times as a way to assist in the grieving process. What do you think makes this suggestion different from unhealthy avoidance of grief?

4. Think of some of the popular movies that you have seen where grief and loss have

played a major role in the plot. How has the grief in these movies been portrayed? What were some of the responses from other members of the cast to the person in the movie who is bereaved? What messages do these movies convey about grief to the public?

REFERENCES Arnold, C. (Ed.). (2018). Understanding child and adolescent grief: Supporting loss and facilitating grief. New York, NY: Routledge. Ayers, J. W., Althouse, B. M., Leas, E. C., Dredze, M., & Allem, J. P. (2017). Internet searches for suicide following the release of 13 Reasons Why. JAMA Internal Medicine, 177(10), 1527–1529. doi:10.1001/ jamainternmed.2017.3333 Balk, D. (1999). Bereavement and spiritual change. Death Studies, 23(6), 485–493. doi:10.1080/ 074811899200849 Black, J., Belicki, K., & Emberley-Ralph, J. (2019). Who dreams of the deceased? The roles of dream recall, grief intensity, attachment, and openness to experience. Dreaming, 29(1), 57. doi:10.1037/ drm0000100 Buckley, T., Sunari, D., Marshall, A., Bartrop, R., McKinley, S., & Tofler, G. (2012). Physiological correlates of bereavement and the impact of bereavement interventions. Dialogues in Clinical Neuroscience, 14(2), 129. Burton, A. M., Haley, W. E., Small, B. J., Finley, M. R., Dillinger-Vasille, M., & Schonwetter, R. (2008). Predictors of well-being in bereaved former hospice caregivers: The role of caregiving stressors, appraisals, and social resources. Palliative and Supportive Care, 6(2), 149–158. doi:10.1017/ s1478951508000230 Cooper, C. E., Roe, C. A., & Mitchell, G. (2015). Anomalous experiences and the bereavement process. In T. Cattoi & C. Moreman (Eds.), Death, dying, and mysticism (pp. 117–131). New York, NY: Palgrave Macmillan. Corr, C. A., & Corr, D. M., & Doka, K. J. (2018). Death & Dying, Life & Living (8th ed.). Belmont, CA: Wadsworth. Creighton, G., Oliffe, J., Matthews, J., & Saewyc, E. (2016). “Dulling the Edges” young men’s use of alcohol to deal with grief following the death of a male friend. Health Education & Behavior, 43(1), 54–60. doi:10.1177/1090198115596164 Doka, K. J., & Martin, T. L. (2010). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Routledge.



7.  Working With Bereaved Individuals

119

Fowler, J. W. (1981). Stages of faith: The psychology of human development and the quest for meaning. San Francisco, CA: Harper & Row. Funk, L. M. (2010). Prioritizing parental autonomy: Adult children’s accounts of feeling responsible and supporting aging parents. Journal of Aging Studies, 24(1), 57–64. doi:10.1016/j.jaging.2008 .03.003 Hensley, P. L., & Clayton, P. J. (2008). Bereavement: Signs, symptoms, and course. Psychiatric Annals, 38(10), 649–654. doi:10.3928/00485713-20081001-04 Jones, M. P., Bartrop, R. W., Forcier, L., & Penny, R. (2010). The long-term impact of bereavement upon spousal health: A 10-year follow up. Acta Neuropsychiatrica, 22(5), 212–217. doi:10.1111/j.16015215.2010.00482.x Juth, V., Smyth, J. M., Carey, M. P., & Lepore, S. J. (2015). Social constraints are associated with negative psychological and physical adjustment in bereavement. Applied Psychology: Health and Well‐Being, 7(2), 129–148. doi:10.1111/aphw.12041 Khanfer, R., Lord, J. M., & Phillips, A. C. (2011). Neutrophil function and cortisol: DHEAS ratio in bereaved older adults. Brain, Behavior, and Immunity, 25(6), 1182–1186. doi:10.1016/j.bbi.2011.03.008 Koehler, K. (2010). Sibling bereavement in childhood. In C. Corr & D. Balk (Eds.), Children’s encounters with death, bereavement, and coping (pp. 195–218). New York, NY: Springer. Lewis, L., & Hoy, W. (2011). Bereavement rituals and the creation of legacy. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 315–324). New York, NY: Routledge. Luekin, L. J. (2008). Long-term consequences of parental death in childhood: Psychological and physiological manifestations. In. M. Stroebe, R. Hansson, H. Schut, & W. Stroebe (Eds.), Handbook of bereavement research and practice: Advances in theory and intervention (pp. 397–416). Washington DC: American Psychological Association. Park, C. L., & Halifax, J. (2011). Religion and spirituality in adjusting to bereavement: Grief as burden, grief as gift. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 355–363). New York, NY: Routledge. Parker, J. S. (2005). Extraordinary experiences of the bereaved and adaptive outcomes of grief. Omega, 51(4), 257–283. doi:10.2190/fm7m-314b-u3rt-e2cb Parkes, C. M., & Prigerson, H. G. (2013). Bereavement: Studies of grief in adult life (4th ed.). New York, NY: Routledge. Pilling, J., Thege, B. K., Demetrovics, Z., & Kopp, M. S. (2012). Alcohol use in the first three years of bereavement: A national representative survey. Substance Abuse, Treatment, Prevention, and Policy, 7(1), 1–5. doi:10.1186/1747-597x-7-3 Rando, T. A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press. Rosenblatt, P. C. (1996). Grief that does not end. In D. Klass, P. Silverman, & S. Nickman (Eds.), Continuing bonds: New understandings of grief (pp. 45–58). New York, NY: Routledge. Sawyer, J. S., & Brewster, M. E. (2019). Assessing posttraumatic growth, complicated grief, and psychological distress in bereaved atheists and believers. Death Studies, 43(4), 224–234. doi:10.1080/ 07481187.2018.1446061 Slyter, M. (2012). Creative counseling interventions for grieving adolescents. Journal of Creativity in Mental Health, 7(1), 17–34. doi:10.1080/15401383.2012.657593 Sofka, C. S., (2004). Assessing loss reactions among older adults: Strategies to evaluate the impact of September 11, 2001. Journal of Mental Health Counseling, 26(3), 260–281. doi:10.17744/ mehc.26.3.gneaktlxb9l89el6 Sofka, C. S. (2018). Grief, adolescents, and social media. In C. Arnold (Ed.), Understanding child and adolescent grief: Supporting loss and facilitating growth (pp. 163–176). New York, NY: Routledge. Speece, M. W., & Brent, S. B. (1996). The development of children’s understanding of death. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 29–50). New York, NY: Springer Publishing Company. Steffen, E., & Coyle, A. (2017). “I thought they should know… that daddy is not completely gone”: A case study of sense-of-presence experiences in bereavement and family meaning-making. OMEGAJournal of Death and Dying, 74(4), 363–385. doi:10.1177/0030222816686609 Stroebe, M., & Schut, H. (2010). The dual process model of coping with bereavement: A decade on. Omega: Journal of Death & Dying, 61(4), 273–289. doi:10.2190/om.61.4.b

120

II.  Practice and Process

Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. The Lancet, 370(9603), 1960–1973. doi:10.1016/s0140-6736(07)61816-9 van den Berg, G. J., Lundborg, P., & Vikström, J. (2017). The economics of grief. The Economic Journal, 127(604), 1794–1832. Vaughn, K. S., & Gentry, G. K. (2006). Do no harm. In T. J. Vaughn (Ed.), Psychology licensure and certification: What students need to know (pp. 165–174). Washington, DC: American Psychological Association. Vigil, G. J., & Clements, P. T. (2003). Child and adolescent complicated grief and altered worldviews. Journal of Psychosocial Nursing & Mental Health Services, 41(1), 30–39. Worden, W. R. (2018). Grief counseling and grief therapy (5th ed.). New York, NY: Springer.

CHAPTER 

8

LI VI NG L OS S E S : N O N F I N I T E LOSS, AMB I GUOUS L O S S , A N D C H RO N I C   S OR R OW

LEARNING OBJECTIVES 1. Describe the relationship between grief and the assumptive world. 2. Provide a definition of grief that is inclusive of both death and nondeath losses. 3. Define the terms nonfinite loss, ambiguous loss, and chronic sorrow, identifying the unique features of each. 4. Identify practical suggestions for supporting individuals who experience nondeath losses.

INTRODUCTION In the process of living our lives, we encounter losses on a regular basis, but we often do not recognize their significance because we tend to think of loss in finite terms, mainly associated with death and dying, and not more generally in terms of adaptation to life-altering events and changes. We know that grief is the normal, unique response to loss. However, the assumption is often made that grief is only associated with losses that occur after the death of a loved one. We think that this view of grief is quite narrow. Of course, grief will normally follow the death of someone who we cared about deeply. But does a person have to die for grief to occur? We think that grief is a process that enables us to rebuild our assumptive world

122

II.  Practice and Process

after it has been broken, even shattered, by a significant loss event, and losses that are both death and nondeath-related can assault our assumptions about how the world should work. In this chapter, we explore different types of nondeath losses, their unique features, and their impact on us. Most of the current bereavement literature focuses on death-related losses, and many of the measures used in bereavement research are rooted in the identification of “separation distress” from another individual as the primary feature distinguishing grief from other responses and states, such as posttraumatic stress, depression, and anxiety (Maciejewski, Maercker, Boelen, & Prigerson, 2016). Separation distress is characterized by yearning, longing, preoccupation, and searching for the deceased individual (Boelen, Lenferink, Nickerson, & Smid, 2018). However, the emphasis on grief in terminology that relates only to the death of a person does not consider the possibility that the same grieving process also allows individuals to integrate significant losses that are perhaps not as tangible or overt. In reflecting upon this aspect of bereavement theory and research, we need to consider the possibility that the emphasis on separation distress after the death of a loved one may be limited in scope. Grief can be more broadly defined as the distress that occurs when an individual’s existing assumptive world is lost because of a significant life-changing event, or what Tedeschi, Shakespeare-Finch, Taku, and Calhoun (2018) would refer to as a “seismic” life event. Indeed, Bowlby’s (2005) descriptions of yearning, pining, longing, and searching (which are all considered the hallmarks of separation distress over the loss of a significant attachment figure) can be identified in various ways in the experiences of non-death losses as well.

THE ASSUMPTIVE WORLD AND LOSS Significant life-changing events can cause us to feel deeply vulnerable and unsafe, because the world that we once knew, the people that we relied on, and the images and perceptions of ourselves may prove to be no longer relevant in light of what we have experienced. Grief is both adaptive and necessary in order to rebuild the assumptive world after its destruction. It would certainly follow that the process of making meaning, which is a part of the grief response, is applicable to both death-related and non-death-related losses. Papa and Maitoza (2013) explored grief in the presence of involuntary job loss. Their findings showed support that grief is contingent upon loss of a self-defining role as opposed to loss of others exclusively. Papa, Lancaster, and Kahler (2014) also found similar results suggesting that grief is not a unique response to loss of loved one, but instead it may be a common phenomenology across many types of loss. In a study of bereaved university students, Varga (2016) found that many of her participants indicated that nondeath losses had more significance in their lives than did death-related losses: My greatest loss came from my fiancée leaving me and not from a death. This was a more significant loss than any death in my family so far and affected my studies to the point of me having to take time away from my education. (p. 182) Cooley, Toray, and Roscoe (2010) developed an instrument to measure grief after all types of death and nondeath loss events. The Integration of Stressful Life Events Scale



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

123

(ISLES)—Nonbereavement Version, developed by Holland, Currier, and Neimeyer (2014), measures struggles with the comprehensibility of the loss event and individual’s sense of secure grounding or footing in the world, and the Social Meaning in Life Events Scale (SMILES; Bellet, Holland, & Neimeyer, 2019) identifies issues related to validation or invalidation of loss experiences and responses within an individual’s social network and provides an indication of needs for social support and validation in different types of loss experiences. Both of these measures can be useful in the context of non-death-associated grief. Moving away from the strict definition of grief only occurring after loss through death could be potentially helpful to the clinical process with clients who grieve all types of losses. We hope to see more research in the future that addresses the process of grief after the experience of nondeath losses, allowing recognition of grief that occurs in a much broader context than only after a death occurs. As we have already discussed, attachment is identified as a key element in grief, and the attachment model provides an ethological1 element to the grieving process. Bowlby’s (1988) research demonstrated that the searching and pining behaviors seen in young children who were separated from their mothers resemble the behavior seen in young primates that were subjected to similar conditions. Parkes and Prigerson (2013) expanded this work into the area of adult bereavement and suggested that the attachment system, and the resulting grief when that system is threatened by separation, is an extension of a process that has evolved over time to optimize feelings of safety and to enhance the chances for survival of the individual. From the perspective of evolutionary biology, attachment and the resulting grief that comes with separation appear to confer a survival advantage to the individual. If grief and attachment are thus interrelated, then to what are we attached when we grieve a nondeath loss, such as loss of a sense of safety, loss of our homeland, or loss of employment? It could be that these defining, overarching losses involve either the loss of an aspect of ourselves to which we are attached or to our place in the world, which makes us feel safe and secure. For example, it is common for immigrants to yearn for their family and friends who are still present in their homeland, to search for what is familiar in their new environment, and to look for commonalities with their known culture in the new country of their arrival. The well-known term “comfort food” implies that identification with foods that are associated with our family and cultural roots provides a sense of comfort when we are stressed or are in unfamiliar territory. Individuals who have lost their jobs may pine for their old lives or selves to return to them, reminiscing about what they used to do or who they used to be. The natural process of aging often catches us by surprise and we wonder, “Where did that woman in the mirror come from, and where did I go?” The disequilibrium that results from these types of losses can activate the attachment system, motivating us to draw closer to what is familiar and safe, and the grieving process enables us to adapt to some part of ourselves or our life that is markedly different from what it was before. As discussed earlier, Janoff-Bulman (1992) draws a connection between one’s Ethology is concerned with the adaptive, or survival value of behavior and its evolutionary history. It emphasizes the genetic and biological roots of development and behaviors that are instinctually programmed into an animal’s normal repertoire of responses to given events. 1

124

II.  Practice and Process

assumptive world and one’s attachment system, stating that how one relates to and views the world, others, and oneself is an extension of the attachment system that is formed at a very young age. Thus, it would make sense that threats to the assumptive world resonate back to the attachment system upon which that world was built.

NONFINITE LOSS AND CHRONIC SORROW Patricia met James the week after her mother died from a prolonged fight with cancer. James was sitting at a table in a coffee shop, and the only empty chair in the entire place was next to him at the same table. He looked like he was content to read his paper while sipping his drink, and Patricia needed a place to set her laptop down to work while she drank her morning coffee. James was more than happy to offer the chair and table top to Patricia, and once they started talking, they hit it off very well. Over the next year, they dated, traveled together, and met each other’s extended families and close friends. They were such a good fit—even their dogs liked each other! They were married the next year, and they settled into a comfortable routine of sharing meals, walking the dogs, traveling, and reading snippets of the paper to each other on Sunday mornings. They also began trying to have children, and they had discussed the possibility of either adoption or fostering a child to share their loving home with them. One Sunday morning, James woke up and did not feel well. He was dizzy and felt weak. He called out to Patricia as he was getting out of the shower, and then collapsed in a heap on the floor. Patricia called 911 and an ambulance came and took James to the emergency department of the nearest hospital. Patricia was told that James had suffered a stroke and that he would survive, but it was unlikely that he would be able to speak, and he would not be able to use one side of his body. He would have a great deal of difficulty walking because of this weakness, and it was recommended that he spend a few months in a rehabilitation center to help him to gain as much function back as possible. Patricia was now 42 years old. They did not have children. Their parents were older and had significant health problems. James was able to come home after Patricia made modifications to the house to accommodate a wheelchair and the special needs he had for personal care. She resigned from her position at work so that she could care for James, taking early retirement, which paid her less than half of her usual income. As time went on, fewer and fewer friends came over to visit; most of the time when the doorbell rang, it was someone from the home health agency arriving to provide care of some sort or to bring medical supplies that were needed. James could understand what Patricia said to him, but he would become very frustrated when she could not understand what he wanted or needed. After several months of caregiving, Patricia slumped herself down in a chair in the corner of the bedroom while James slept. Tears flooded as she assessed her life—or what was left of it. She would never have children. She could not just run to the store to pick something up without making arrangements for someone to be with James. James could stay like this for years, or he could get worse, and she often worried about neglecting something important and cause a complication to occur to James. She felt completely exhausted and alone.



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

125

This scenario has many losses in it. However, none of the losses are because someone died; rather, the losses are ongoing, and they exist and mingle with the everyday life of Patricia and James as time goes on. We would call these losses living losses, and most of them would fit into the category of nonfinite loss. Nonfinite losses are those loss experiences that are enduring in nature, usually precipitated by a negative life event or episode that retains a physical and/or psychological presence in an ongoing manner (Bruce & Schultz, 2002). Some forms of nonfinite loss may be less clearly defined in onset, but they tend to be identified by a sense of ongoing uncertainty and repeated adjustment or accommodation. Some nonfinite losses begin as finite events, but their aftereffects will be experienced for the rest of an individual’s life. This is the case with Patricia and James, as the stroke itself was a finite event; the ongoing needs for care as well as the uncertainty and complete change in their relationship and lifestyle represent the nonfinite aspects of this loss experience. There are three main factors that separate nonfinite loss experiences from the experience of a death-related loss: 1. The loss (and grief) is continuous and ongoing, although it may follow a specific

event, such as an accident or diagnosis.

2. The loss prevents normal developmental expectations from being met in some

aspect of life, and the inability to meet these expectations may be because of physical, cognitive, social, emotional, or spiritual losses.

3. The inclusion of intangible losses, such as the loss of one’s hopes or ideals related

to what a person believes should have been, could have been, or might have been (Schultz & Harris, 2011).

The cardinal features of the experience of nonfinite losses include: ■■

There is ongoing uncertainty regarding what will happen next.

■■

There is often a sense of disconnection from the mainstream and what is generally viewed as “normal” in human experience.

■■

The magnitude of the loss is frequently unrecognized or not acknowledged by others.

■■

There is an ongoing sense of helplessness and powerlessness associated with the loss (Schultz & Harris, 2011).

Jones and Beck (2007) further add to this list a sense of chronic despair and ongoing dread, because individuals try to reconcile themselves between the world that is now known through this experience and the world in the future that is now anticipated. In short, the person who experiences nonfinite loss is repeatedly asked to adjust and accommodate to the loss. At the same time, because nonfinite loss is often not well understood, the experience may go unrecognized or unacknowledged by others. Support systems may tire of attempting to provide a shoulder to lean on. A related concept to nonfinite loss is that of chronic sorrow, a term that was first proposed by Olshansky (1962) after his observations of parents whose children were born with disabilities. He noticed that these parents experienced a unique form of grieving that never ended as their children continued to live and the hopes that they had for these children

126

II.  Practice and Process

were repeatedly dashed as time went on. Shortly after the introduction of the concept by Olshansky, there were a few articles written about the adjustment and coping in parents of children with various developmental disabilities. Since then, most of the research associated with the concept of chronic sorrow has been reported in the nursing literature. The concept of chronic sorrow has been described in multiple sclerosis, parenting a child with a mental health problem, Alzheimer’s disease, autism, infertility and involuntary childlessness, mental illness, and caring for a child with disabilities. Chronic sorrow has also been linked to Parkinson’s disease, mental retardation, neural tube defects, spinal cord injury, schizophrenia, and chronic major depression (Roos, 2017). Chronic sorrow is often found in situations involving long-term caregiving. Chronic sorrow is defined by Roos (2017) as: a set of pervasive, profound, continuing, and recurring grief responses resulting from a loss or absence of crucial aspects of oneself (self-loss) or another living person (other-loss) to whom there is a deep attachment. (p. 25) The way in which the loss is perceived determines the existence of chronic sorrow. The essence of chronic sorrow is a painful discrepancy between what is perceived as reality and what continues to be dreamed of or hoped for. The loss is ongoing since the source of the loss continues to be present. The loss is experienced as a living loss. Chronic sorrow remains largely disenfranchised and often escalates in intensity or is progressive in nature. Although chronic sorrow is often linked to a defining moment, a critical event, or a seismic occurrence, it can just as easily be the hallmark of the slow insidious realization of what a diagnosis means over time and how it has caused change for the lives in its wake. In our discussions in this chapter, the term nonfinite loss will refer to the loss or event itself, and chronic sorrow will refer to the response to ongoing, nonfinite losses. Burke, Eakes, and Hainsworth (1999) describe chronic sorrow as akin to grief-related feelings that emerge in response to an ongoing disparity resulting from the loss of the anticipated and expected normal lifestyle of an individual. Teel (1991) stated that in addition to the disparity that exists between what is expected or hoped for and what actually is in reality, the chronicity of the feelings and the ongoing nature of the loss separate chronic sorrow from other forms of grief. According to this author, chronic sorrow can be precipitated by the permanent loss of a significant relationship, lost functionality, or self-identity. Lindgren, Burke, Hainsworth, and Eakes (1992) define the characteristics of chronic sorrow to include: (a) a perception of sadness or sorrow over time in a situation with no predictable end, (b) sadness or sorrow that is cyclic or recurrent, (c) sadness or sorrow that is triggered internally or externally, and (d) sadness or sorrow that is progressive and can intensify. Chronic sorrow is differentiated from the grief response after a death in that the loss itself is ongoing, and thus the grief is also ongoing and does not end. These authors stress the peaks and valleys, resurgence of feelings, or periods of high and low intensity that distinguish chronic sorrow from other types of grief responses. An individual’s emotions might swing between being emotionally flooded on one side, with being emotionally numb and paralyzed at the other side of an emotional pendulum. Most people who experience chronic sorrow generally reside somewhere between these two end points, but fluctuations are common.



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

127

TABLE 8.1  Comparison of Clinical Depression and Chronic Sorrow CLINICAL DEPRESSION VERSUS CHRONIC SORROW DEPRESSION

CHRONIC SORROW

Mood disturbance with lack of energy and engagement as primary features that create difficulties in functioning

Lack of energy is a by-product of exhaustion from the ongoing need to cope, accommodate, and adjust to the loss

Symptoms are often diffuse and difficult to pinpoint onto events

Sorrow usually relates readily back to the ongoing loss experience

Can be temporary and improve over time

Lasts as long as the loss is present

May be responsive to medication

Does not typically respond to medication (unless depression overlaps)

Roos (2017) also states that the loss involved in chronic sorrow is a lifetime loss and remains largely unrecognized for its significance. One’s assumptive world is shattered and there is no foreseeable end, with constant reminders of the loss. She states that there is also an undercurrent of anxiety and trauma that separates this type of response from grief that is experienced after the death of a loved one, and the fact that the person usually continues to function separates it from primary clinical depression (Table 8.1). Chronic sorrow differs from posttraumatic stress disorder because of the ongoing nature of the loss and the fact that it is not a reaction to an event that has occurred, even though there may be an event that defines when the loss began. The traumatic material in nonfinite loss is related to the degree of helplessness and powerlessness that is felt in light of a situation that has profound, ongoing, and life-altering implications for the individual. Roos (2017) makes the point that chronic sorrow may apply more to those who are caregivers, because the affected individual may not be able to internalize the world in such a way as to be able to have dreams or life goals, and the intensity of the experience of chronic sorrow is related to the potency and magnitude of the disparity between the reality of the situation and the dream to which a person may cling. The outcome is really unknown, or the progression of what will unfold is unknown, so unpredictability complicates the process. The ongoing presence of the person or the loss inhibits reinvestment into other aspects of life, and there are “surges” of grief that are often triggered by various events, as might occur in individuals whose loss was related to the death of another individual.

AMBIGUOUS LOSS Janice pulls her car into the garage and begins to unload the groceries into the kitchen. She knows that her husband, Richard, is home because his car is in the garage, but she does not expect a greeting from him when she gets in the door, and she also does not seek him out to say hello when she gets home. Their two teenage children, Cynthia and Rachel, come home from school and immediately go upstairs to their rooms and close the doors. Janice finishes

128

II.  Practice and Process

unloading the groceries and prepares dinner. She calls them all when dinner is ready, and they sit at the table to eat together. However, Richard turns the TV on as they are about to sit down at the table, and he watches the news while eating, not saying much to Janice or the girls. Cynthia has begun hanging out with friends from the volleyball team, and she spends a good portion of the dinner time texting back and forth to them on her cell phone. Rachel has her headphones on when she comes to the table, not bothering to remove them when she begins to eat dinner. Janice looks around at the table. She tries to make conversation and ask each one of them about their day. Richard mutters something quick while still watching the TV program, like “Just fine . . . busy,” whereas Cynthia tries to talk and text at the same time without success, and Rachel acts perturbed at having to remove her headphones to answer her mother’s query. Finally, Janice too eats in silence and watches the TV. Later that night, Janice feels overwhelmed with sadness, but she does not know why. She goes downstairs to get a glass of milk, sits at the kitchen table, and begins to cry. Many of the nondeath losses that are experienced by individuals are very difficult to name, describe, or validate. As stated previously, many losses are not clearly defined because there is no identifiable “death.” For many individuals, it may be unclear exactly what has been lost. The loss may or may not involve a person and there may not be a defining experience to denote where the loss actually originates. In her development and exploration of loss experiences where there was significant ambiguity, Boss (1999) first used the term ambiguous loss. She described two situations in which ambiguous loss occurs. In the first scenario, the person is perceived as physically absent but psychologically present. Examples may be when a person is missing, such as in divorced families when the noncustodial parent is absent but very much present in the minds of the children. Prisoners, kidnapping victims, relatives serving their country overseas, adoptive families, and situations when a person is absent or missing but very much present in the minds or awareness of their loved ones may also fit this description. Another frequent example would be grandparents who lose contact with their grandchildren after the parents of these children divorce, so they are physically not able to spend time with them, yet thoughts of these children frequently occupy their minds and cause a feeling of grief. In the second scenario described by Boss, ambiguous loss may be identified when the person is physically present but perceived as psychologically absent. Examples of this type of loss may be when a family member has Alzheimer’s disease, acquired brain injury, autism, a chronic mental illness, or if there is a family member who is psychologically unavailable because of addictions or some type of ongoing distraction or obsession, as is the case for Janice with her family. Each of these scenarios leaves individuals feeling as if they are “in limbo” as they struggle to learn to live with ambiguity (Boss, 2016). Boss’s first observations of this phenomenon occurred when she engaged with families in a therapeutic setting, where the family system was outwardly intact, but one of the members was absent psychologically from the family through obsessive workaholism or addiction. Key aspects of ambiguous loss include the following (Boss, 2016): ■■

The loss is confusing, and it is very difficult to make sense of the loss experience (as when a person is physically present, but emotionally unavailable).



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

129

■■

Because the situation is indeterminate, the experience may feel like a loss, but not be readily identified as one. Hope can be raised and destroyed so many times that individuals may become psychically numb and unable to react.

■■

Because of ongoing confusion about the loss, there are frequent conflicting thoughts and emotions, such as dread and then relief, hope and hopelessness, wanting to take action and then profound paralysis. People are often “frozen” in place in their reactions and unable to move forward in their lives.

■■

Difficulty problem-solving because the loss may be temporary (as in a missing person) or it may be permanent (as in an acquired head injury).

■■

There are no associated rituals and very little validation of the loss (as opposed to a death where there is official certification of the death and prescribed rituals for a funeral and disposition of a body).

■■

There is still hope that things may return to the way they used to be, but there is no indication of how long that may take or whether it will ever happen (e.g., if a family member enters treatment for an addiction or if a couple enters marital therapy).

■■

Because of the ambiguity, people tend to withdraw instead of offer support because they do not know how to respond, or there is some social stigma attached to the experience.

■■

Because the loss is ongoing in nature, the relentless uncertainty causes exhaustion in the family members and burnout of supports, both personal and professional.

Boss (2016) describes the experience of ambiguous loss like a “never-ending roller coaster” that affects family members physically, cognitively, behaviorally, and emotionally. Physical symptoms may include fatigue, sleep disturbances, and somatic complaints that may affect various body systems. Cognitive symptoms may include preoccupation, rumination, forgetfulness, and difficulties concentrating. Behavioral manifestations may be expressed through agitation, withdrawal, avoidance, dependence, or a pressing need to talk at times. Emotionally, individuals may feel anxious, depressed, irritable, numb, and/or angry. It is not uncommon to be misdiagnosed with an anxiety disorder or a major depressive disorder (Boss & Ishii, 2015).

LIVING LOSSES There is a great deal of overlap between losses that are nonfinite and losses that are ambiguous (Figure 8.1). Perhaps much of the distinctions have to do with their origin in different fields of study, and thus the lens that is used to describe these experiences reflects different ways of viewing loss experiences that may have many similar features. In the literature, nonfinite loss is described more from an intrapersonal perspective, with the loss experience focusing on the individual’s perception and coping (e.g., what did I have that I am now losing), whereas ambiguous loss is a concept that was formulated within a family stress model, and the loss is described in terms of how the family members perceive and define the loss according to the boundaries of the family system (e.g., who is absent from the family system that should be present). In the descriptions

130

II.  Practice and Process

Nonfinite Loss Intangible Losses

Chronic Sorrow

Tangible Losses

Ambiguous Loss

FIGURE 8.1  Overlapping constructs in nondeath loss and grief.

of nonfinite loss and ambiguous loss, the common features include: (a) dealing with ongoing uncertainty that causes emotional exhaustion, (b) shattering of assumptions about how the world should be, and (c) a lack of rituals and validation of the significance of these losses. Nonfinite loss, ambiguous loss, and chronic sorrow may be linked not only to real losses, but also to perceived, symbolic, or secondary losses. They may all be accompanied by shame and self-loathing that further complicate individual authenticity and truthfulness in other relationships, thereby adding to the struggle with coping. For example, Janice may blame herself by thinking that she has been a poor partner to Richard or an inadequate mother to Rachel and Cynthia for her family to be so disconnected; this self-perception could undermine her sense of self as worthy or valuable to others, which is a core aspect of the assumptive world. Although ambiguous losses, nonfinite losses, and chronic sorrow are often disenfranchised (Boss, 2009; Casale, 2009; Doka, in press; Roos, 2017), the ongoing grief is normal and understandable. Recognition that life as it has been or was expected to be is lost and has been replaced by an initially unknown, unwanted, and often terrifying new reality is extremely difficult, forcing a new appraisal of one’s assumptive world. Beliefs that life is predictable and fair and the notion of justice and compensation cannot survive in the new reality. The self and the world must be relearned. This process is often a disturbing and ongoing focus of concern. There exists a significant body of research on ambiguous loss that indicates a relationship to depressive symptoms and family conflict (Boss, 2009; Carroll, Olson, & Buckmiller, 2007).

IMPLICATIONS FOR COUNSELING The practice considerations related to both ambiguous loss and chronic sorrow underscore the importance of normalizing the ongoing grief that is present. The main issues that create the most difficulty for those affected by living losses are the fact that the grief persists for a



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

131

prolonged or undetermined time, and the uncertainty about how things will or will not progress creates an undercurrent of anxiety, which is often experienced as an unmet expectation by professional caregivers. Exhaustion is common for the ones directly affected by the loss as well as by the helpers who are involved in the situation. Social supports begin to dwindle as people tire of the ongoing litany of loss, and as relationships change due to differing abilities and priorities. It is important to recognize that in these scenarios, the ongoing grief is a normal reaction whether the loss is related to something tangible, such as a person or a thing that is greatly valued, or something less tangible, such as a hope or expectation. Because the loss and its effects are ongoing in nature, the grief and sorrow that occur secondary to the loss are ongoing as well, without any end in sight. Flexibility in providing counseling to an individual, couple, family, and group in various constellations at different times can assist in supporting those who are taking on most of the responsibilities. Finding ways to adjust and redefine roles in the family can help to minimize chaos, reduce stress, and improve relationships. One other important point to note is that nonfinite and ambiguous losses may comingle with losses that occur from death. For example, one client who sought counseling for support after her husband died came initially to share her grief over the loss of her husband. Later on, the grief was more about the loss of herself when she married her husband, who had been a very controlling and abusive person in the marriage. The initial consultation was for a death-related loss, followed by another layer of her grief that was both nonfinite and ambiguous in nature.

Name and Validate the Loss Many nonfinite and ambiguous losses and losses that involve an ongoing, chronic process are disenfranchised in nature. Disenfranchised losses are those that are either not recognized or acknowledged, often have stigma attached to them, and no rituals to provide a sense of meaning to what has happened (Doka, in press). Recognizing and naming these losses is cited by Doka (in press) and Boss (2006, 2009) as the first step in offering support to individuals who have experienced disenfranchised grief from loss experiences that are not recognized. The ability to name the experience and its unique effects that are often unacknowledged by others can provide a powerful source of strength to those who experience ambiguous loss and chronic sorrow. Clients who begin to understand the nature of these losses and receive validation for them often experience relief and improved self-concept almost immediately (Roos, 2017). In a study of infertile women, Harris (2009) reported that recognition of the ongoing intense grief response to their infertility allowed participants to spend less time attempting to seek validation for their experiences and more time focusing on active problem-solving within the confines of their situation. It might be helpful to these clients if the counselor highlights the aspects of the assumptive world that have been violated by what has happened, identifying the significant work involved in rebuilding that world after it has been shattered through these kinds of losses. Considering potential rituals that might acknowledge and validate the loss experience might also be helpful (Practice Example 8.1).

132

II.  Practice and Process

P R A C T I C E EXAM PLE 8 . 1 USE OF RITUAL TO ACKNOWLEDGE NONDEATH LOSS

Anna and her husband of 7 years had separated after she realized that he was involved with another woman from work. Anna felt alone and demoralized. She doubted herself a lot, thinking that if her husband had chosen someone else over her, then something was wrong with her. Anna’s friends at work were concerned for her. They knew she was struggling but they were not sure what to say or do. One day in the lunchroom, Anna confided in one of her friends that she felt like someone had died, but nobody was sending her flowers. That gave her friend an idea. When Anna went to work the next day, there was an invitation on her desk. When she opened it, she did not know whether to laugh or to cry. She had been invited to attend the funeral of her marriage. That evening, her friends picked her up and brought her to one of their houses, where everyone was dressed in black. The “celebrant” talked about all of the hopes that Anna had when she had gotten married and then solemnly discussed the loss of the relationship. At the end of the “service,” Anna was brought to the front to read her “divorce vows,” which included a promise to love herself, trust herself, and never allow someone else to determine her worth. While doing the ritual with her friends was both funny and painful, she felt lighter at the end. She realized that she had wonderful friends who cared a lot for her. She also had no idea what the future held, but she knew that other women in this group had gone through divorce and they seemed to be fine, even happy. Anna felt hopeful that one day she might be able to be happy and laugh again like her friends.

Foster Realistic Expectations The more success-oriented a culture is, the more difficult it is to accept losses that do not have a defined closure (Boss, 2016). There is also the romanticized ideal of “overcoming” adversity that may be highly unrealistic for individuals who are facing nonfinite and ambiguous losses. The focus of counseling is to identify the strengths and resilience that is present, while understanding that there are realistic limitations to one’s tenacity and capacity. Clients learn to control what they can and to let go of what they cannot control. This letting go is not something that is easily done, and there are very few role models in Western society to demonstrate acceptance of limitations instead of overcoming all odds through insurmountable difficulties—a message that readily becomes an expectation, reinforced through popular media, but that rarely occurs in real life. Relationships get redefined, and modalities that focus on awareness and acceptance of ambiguity, such as meditation, yoga, and mindfulness, may take on new meaning. Often, there is a redefining of the self that occurs, along with new interests, hobbies, and connections to others who understand experiences that are surrounded by ambiguity and uncertainty.



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

133

Reconstruct Identity Patricia’s personal identity changed quickly from that of a woman who was embarking on the start of an exciting new phase of her life to the ending of her life as she once knew and anticipated it as she became the caregiver to a man who was now disabled and who now seemed much older than her. Janice was overwhelmed with sadness at the realization that the family she had always dreamed of having was not a source of safety and comfort, but a means whereby she was essentially made invisible and rendered chronically exhausted. One’s personal identity changes in the presence of these types of losses. The work of counseling will involve redefinition of one’s identity in a way that is consistent with reality and also that allows for the recognition of the person as an individual with unique abilities, skills, and strengths that may need other avenues for validation and expression. Patricia will need to find value and worth outside of her marriage and work, with a new network of friends who can accommodate her limitations, in addition to finding alternative outlets to channel her needs for expression and meaning (Practice Example 8.2).

Normalize Ambivalence It is not unusual to have mixed emotions when you do not know whether someone you love is here or not or whether a situation that seems intolerable will ever end. Patricia sometimes fantasized about James dying and then felt tremendous guilt when she would

P R A C T I C E EXAM PLE 8 . 2 WITNESSING THE PERSONAL IDENTITY CHANGE OF A CAREGIVER

Shawna was a primary nurse in a busy neurology clinic. Don, a 46-year-old man with multiple sclerosis, had been assigned to her team. Don’s 71-year-old mother cared for him. She called Shawna frequently, reporting new symptoms, and asking for help with Don’s care. Shawna would review these calls with the primary doctor for her team, and he would sometimes change medications and dosages, but he would often tell Shawna that there was nothing more that he could do for Don. Both of them began to dread the calls from Don’s mother, as they felt an expectation from her that they could always do something more for Don when there was not anything else they knew to do. Shawna asked the receptionist to always take a message when Don’s mother called. She would put off returning the call until the end of the day. She felt badly for doing this, but the sense of dread she felt when seeing there was a message from Don’s mother was worse. Sensing that Shawna and the doctor were withdrawing from her, Don’s mother showed up at the clinic one day in tears, saying that she felt they were abandoning her and Don when they had nowhere else to go for help.

134

II.  Practice and Process

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

Identify Resources Helping clients with information about community resources and other supports is a high priority. Identifying potentially damaging triggers (both external and internal) and implementing strategies to reduce the effects of these triggers can be very useful. Emphasizing the highly individualized nature of grief helps to reduce self-criticism. It is also important to be aware that approaches to some conditions are inappropriate and may worsen responses to losses that are ambiguous or ongoing in nature (e.g., pushing for closure or resolution). In this regard, counselors need to understand that these individuals may have already had destructive experiences with prior professionals or well-meaning but uninformed helpers (Harris, in press). As these types of loss experiences become more commonplace, it is vitally important for helping professionals to develop a basic understanding of these phenomena in order to avoid inadvertently pathologizing a normal response to these very difficult types of losses. Identifying resources may also involve identifying personal resources that are available to the client. For example, one of our clients whose husband had advanced Parkinson’s disease spent a session describing the intolerable situation she was in, being essentially homebound with a man whose declining mental capacity and functionality overwhelmed her strength and patience. The session turned into an opportunity to brainstorm how one of her husband’s friends could organize all of his other friends and extended family members to regularly come for “shifts” to do something with him at the house so that she could plan to do the things she wanted to do on her own or with her own friends away from the home. In her sessions, she began to realize that she was initially trying to protect her husband from embarrassment about his condition by not inviting people to their home. However, she realized that the shame over his loss of functionality essentially trapped them together in the home, causing more tension and stress for each of them. In recognizing that they both needed the support of others, she found a solution that provided relief for each of them.



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

135

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

GLOSSARY Ambiguous loss  Loss that remains unclear, cannot be fixed, and has no closure. It can be physical or psychological. Present in losses in which an individual may be psychologically present but physically absent or in losses in which an individual may be physically present but psychologically absent. Chronic sorrow  An ongoing response to losses that are continual and unending in nature; the chronicity of the feelings and the ongoing nature of the loss separate chronic sorrow apart from other forms of grief. Living losses  Losses that will remain as an ongoing presence in the life of an individual; the individual will continue to “live” with the loss experience. The ongoing nature of the loss will require continual adaptation and adjustment. Nonfinite losses  Loss experiences that are enduring in nature, usually precipitated by a negative life event or an episode that retains a physical and/or psychological presence in an ongoing manner. Separation distress  The presence of yearning, longing, preoccupation, and searching for the deceased individual after a death.

QUESTIONS FOR REFLECTION 1. Go back to the loss line exercise from Chapter 4, “The Social Context of Loss.” If you

did not do this exercise before, complete it now. Once you are done, look at the losses that you have noted on your loss line. Which of these losses might be considered nonfinite losses—losses that forever changed you and that you continue to recognize in your life now? Can you think of any losses that were ambiguous in nature? How did you handle these losses? How did others respond to your experiences of these losses?

2. Why do you think nonfinite and ambiguous losses are often not recognized or

acknowledged socially?

3. Think of some popular movies or television programs that provide examples of

nonfinite and ambiguous losses. How were these losses portrayed in these films? Before you were aware of these concepts, how would you have viewed these kinds of loss experiences?

136

II.  Practice and Process

4. One of the biggest challenges for individuals who face nonfinite and ambiguous

losses is the ongoing nature of the grief and the anxiety that accompanies the uncertainty associated with these losses. What are some of the social implications for individuals who experience these kinds of losses? Can you think of ways to offer support to individuals like Patricia from our case study in this chapter?

REFERENCES Bellet, B. W., Holland, J. M., & Neimeyer, R. A. (2019). The Social Meaning in Life Events Scale (SMILES): A preliminary psychometric evaluation in a bereaved sample. Death Studies, 43(2), 103–112. doi:10. 1080/07481187.2018.1456008 Boelen, P. A., Lenferink, L. I., Nickerson, A., & Smid, G. E. (2018). Evaluation of the factor structure, prevalence, and validity of disturbed grief in DSM-5 and ICD-11. Journal of Affective Disorders, 240, 79–87. doi:10.1016/j.jad.2018.07.041 Boss, P. (1999). Ambiguous loss. Cambridge, MA: Harvard University Press. Boss, P. (2006). Loss, trauma and resilience: Therapeutic work with ambiguous loss. New York, NY: Norton. Boss, P. (2009). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press. Boss, P. (2016). The context and process of theory development: The story of ambiguous loss. Journal of Family Theory & Review, 8(3), 269–286. doi:10.1111/jftr.12152 Boss, P., & Ishii, C. (2015). Trauma and ambiguous loss: The lingering presence of the physically absent. New York, NY: Springer Publishing Company. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York, NY: Basic Books. Bowlby, J. (2005). A secure base: Clinical applications of attachment theory. New York, NY: Taylor & Francis. Bruce, E. J., & Schultz, C. L. (2002). Nonfinite loss and challenges to communication between parents and professionals. British Journal of Special Education, 29(1), 9–13. doi:10.1111/1467-8527.00231 Burke, M. L., Eakes, G. G., & Hainsworth, M. A. (1999). Milestones of chronic sorrow: Perspectives of chronically ill and bereaved persons and family caregivers. Journal of Family Nursing, 5(4), 374–387. doi:10.1177/107484079900500402 Carroll, J. S., Olson, C. D., & Buckmiller, N. (2007). Family boundary ambiguity: A 30-year review of theory, research, and measurement. Family Relations, 56(2), 210–230. doi:10.1111/j.17413729.2007.00453.x Casale, A. (2009). Distinguishing the concept of chronic sorrow from standard grief: An empirical study of infertile couples (Doctoral dissertation, Silver School of Social Work, New York University) (UMI No. 3353016). Cooley, E., Toray, T., & Roscoe, L. (2010). Reactions to loss scale: Assessing grief in college students. Omega: Journal of Death and Dying, 61(1), 25–51. doi:10.2190/om.61.1.b Doka, K. (Ed.). (2020). Disenfranchised grief and non-death losses. In D. Harris (Ed.), Non-death loss and grief: Context and clinical implications. New York, NY: Routledge. Harris, D. (2009). The experience of spontaneous pregnancy loss in infertile women who have conceived with the assistance of medical intervention. Retrieved from Proquest Digital Dissertations (UMI No. 3351170). Harris, D. (in press). Non-death loss and grief: Context and clinical implications. New York, NY: Routledge. Harris, D., & Daniluk, J. (2010). The experience of spontaneous pregnancy loss for infertile women who have conceived through assisted reproduction technology. Human Reproduction, 25(3), 714–720. doi:10.1093/humrep/dep445 Holland, J. M., Currier, J. M., & Neimeyer, R. A. (2014). Validation of the Integration of Stressful Life Experiences Scale—Short Form in a bereaved sample. Death Studies, 38(4), 234–238. doi:10.1080/07 481187.2013.829369 Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY: Free Press.



8.  Living Losses: Nonfinite Loss, Ambiguous Loss, and Chronic Sorrow

137

Jones, S. J., & Beck, E. (2007). Disenfranchised grief and nonfinite loss as experienced by the families of death row inmates. Omega, 54(4), 281–299. doi:10.2190/a327-66k6-p362-6988 Lindgren, C., Burke, M., Hainsworth, M., & Eakes, G. (1992). Chronic sorrow: A lifespan concept. Scholarly Inquiry for Nursing Practice, 6, 27–40. Maciejewski, P. K., Maercker, A., Boelen, P. A., & Prigerson, H. G. (2016). “Prolonged grief disorder” and “persistent complex bereavement disorder,” but not “complicated grief,” are one and the same diagnostic entity: An analysis of data from the Yale Bereavement Study. World Psychiatry, 15(3), 266– 275. doi:10.1002/wps.20348 Olshansky, S. (1962). Chronic sorrow: A response to having a mentally defective child. Social Casework, 43(4), 190–193. doi:10.1177/104438946204300404 Papa, A., Lancaster, N. G., & Kahler, J. (2014). Commonalities in grief responding across bereavement and non-bereavement losses. Journal of Affective Disorders, 161, 136–143. doi:10.1016/j.jad.2014.03.018 Papa, A., & Maitoza, R. (2013). The role of loss in the experience of grief: The case of job loss. Journal of Loss and Trauma, 18(2), 152–169. doi:10.1080/15325024.2012.684580 Parkes, C. M., & Prigerson, H. G. (2013). Bereavement: Studies of grief in adult life. London, UK: Routledge. Roos, S. (2017). Chronic sorrow: A living loss. New York, NY: Brunner-Routledge. Schultz, C. L., & Harris, D. L. (2011). Giving voice to nonfinite loss and grief in bereavement. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 235–245). New York, NY: Routledge. Tedeschi, R. G., Shakespeare-Finch, J., Taku, K., & Calhoun, L. G. (2018). Posttraumatic growth: theory, research, and applications. New York, NY: Routledge. Teel, C. S. (1991). Chronic sorrow: Analysis of the concept. Journal of Advanced Nursing 16(11), 1311– 1319. doi:10.1111/j.1365-2648.1991.tb01559.x Varga, M. A. (2016). A quantitative study of graduate student grief experiences. Illness, Crisis & Loss, 24(3), 170–186. doi:10.1177/1054137315589700

CHAPTER 

9

WO RKI N G W I T H E M O T I O N S — Y O U R S AND THE I R S

LEARNING OBJECTIVES 1. Discuss the importance of focusing on emotions in the counseling process. 2. Define emotional intelligence and describe a model of working with emotions based on emotional intelligence. 3. Identify how a feeling vocabulary can be used in counseling practice. 4. Explore the four main feeling states and their function in human experiences. 5. Discuss the role of the counselor’s feelings in the therapeutic relationship.

INTRODUCTION Probably one of the biggest concerns for counselors who begin to practice in the area of grief counseling is how to work with strong emotions as they arise in clients. Although we have earlier shared that not everyone will grieve through the sharing and expression of their feelings, many clients will experience strong emotions as part of their grief. In this chapter, we explore the role that emotions might play in the grieving process, and how counselors can help their clients to benefit from working constructively with their feelings. Many bereaved clients will feel overwhelmed by their feelings, and they will come to counseling in hopes of learning to contain their feelings. The good news is that clients can often learn how to manage their feelings and regulate their emotions through the counseling

140

II.  Practice and Process

process, but the hard part is that they learn to do this by first having to focus on them. In their everyday world, bereaved individuals are often given much advice and receive many messages that minimize their experience, probably with the intent of helping them to manage their feelings. In the counseling process, however, we often do just the opposite, and a lot of time is often spent exploring and gaining insights from feelings rather than trying to avoid or minimize them. Thus, what may occur is that we might, at first, intensify the feelings because we pay attention to them, and even focus on them instead of trying to diminish and contain them for the sake of social propriety. The identification of and work with feelings can be very rewarding and empowering for clients, ultimately moving them into deeper work that allows them to recognize their strengths and potential for growth. There is some discussion about the difference between feelings and emotions. Typically, feelings are viewed as faster than emotions in terms of response (referring to the response time of the feeling and how fast it arises in real-time stimulation), and it takes someone less time to recognize feelings because they are instant reactions to stimuli that occur in the present moment. Emotions tend to be viewed as a longer-term effort, after an individual has had an opportunity to reflect upon feelings that have surfaced, and meaning or significance has therefore been assigned to the felt experience. Feelings are closer to sensory stimulation; thus, if you touch something, you feel it almost instantaneously, which is a fast reaction. An emotion could represent a deeper experience because it might affect more aspects of you, and you may become more invested in it because you have delved into and reflected upon the experience more, but that is only because it is now also attached to your cognitions and interpretations more. For example, depression will have more of an impact on you than just an isolated feeling of sadness. We find these distinctions are mostly academic, though, and for the purposes of this chapter, we use these two terms interchangeably because both feelings and emotions are important in our discussion, and the work with feelings and emotions in the counseling setting is going to involve the same process.

THINKING CRITICALLY ABOUT FEELINGS Individuals who live in Western-oriented societies tend to think of feelings as primitive, irrational, weak, pathetic, and an indication that someone is out of control. Stop and think for a moment about how many derogatory terms and phrases are there to describe someone who readily expresses emotions and what these phrases imply: “He lost it.” “She was hysterical.” “He went nuts.” “I need to get a grip.” The implication is clear: If you express strong emotion, you are out of control, and you need to regain your composure quickly. Stoicism and rationality are espoused as true virtues; for example, “He’s holding up so well,” or “She is staying strong for the kids.” Individuals who deny their emotions and function solely from an analytical, rational perspective are seen as



9.  Working With Emotions—Yours and Theirs

141

smarter, more competent, and desirous. Feltham (2010) ventures to address the issue of emotion in counseling by stating that the most effective counselors tend to be those who are more naturally intuitive and emotionally responsive, both characteristics that are more acceptable to feminine socialization patterns. He concludes that most counseling theory is generated by men and places cognitive processing at the top of what is most desirable in counseling practice. He also states: There is a prejudice against raw emotion and direct knowledge, and a demand for theoretical justification. Crying remains an uncomfortable phenomenon and is rare in public and in educational institutions, as is expressed anger. Direct, heartfelt responses to the common human experiences of loss and heartache receive relatively little attention in counselling training. (p. 184) We have previously discussed the importance of the counselor’s focused and compassionate presence within the counseling relationship. Genuine caring and compassion are feeling oriented, and clients are very likely to “know the difference between a counselor who really cares deeply and one who either struggles to do so or who is primarily cognitively rather than emotionally oriented” (Feltham, 2010, p. 184). Similarly, Levitt, Butler, and Hill (2006) and Timulak (2010) state that the counselor’s ability to perceive, share, and explore emotional content was reported by clients as the most valued components of their therapy work. Watson and Bedard (2006) compared outcomes in clients who received process experiential therapy (PET) versus those who received cognitive behavioral therapy (CBT) and found that clients who had received PET, with its focus on emotional content and expression, were more deeply engaged in the therapeutic process and more likely to positively engage with their emotions readily afterward. Similarly, Fisher, Atzil-Slonim, Bar-Kalifa, Rafaeli, and Peri (2016) found that the client’s emotional experience was one of the most important determinants of the therapeutic process, which then predicted greater improvement in functioning. These statements are not meant to indicate that counselors who are more cognitively focused are less effective, but to emphasize the importance of being open to the exploration of feelings as part of the counseling process. Likewise, the ability for counselors to access their own feelings and intuition is important in order to be able to effectively engage with clients’ feelings and emotional states. As counselors, we will be touched and moved by the pain and suffering of our clients, and we do share a common human lived experience with them (Matise, 2015). However, showing emotions, especially openly with clients, can be interpreted by some as a sign of weakness or lack of professionalism (Curtis, Matise, & Glass, 2003). However, it can also be argued that showing our true feelings with clients is a form of congruence and genuineness, when filtered through the lens of the client’s best interests. Disclosing our personal reactions to our client’s stories can also be a valuable form of self-disclosure that serves as validation and normalization of our clients’ feelings. It is important to place feelings into the appropriate social and cultural context—and in most modern Western societies, feelings are devalued and stigmatized, so it is important to look critically at how intellect and cognition are privileged, and emotions and intuition are devalued—and yet both these entities are important aspects of the whole human experience.

142

II.  Practice and Process

FUNCTIONAL FEELINGS In the therapeutic setting, feelings can be seen as valuable indicators of what is most important to the client’s process. They give an indication of what Gendlin (1978) referred to as the “felt sense” of the client in a situation, and when you are able to identify and focus on the client’s feelings, you are probably working very directly with the places of most concern and difficulty to the client. Indeed, emotion-focused therapy was developed with the understanding that attending to clients’ emotions and the meanings attached to them are the primary sources of new information that can be used in the construction of new meanings and eventual working through of painful events (Paivio, 2013). You may recall our earlier discussion of the use of immediacy in the counseling process in Chapter 6, “The Basics of Counseling Practice.” Immediacy includes working in the here and now, with the feelings that are currently arising in the session. Schneider (2016) states that working in the here and now, noting feelings that are present in the client during the session, enables the most potential for insights, growth, and change in clients that can then be applied outside of the therapeutic environment. In the counseling session, it is important to help clients to learn to befriend their feelings and to try to learn from them. Although not everyone experiences strong feelings in response to significant life events, when intense feelings arise and we try to block them, we can end up feeling more anxious. Suppressing strong feelings takes a lot of energy and it can “backfire” when the defenses that function to contain the feelings are overloaded in some way. When this happens, the suppressed feelings can end up being released in a flood that can be overwhelming to the person and to the people in proximity to that person (Practice Example 9.1). We need to be able to experience feelings appropriately—in a way that is constructive, in the proper environment, and with the ability to reflect upon them as well. It is important to connect compassionately with feelings as they arise in order for defense to soften; approaching feelings in this way will eventually lessen the anxiety that the suppression of feelings creates. Feelings tend to “live” in our bodies, and we often experience a physical sensation when strong feelings are present. Sometimes, we will experience a “charge” with an emotion, which can be felt as a strong physical association with a certain feeling. We interpret this “charge” as the feeling attempting to get your attention that something important is happening and needs your focus. People often remark about feeling nauseous or their stomach being upset, being jittery or shaky, hot or cold, clammy, or heavy in their chest. You may have heard of the “fight–flight” response to stress, which is the way our bodies respond when we feel acutely stressed, frightened, or threatened. There is a direct link between how we feel and how our bodies respond, and we can often rely upon the signals in our bodies to help us identify our feelings and to channel them in ways that are healthy and constructive. In many ways, it is much easier to be “in our heads,” but experiencing life from a cognitive orientation alone means that we are denied the full and rich depth of being a complete person, which involves an integration of our thoughts, feelings, and physicality.

EMOTIONAL INTELLIGENCE For the last century, we have become very focused on developing our intellectual abilities. With the introduction of the Stanford–Binet intelligence test in 1916 (SB5; Fancher, 1985), the Wechsler Adult Intelligence Scale (WAIS) in 1939, and the Wechsler Intelligence Scale



9.  Working With Emotions—Yours and Theirs

143

P R A C T I C E EXAM PLE 9 . 1 LEARNING HOW TO EXPERIENCE INTENSE EMOTIONS

Pam’s husband died a year ago of a progressive neurological disease after being diagnosed 2 years prior. Pam often arrived late to her sessions because she was so busy at work. She would talk openly about her husband’s illness and their relationship, but if she began to get emotional, she would immediately divert herself into another topic. When the counselor asked how she felt, she would reply, “Well, you know . . . how anyone in my situation would feel . . .” and would then move onto something else. It was apparent that Pam was afraid of her feelings and was very uncomfortable discussing them. One day, Pam came into her session and told the counselor about a situation at her bank. She was applying for a line of credit to make changes to her home now that she no longer needed to worry about accessibility for her husband’s wheelchair in the living spaces of the house. The officer at the bank, not knowing that her husband had died, asked if the home was her property or in joint ownership with her husband, as his name was still on her accounts. Pam described being overcome with grief and sadness at that moment, unable to stop herself from sobbing in the bank in front of many people. The bank officer tried to usher her into a private area, and she felt humiliated as he did so. Her comment to the counselor was, “I don’t like having these emotions, and this incident just proved why.” Pam’s counselor took this opportunity to reflect back to Pam that intense emotions can be scary and difficult, but perhaps if she could “dose” herself with her feelings at times, they would not be triggered in such a big way again. Pam then asked for guidance about how to do this.

for Children (WISC) in 1949 (Frank, 1983), people focused on “IQ” as an indicator of who was smart, who was most likely to succeed, and who would be revered socially. Although Wechsler especially tried to look at more global capacities, such as the ability to solve real-life problems and to navigate successfully within one’s environment, the focus was still mostly on rationality and cognitive reasoning. Emotional components of the human experience were seen as secondary, and possibly a hindrance, to the measure of cognitive potential that was present in each individual. The value placed upon cognitive excellence and rational problem solving has become generalized to expectations about a person’s character, ability to navigate social situations, and a general belief that people who are “smart” by these standards are those who should be revered, emulated, and given deference. In reality, these expectations do not exactly work out in terms of personal success, social integration, and in the cultivation of empathy and compassion for others. We can all think of individuals in various professions who are brilliant in terms of their intellectual capacity, academic accomplishments, and rational problem-solving abilities, who, nonetheless, have a great deal of difficulty managing their personal relationships and getting along with others, or are not able to work with others in settings that require teamwork. So, intellectual prowess is admirable, but it leaves something missing in

144

II.  Practice and Process

terms of relating to others. Dr. Sheldon Cooper, in the popular show The Big Bang Theory (Galecki et al., 2008), provides a good example of someone who is intellectually brilliant but who struggles socially, having a great deal of difficulty navigating relationships with colleagues and individuals who try to be his friends. Although television shows are meant to be entertaining, they are a reflection of popular culture and often provide good examples of how our social emphasis on intellectual intelligence and cognitive processing are not the measures of a person who is necessarily successful in life. The point of this discussion is that we live in a society that highly prizes intellectual capacity, while dismissing social and emotional capacities, which are not only important but also necessary assets for a person to live in harmony with others and to be able to engage in relationships that are meaningful and reciprocal. Most of our relationships with others are predicated upon our ability to care, to empathize, and to respond to others in mutual and meaningful ways. Most attachment behaviors are also demonstrated through emotionally mediated behaviors, such as attunement and empathy (Kosminsky & Jordan, 2016). Grief is often viewed as a wound to our attachment system, and the responses to separation and a wounded attachment system are often emotional ones. Thompson (2012) identifies that an effective practitioner must have the ability to tune into the client’s emotions and then to help the client to make the link between these emotions and their experiences of loss. The first use of the term “emotional intelligence” is usually attributed to a doctoral thesis titled A Study of Emotion: Developing Emotional Intelligence (Payne, 1985). In essence, emotional intelligence (EI) is the ability to identify, express, understand, manage, and use emotions (Kotsou, Mikolajczak, Heeren, Grégoire, & Leys, 2019). Other authors have explored the concept of EI (sometimes referred to as either EI or emotional quotient or EQ; Goleman, 1995; Mayer, Salovey, & Caruso, 2008). Instruments were developed to measure various aspects of EI, including the Emotional Competency Inventory, the Emotional Quotient Inventory— Short Form (Parker, Keefer, & Wood, 2011), and the Emotional and Social Competency Inventory (Bradberry & Greaves, 2009). There are also several self-report and self-assessment scales available to the public via the Internet (Mayer, Roberts, & Barsade, 2008). Goleman’s exploration of EI is probably the best known and popular because of the publication of his popular book of the same name (Goleman, 1995) and the release of a secondary book titled Social Intelligence (Goleman, 2006). According to Goleman, to be successful requires the effective awareness and understanding of yourself, including your feelings, intentions, and responses, as well as the ability to understand the feelings and responses of others. The awareness of EI and its cultivation are important in grief counseling because it is very important for both counselors and their clients to develop a capacity to work with emotions that fosters competence rather than flooding because of emotional overloading. Working intelligently with emotions that arise in clients is a process that involves assisting clients to: 1. Identify the primary emotion(s) that is/are currently present 2. Be able to name and/or describe the intensity of the emotion(s) 3. Find a way to work with emotions in a healthy manner 4. Seek to understand the message or meaning that comes from the emotion(s)



9.  Working With Emotions—Yours and Theirs

145

It is amazing to realize how little attention has been paid to the emotional content of our experiences and how readily we try to suppress or deny feelings rather than learning to work with them constructively. Many clients do not really know how to begin identifying their emotions and readily get stuck when asked what they are currently feeling. For example, a counselor might see a client clenching his fist, tightening his jaw, and becoming red in the face, only to find the client will respond to a question about how he is feeling with, “I don’t know . . . just upset, that’s all.” Learning to identify feelings may involve some education for our clients as to how to accurately describe what they are feeling and what to do with the feelings that they recognize in themselves. A good place to start might be to share with clients a “feeling vocabulary list” to help them to learn to identify what they are feeling (Exhibit 9.1). We often try to simplify things by suggesting that there are four basic feeling states: sad, mad, glad, and scared. You can then brainstorm different words that could be used to describe varying aspects of each of these feeling states. We often suggest that you begin with words that describe the least intense sensation of that feeling “cluster” and gradually progress to the most intense description of that feeling. For example, feeling words to describe mad might include irritated, annoyed, frustrated, angry, enraged, and furious. There are many different ways to help clients to work constructively with their emotions. Sometimes, just naming the feeling and talking about it can be enough for a client to address what is being brought to the surface by that emotion. As mentioned in the previous section, emotions sometimes carry a “charge” with them that we experience physically. Clients can sometimes feel intimidated by this intense sensation, afraid that in exploring their emotions, they will lose control over them, or they will say or do something that is not congruent with how they view themselves. Choosing a way to work constructively with different emotions should be based on the client’s personality and comfort level with the counselor, and this process can be facilitated by drawing from the strengths and interests of the client, that is, if the client likes to write, draw, paint, enjoys music, and so on. We discuss more specific ideas later in Chapter 11, “The Clinician’s Toolbox: Therapeutic Modalities and Techniques in the Context of Grief ” (see also Practice Example 9.2). Some ideas about helping clients to identify and work constructively with their feelings are as follows: ■■

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



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

■■

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



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

■■

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



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

■■

Help clients to sort out confused or conflicted feelings:

146

II.  Practice and Process

EXHIBIT 9.1 FEELING VOCABULARY LIST Abandoned Abused Accepted Affectionate Afraid Agitated Alarmed Alienated Alone Amazed Amused Angry Anguished Annoyed Anxious Appreciative Ashamed At ease Awful Awkward Baffled Battered Belittled Belligerent Below par Bewildered Bitter Blue Bored Bottled up Branded Broken Calm Capable Cast off Cheapened Cheerful Competent Confident Conflicted Confused Constrained Contented Criticized Crushed Debased Defeated Deficient Deflated Dejected

Demoralized Depressed Desolate Despair Desperate Despised Despondent Destroyed Discontented Discouraged Discredited Disgraced Disinterested Disliked Dismal Displeased Dispassionate Dissatisfied Distressed Distrustful Disturbed Done for Doubtful Downhearted Downtrodden Dread Dreadful Ecstatic Elevated Embarrassed Empty Enraged Enthusiastic Envious Euphoric Exalted Excited Excluded Exhausted Exhilarated Exposed Fantastic Fearful Fine Fit Foolish Forlorn Forsaken Frantic Friendly

Frightened Frustrated Furious Futile Glad Glorious Good Grand Grateful Gratified Great Guilty Happy Hateful Hatred Helpful Helpless Hesitant Hindered Hopeless Horny Horrible Humble Humiliated Hurt Hypocritical Ignored Ill at ease Impaired Impatient Impotent Imprisoned Inadequate Incapable Incompetent Ineffective Inept Inferior Inflamed Insecure Insignificant In the dumps Intimidated Irritated Jazzed Jealous Jilted Jittery Joyful Jumpy

Laughed at Left out Lonely Lonesome Longing Loved Loving Lousy Low Mad Maligned Miffed Miserable Mistreated Misunderstood Needed Negative Neglected Nervous Numb Obsolete Offended On edge Oppressed Optimistic Ostracized Outraged Overlooked Overwhelmed Panicky Passionate Perplexed Pleased Powerless Pressured Proud Put down Puzzled Reborn Rebuked Regretful Rejected Rejuvenated Relaxed Relieved Resentful Restless Revengeful Ridiculed Ridiculous

Rotten Run down Sad Satisfied Scared Selfish Sensual Serene Sexy Shaky Shocked Sickened Skeptical Slandered Spiteful Startled Surprised Suspicious Swamped Tearful Tense Terrible Terrified Threatened Thrilled Tormented Transcendent Trusting Uncertain Uncomfortable Uncooperative Underrated Understood Uneasy Unhappy Unimportant Unloved Unqualified Unsatisfied Unsure Upset Uptight Wanted Warmhearted Washed up Whipped Worried Worthless Worthy



9.  Working With Emotions—Yours and Theirs

147

P R A C T I C E EXAM PLE 9 . 2 LEARNING TO WORK WITH EMOTIONS

John’s 22-year-old daughter was killed in a tragic accident 6 months ago. John’s pastor had met with him several times to help him to come to terms with his daughter’s death. John tended to focus on what he could have done differently to prevent his daughter’s death, from helping her with the car maintenance to offering to drive her places instead of her driving alone. His pastor had often tried to get John to talk about his feelings, but he did not know how to describe what he felt, and it all seemed jumbled up into a knot in his stomach. John decided to seek the assistance of a grief counselor to get more insights on his grief. In one of the sessions, John described the “knot” in his stomach. The counselor asked John if he could imagine what this knot would say if it could speak. As John tried to do this, he became visibly upset. With tears in his eyes, he said, “I should have done SOMETHING,” to which the counselor replied, “It’s horrible to have loved your daughter so much and to feel so powerless about her death.” John began to sob. He told the counselor that he had a tremendous amount of guilt over his daughter’s death. Over the next few sessions, John found it helpful to focus on how his body felt as a way to identify his own feelings and what he needed to do in order to work with them and his overwhelming grief.



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

■■

Help clients to gain an understanding that they can have more than one feeling at a time and that it is normal to have dichotomous feelings occurring at the same time (e.g., happy and sad, excited and scared):



“I hear that you are looking forward to seeing your family again, but I also sense a part of you might be dreading this visit too . . . what do you think?”

■■

Use feelings to help reconnect clients with the deceased person(s), if that would be beneficial:



“Pretend that you are your wife and I will pretend to be you. Can you think of what she might be feeling if she were with you right now?”

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

148

II.  Practice and Process

words and the experience that is occurring through the nonverbal cues and emotional tone of what the client is saying as well.

WORKING WITH DIFFERENT EMOTIONS Important guidelines for counselors to have in place are that they need to: (a) be aware of their own emotions when they come to the surface, (b) cultivate an ability to work constructively with these emotions, and (c) be able to apply the same “rules” about honoring emotional content and material in their lives as they expect from their clients. These things will affect how a counselor will be able to facilitate emotional work and process with clients (Practice Example 9.3). When you begin to sense that there is a lot of emotion present in the client, it might be helpful to try to slow the session down. Empathic responses or immediacy may be used, depending on what the client is experiencing. The client may only stay with the feelings for 5 seconds, but in staying with these feelings, even if for a very brief time, there may be a sense of competency and relief afterward. Emotions are often intensified in the sessions, and clients are invited to go to a deeper level, closer to their core feelings. Stay with the feelings as long as the

P R A C T I C E EXAM PLE 9 . 3 COUNSELOR SELF-AWARENESS IN WORKING WITH EMOTIONS

Wendy was a new counselor in a downtown counseling agency. She had been assigned a client whose family had been killed when a tornado ripped through their house while she was away on a business trip. The client would often talk very fast, dart her eyes around the room, and repeatedly talked about “horrible things that can happen” to people without warning. Wendy would anxiously anticipate her sessions with this client because she felt so helpless and overwhelmed by the client’s story. In supervision, Wendy described her feelings when in sessions with this client. Her supervisor reminded her of the need for her to care for herself and to ground herself before this client’s sessions, and they practiced ways that Wendy might be able to do this. The following week, when the client returned, Wendy began feeling the same anxiety that had arisen in the previous sessions. She felt her heart rate increasing and noticed that she was breathing in fast, shallow breaths as the client talked. She consciously began to breathe more slowly and deeply, and she became aware of her body sitting in the chair. Inside her head, she said, “I want to be here and be present.” As her breathing slowed and deepened, her client began to talk more slowly as well. At one point, they both looked at each other, and Wendy said, “This is so very hard for you, and I can feel how anxious you are as you talk. Let’s take some deep breaths together, and then maybe you can tell me what one thing we need to focus on to start today.” While her sessions with this client always remained intense, Wendy no longer felt paralyzed by her own feelings and was able to be more present and focused with the client.



9.  Working With Emotions—Yours and Theirs

149

client tolerates it and stays connected to them in the session. Once the client begins to shift out of the feelings, talk about what the client felt and put it into a context. A good suggestion for follow-up with clients after they have gone deeply into emotional work is to first validate that it is hard work and then to ask what the experience was like for them. Often, working in this way with emotions brings a sense of exhaustion, but also a sense of clarity. After exploring feelings, a shift may occur in the client’s perceptions, although it may not be apparent right away. If your client is struggling with intense emotions, try to normalize the feelings and assure them that these feelings will not continue with this same intensity and magnitude forever. One helpful statement might be, “It is very difficult and intense right now for you, but it will not always be this way down the road.” If the client has attempted to keep emotions under control by suppressing them for a long time, initially experiencing the emotions may carry the fear of being overwhelmed, rendered nonfunctional, or paralyzed by these feelings. Remind your clients that they have the choice about how they want to handle their emotions and provide modeling in the session that allows them to focus on the emotions and then get some distance from them in alternating waves. Normalize clients’ concerns that feelings (especially those that are intense or carry a physical “charge”) can be scary and that this is difficult work. As we discussed earlier in the section on resistance, you must be respectful of people’s defenses, and your goal is not to insist that people emote, but to recognize when clients need your assistance in working constructively with the emotions that are present. You, as the counselor, need to be able to help the client find what they need, both internally for control and externally for the release of the emotional material. There are times when clients need help in containing their emotions (different from suppression), especially when they are overwhelmed or feeling unsafe (Kennedy-Moore & Watson, 2001). The issue of containment is explored more in Chapter 10, “When Grief Goes Awry,” where we discuss how trauma and grief overlap. Also, some specific therapeutic modalities that may help clients to work constructively with their emotions are discussed in Chapter 11, “The Clinician’s Toolbox: Therapeutic Modalities and Techniques in the Context of Grief.” We recognize that once clients begin to focus on their story and what has brought them to counseling, feelings often rise to the surface readily. It is hoped that this chapter helps you, as the counselor, to be open to your clients’ experiences of emotional material and be able to facilitate your clients’ process with quiet confidence and compassion. Remember that most people want a deeper connection with their inner self and that usually occurs by working with emotions.

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

Fear—functions to help in self-protection, and it often arises when we do not feel safe. It is important to sort out old fears from what has happened in the past versus anxiety about what is happening in the present by listening to what has happened

150

II.  Practice and Process

in the past and how it is being interpreted by the client in the current situation. For example, if a client has had a difficult situation with other helping professionals, the anxiety that is present in the session may be related to fear of how you might respond rather than to something more general in their life experience. It is important to remember that we become afraid for a reason, and the first consideration when a client is fearful is to ensure that they feel safe, first with themselves, then with you in the session, and then in their current environment and experiences outside of the session. There is a difference between fear and generalized anxiety. Fear is usually associated with something specific, even if the trigger for the fear may seem elusive at first. Anxiety tends to be more generalized and does not usually have a specific focus, although the anxiety may transfer to various situations when it is intensified. When people are afraid, they may have a sense of “going cold” inside, and their hands and feet may also feel cold or numb. Some people are agitated by fear (hyperarousal) and others are paralyzed by it (hypoarousal), so people may speak very fast and seem keyed up, or they may actually come across as very contained, disconnected, and shut down. It is only with time and gentle exploration that you may have a deeper understanding of the source of the fear, or the background to the anxiety that your client is experiencing. Breath is associated with fear, and you will often notice that when clients become more anxious, breathing may become more rapid and shallow, or they may actually hold their breath without even realizing it. It can sometimes be helpful for the counselor to breathe along with clients as they share their stories, and if the counselor notices that they are not getting enough air when following the client’s breathing pattern, it might be an opportunity to say something like, “Let’s just take a deep breath together and slow things down a bit, okay?”



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





9.  Working With Emotions—Yours and Theirs

151

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



■■

Anger—serves the purpose of a warning light and gives energy to get past blocks. Anger tells you that something is wrong, and it often comes up when a person feels violated or treated unfairly in some way. It can also be protective when a person feels threatened or vulnerable. It is very important that clients understand that anger is okay and that it is a natural part of the grieving process for many people. If you think of being robbed of something that is precious and irreplaceable to you, one of the first reactions you might experience would be anger toward someone who could do such a thing. Grief is no different, because when you lose someone you love, or when you experience a significant loss, there is often a feeling of being robbed, a feeling of being deprived, and a constant reminder of the unfairness in how events have unfolded—and anger would be a natural response to any of these scenarios. Care must be taken to disentangle anger from violence, and if your client has experienced violence associated with anger in the past, this emotion might be a scary and difficult experience. A good image of constructive anger is to describe it as a life force that can be empowering and highly informative of when a client needs to attend to what is happening in a very conscious way. Anger is like the mushroom that pushes through the concrete in the sidewalk—we sometimes need this energy in order to get through the blocks that are present and preventing us from moving forward. Constructively channeling anger is what has been at the core of some very well-known advocacy groups and support organizations, such as Mothers Against Drunk Driving, so it is important to understand that a person can experience anger as a positive and healthy emotion.



152

II.  Practice and Process

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



■■

Sadness—is often more socially acceptable than anger, especially for women. In sadness, a person tends to retreat inside; sometimes, clients seem to “melt” into themselves when they express their sadness. It might be helpful for the client to have something to hold, such as a pillow, a small blanket or throw, or a stuffed animal. If clients experience deep, intense sadness, they may begin to sob heavily and rock back and forth. You are the supportive witness to their experience, and the importance of your presence should not be underestimated. Most people are very self-conscious when they are crying in front of another person, so rather than staring at the person when they are crying, we would suggest that you drop your gaze a little from their face to their shoulder or knees and wait patiently. You can breathe with the person silently. You can gently let the client know that it is okay to cry and okay to feel this much. Let people breathe deeply in and let the sadness out with their breath. Beginning counselors may feel a great urge at a time like this to jump in and “rescue” the client, but this may be the only time and place that the client can actually enter fully into the sadness without having to worry about what someone else thinks or feels as a result of the expression of such profound emotional pain. After experiencing deep sadness, the client may want contact, and it is very important to be clear about what the client wants and needs (not what the counselor wants and needs!). In my (D.L.H.) client office, I keep a soft chenille throw over the back of my chair. If a client goes into a place of deep sadness, I will sometimes take the throw and wrap it around their shoulders as a gentle form of contact that is nonintrusive to the client’s process. I also have a soft pillow that they can





9.  Working With Emotions—Yours and Theirs

153

hug against their body as a form of self-soothing. There is a tendency to come out of this type of expression slowly. It is important to reassure clients that they will have time at the end of the session to “regroup” before finishing the time together. It is also the counselor’s responsibility to ensure that the client has returned to a sense of normalcy before leaving the office and driving a car. Some of our clients choose to go for a brief walk to regroup after an intense session before getting into their car and driving away. One final suggestion for clients when they are experiencing strong emotions outside of the sessions is to find ways for them to recognize their feelings and work with them, but to also be able to contain them and bracket their feelings when necessary. Clients can have “grief drawers” in their homes, in which they can store pictures, music, memorabilia, and linking objects. When clients realize that strong feelings are arising, they can open the drawer and use these items to facilitate some of their grieving process (Harris, 2015). Some clients may light candles when they are actively involved in this work—when the candle is lit, they focus their attention and emotional energy on the contents of the drawer and the associated feelings that arise at that time. When they are done, they can blow out the candle, put the things back into the drawer, and close it shut. Clients may choose to write about this experience in a journal and share it with you when they come for their next session. Clients can use music to do something similar—when a particular song is done, or the CD is finished, they actively move away from the emotional processing and consciously move into another room as a form of bracketing the experience. Clients need to know that they can enter deeply into their emotional experiences with competence and feel empowered by their emotions rather than crippled by them. Learning how to go deeply into and then to come back out of the intensity is a valuable skill that can be helpful in this process.

WHAT ABOUT THE COUNSELOR ’S FEELINGS? Our students often ask us if we have cried with our clients and how we feel about the counselor sharing his or her feelings with the client. On the surface, there is generally a perception that crying in professional settings is an indicator of lack of professionalism or a sign of weakness on the part of the counselor. The answer may be that it can be a good thing and it can also be an indication of the counselor’s need to attend to personal issues that may need to be addressed (Curtis et al., 2003). Levitt et al. (2006) cite many clients’ positive responses to their counselors’ disclosures of their own feelings and indications of being touched by their clients’ stories (Practice Example 9.4). As counselors, we are human beings and we connect with our clients at a deep and empathic level. To hear stories of pain, suffering, and deprivation and not be affected would be highly unrealistic, and sometimes as we fully enter our clients’ world, we will be deeply moved by their stories and experiences (Kottler & Carlson, 2014; Yalom, 2009). A normal human reaction might involve tears that fall as we listen to a client’s painful story, and these tears simply validate the depth of the client’s experience and our shared human connection. Problems occur if the client’s story triggers an area of vulnerability within the counselor, and the feelings that come to the surface for the counselor are not those in resonance with the

154

II.  Practice and Process

P R A C T I C E EXAM PLE 9 . 4 SHARING THE FEELINGS IN THE COUNSELI NG SESSION

Mika worked as a social worker in a reproductive medicine practice. One day, a patient named Farrah came to see her. Farrah described going through years of infertility treatment with her husband because they desperately wanted a family of their own. Finally, Farrah became pregnant and she and her husband were elated. However, when they went for a follow-up ultrasound to see the baby, they were told that there was no heartbeat. The baby had died inside her. Farrah was wracked with grief and pain. Mika handed Farrah a pillow to hold against her body as she sobbed. When Farrah was exhausted from crying, she looked up and saw that there were tears streaming down Mika’s face. She then said, “I can see how much you care. Thank you for being here for me and sharing my pain.”

client but a personal reaction to the client’s material that is based on the needs and unresolved material in the counselor. Counselor’s feelings that take the focus of the session away from the client could be damaging to clients, and the counselor could inadvertently use the client to process his or her own unresolved emotional material, which is highly unethical. In Chapter 13, “Caregiver Issues for Grief Counselors,” we discuss the role and value of supervision for counselors, which provides a safe place for the counselor to work through personal issues that arise in sessions with clients.

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

GLOSSARY Emotional intelligence  The level of an individual’s ability or skill to identify, express, understand, and use emotions. Feeling vocabulary  Ability to accurately identify and name a particular emotion in terms of its intensity and application to a given situation. “Felt sense”  Term identified by Gendlin to describe an unclear, pre-verbal sense of something significant as that “something” is experienced in the body. It is not the same as an emotion, because it is typically unclear and vague, and it is always more than any attempt to express it verbally. “Fight–flight” response  Also referred to as the acute stress response; a bodily response to a perceived threat or acute stressor with a discharge of the sympathetic nervous system, priming the animal for fighting or fleeing in response to a threat.



9.  Working With Emotions—Yours and Theirs

155

QUESTIONS FOR REFLECTION 1. What were you taught about emotions when you were growing up? How has this

learning in your formative years influenced how you handle your emotions, and the emotions of others?

2. Think of the four main domains or emotions (sad, mad, glad, and afraid), and

look over the feeling vocabulary that was posted in this chapter. Which of these emotions is the most difficult for you personally? Which is most difficult for you to handle from someone else? How might your reactions to emotions affect your interactions with your clients?

3. What do you think is the difference between containing/bracketing emotions and

suppressing emotions in the context of counseling?

4. Go to the following web link to access an online test for EI and take the test:

testyourself.psychtests.com/testid/2092. What were your thoughts and feelings as you took the online self-test? Can you think of examples in day-to-day functioning where EI would be valuable?

REFERENCES Bradberry, T., & Greaves, J. (2009). Emotional intelligence 2.0. San Francisco, CA: Publishers Group West. Curtis, R., Matise, M., & Glass, J. S. (2003). Counselling students’ views and concerns about weeping with clients: A pilot study. Counselling and Psychotherapy Research, 3(4), 300–306. doi:10.1080/1473 3140312331384303 Fancher, R. E. (1985). The intelligence men: Makers of the IQ controversy. New York, NY: Norton. Feltham, C. (2010). Critical thinking in counselling and psychotherapy. Thousand Oaks, CA: Sage. Fisher, H., Atzil-Slonim, D., Bar-Kalifa, E., Rafaeli, E., & Peri, T. (2016). Emotional experience and alliance contribute to therapeutic change in psychodynamic therapy. Psychotherapy, 53(1), 105–116. doi:10.1037/pst0000041 Frank, G. (1983). The Wechsler enterprise: An assessment of the development, structure, and use of the Wechsler tests of intelligence. Oxford, UK: Pergamon Press. Galecki, J., Parsons, J., Cuoco, K., Helberg, S., Nayyar, K., Lorre, C., . . . Warner Home Video (Firm). (2008). The Big Bang Theory. Burbank, CA: Distributed by Warner Home Video. Gendlin, E. T. (1978). Focusing. New York, NY: Everest House. Goleman, D. (1995). Emotional intelligence. New York, NY: Bantam. Goleman, D. (2006). Social intelligence: The new science of human relationships. New York, NY: Bantam. Harris, D. L. (2015). The grief drawer. In R. A. Neimeyer (Ed.), Techniques of grief therapy (Vol. 2, pp. 173–176). New York, NY: Routledge. Kennedy-Moore, E., & Watson, J. C. (2001). How and when does emotional expression help? Review of General Psychology, 5(3), 187–212. doi:10.1037//1089-2680.5.3.187 Kosminsky, P., & Jordan, J. (2016). Attachment-informed grief therapy: The clinician’s guide to foundations and applications. New York, NY: Routledge. Kotsou, I., Mikolajczak, M., Heeren, A., Grégoire, J., & Leys, C. (2019). Improving emotional intelligence: A systematic review of existing work and future challenges. Emotion Review, 11(2), 151–165. doi:10.1177/1754073917735902 Kottler, J. A., & Carlson, J. (2014). On being a master therapist: Practicing what you preach. Hoboken, NJ: Wiley.

156

II.  Practice and Process

Levitt, H., Butler, M., & Hill, T. (2006). What clients find helpful in psychotherapy: Developing principles for facilitating moment-to-moment change. Journal of Counseling Psychology, 53(3), 314– 324. doi:10.1037/0022-0167.53.3.314 Matise, M. (2015). An exploration of the personal experiences and effects of counselors’ crying in session. Professional Counselor, 5(1), 28–38. doi:10.15241/mm.5.1.28 Mayer, J. D., Roberts, R. D., & Barsade, S. G. (2008). Human abilities: Emotional intelligence. Annual Review of Psychology, 59, 507–536. doi:10.1146/annurev.psych.59.103006.093646 Mayer, J. D., Salovey, P., & Caruso, D. R. (2008). Emotional intelligence: New ability or eclectic traits? American Psychologist, 63(6), 503–517. doi:10.1037/0003-066x.63.6.503 Paivio, S. C. (2013). Essential processes in emotion-focused therapy. Psychotherapy, 50(3), 341–345. doi:10.1037/a0032810 Parker, J. D., Keefer, K. V., & Wood, L. M. (2011). Toward a brief multidimensional assessment of emotional intelligence: Psychometric properties of the Emotional Quotient Inventory—Short Form. Psychological Assessment, 23(3), 762–777. doi:10.1037/a0023289 Payne, W. L. (1985). A study of emotion: Developing emotional intelligence; self integration; relating to fear, pain and desire. Dissertation Abstracts International, 47, 203A (University microfilms no. AAC 8605928). Schneider, K. J. (2016). Existential–humanistic psychotherapy. In I. Marini & M. Stebnicki (Eds.), The professional counselor’s desk reference (pp. 201–206). New York, NY: Springer Publishing Company. Timulak, L. (2010). Significant events in psychotherapy: An update of research findings. Psychology and Psychotherapy: Theory, Research and Practice, 83(4), 421–447. doi:10.1348/147608310x499404 Thompson, N. (2012). Grief and its challenges. Basingstoke, UK: Palgrave Macmillan. Watson, J. C., & Bedard, D. L. (2006). Clients’ emotional processing in psychotherapy: A comparison between cognitive–behavioral and process–experiential therapies. Journal of Consulting and Clinical Psychology, 74(1), 152–159. doi:10.1037/0022-006x.74.1.152 Yalom, I. R. (2009). The gift of therapy. New York, NY: Harper Collins.

CHAPTER 

10

WH EN GR I E F GOE S AW R Y

LEARNING OBJECTIVES 1. Describe when grief is considered to have gone awry and warrants professional intervention. 2. Differentiate between traumatic loss and traumatic grief. 3. Discuss the difference between grief and depression. 4. Describe the unique features of grief after suicide or homicide. 5. Identify practice suggestions for supporting individuals who experience complicated grief.

INTRODUCTION With there being so much broad variation in what is considered “normal” grief, how do you know when something is wrong, or when a bereaved individual needs more specific professional help? When does grief become problematic, and how do we recognize when that happens? This is a question that continues to challenge researchers and clinicians alike. In the previous chapters, we have discussed how grief is a multifaceted experience and its manifestation among individuals is highly unique and dependent on many interacting factors. But how can you tell when the bereaved cross that “imaginary line” from normal to complicated grief, and what are the implications of grief going awry? Most bereaved individuals find that the acute grief symptoms gradually diminish over time through a natural integrating process. However, approximately 10% of bereaved people experience grief that is ongoing and often debilitating for a long period of time (Stroebe, Stroebe, Schut, & Boerner, 2017).

158

II.  Practice and Process

Recently, there has been a great deal of research that focuses on the group of bereaved individuals who experience unabated grief for a prolonged time, negatively affecting their ability to function and cope. In some instances, the bereaved individual may fear that if he or she stops grieving, the connection with the deceased person will be lost. Another aspect of this type of grief is that the person loses a part of himself or herself with the death of the deceased person and, as a result, feels completely lost. Being bereaved may also be a new defining role and identity for grieving individuals, because they now define themselves by the loss and the role of being “left behind.” In these examples, being bereaved is experienced as a loss of self and identity as well. In this chapter, we review some of the terminologies that are often utilized in the discussion of grief that has veered away from what would be considered a normal trajectory. We also describe some of the main features of “difficult” grief, as postulated by prominent researchers in this area. We also explore some of the clinical implications for complicated grief and for grief that is intermixed with exposure to traumatic events. Finally, we provide an overview of the treatment modalities that are being proposed for therapeutic work with individuals who experience complicated grief.

SORTING THROUGH THE TERMINOLOGY The terminology that is used to describe grief that has somehow gone awry can be confusing. This type of difficult grief is sometimes referred to as complicated grief (CG), prolonged grief disorder (PGD), persistent complex bereavement disorder (PCBD), or traumatic grief (TG) in the published literature (Parkes, 2014; Worden, 2018). These terms are often used interchangeably; their origin and association vary slightly depending on the backgrounds of the researchers and the particular focus of the studies that were conducted to help explicate the criteria for determining when grief has gotten to the point of warranting concern and professional intervention. For the purposes of this chapter, the term complicated grief will be used as an overarching description of difficult grief. In general, CG involves prolonged acute grief symptoms, where the bereaved have difficulty functioning in various ways and are unable to rebuild a meaningful life without the deceased person. Current consensus regarding the criteria for CG states that it may be present after any loss that is extremely personally devastating. This devastation may be related to the way the death occurred, the relationship to the deceased, and/or personal factors related to the bereaved individual (Worden, 2018). Regarding the relationship to the deceased, CG is often thought of as a traumatic separation (not to be confused with a traumatic event) from the person who died, with pronounced separation distress and difficulties adjusting to life without the deceased being markedly pronounced (Crunk, Burke, & Robinson, 2017; Parkes, 2014). The American Psychiatric Association (APA) made a significant change to the fifth edition of their Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) concerning the classification of disturbed grief, by including PCBD as a condition for further study (Exhibit 10.1). PCBD comprises 16 symptoms, organized under two symptom clusters, with the first cluster relating to separation distress and the second symptom cluster of “additional symptoms” that is subdivided into signs of “reactive distress to the death” and “social/identity



10.  When Grief Goes Awry

159

EXHIBIT 10.1 DSM-5 CRITERIA FOR PERSISTENT COMPLEX BEREAVEMENT DISORDER A. The individual experienced the death of someone with whom there was a close

relationship. B. Since the death, at least one of the following symptoms is experienced on more days than

not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: 1. Persistent yearning/longing for the deceased. 2. Intense sorrow and emotional pain in response to the death. 3. Preoccupation with the deceased. 4. Preoccupation with the circumstances of the death. C. Since the death at least six of the following symptoms are experienced on more days than

not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: Reactive distress to the death 1. Marked difficulty accepting the death. 2. Experiencing disbelief or emotional numbness over the loss. 3. Difficulty with positive reminiscing about the deceased. 4. Bitterness or anger related to the loss. 5. Maladaptive appraisals about oneself in relation to the deceased or the death (e.g.,

self-blame). 6. Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or

situations associated with the deceased). Social identity disruption 7. A desire to die in order to be with the deceased. 8. Difficulty trusting other individuals since the death. 9. Feeling alone or detached from other individuals since the death. 10. Feeling that life is meaningless or empty without the deceased, or the belief that one

cannot function without the deceased. 11. Confusion about one’s role in life or a diminished sense of one’s identity (e.g., feeling that

a part of oneself died with the deceased). 12. Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g.,

friendships, activities). D. The disturbance causes clinically significant distress or impairment in social, occupational,

or other important areas of functioning. (continued )

160

II.  Practice and Process

EXHIBIT 10.1 (continued) E. The bereavement reaction is out of proportion to or inconsistent with cultural or religious, or

age-appropriate norms. Specify if: With traumatic bereavement: Bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature of the death (often in response to loss reminders), including the deceased’s last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the death. Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright © 2013). American Psychiatric Association. All Rights Reserved.

disruption.” A diagnosis of PCBD would require that an individual experience the death of someone with whom there was a close relationship, have at least one separation distress symptom and six of the additional symptoms that are described for at least 12 months after the death, in addition to functional impairment. There is a caveat at the end, stipulating that the symptomatology must be out of line with the individual’s culture, religion, and age-related norms. Likewise, the World Health Organization (WHO) has proposed a similar change to the 11th edition of the International Classification of Diseases (ICD-11) by adding PGD to the category of “Disorders associated with stress” (WHO, 2019). The PGD includes a description of 12 symptoms, categorized into separation distress and additional symptoms. A diagnosis of PGD requires having experienced a loss, combined with at least one of the two symptoms of separation distress and at least one of the 10 additional symptoms. These symptoms must be associated with functional impairment and have persisted for at least 6 months after the death (WHO, 2019; Exhibit 10.2). Shear (2010) states that typical CG symptoms include persistent feelings of intense yearning or preoccupation with the deceased; shock, disbelief, and anger about the death; difficulties with trust; and engagement in behaviors and activities to try to either avoid reminders of the loss or to feel closer to the deceased (Exhibit 10.3). People with CG often ruminate or obsess over the circumstances of the death, their relationship with the deceased person, or the events and their feelings and reactions since the death (Eisma et al., 2015; Stroebe et al., 2017). It is important for counselors to be familiar with these criteria in order to know when a client may need more intensive assessment and therapeutic support. Risk factors for CG can be grouped into three main categories. The first of these includes personal psychological vulnerability, such as a personal or family history of mood or anxiety disorders (Allen, Haley, Small, Schonwetter, & McMillan, 2013; Bruinsma, Tiemeier, Heemst, van der Heide, & Rietjens, 2015; Shear, 2015a), insecure attachment style (Maccallum & Bryant, 2018; Kosminsky & Jordan, 2016; Schenck, Eberle, & Rings, 2016), and history of trauma or multiple losses (Rozalski, Holland, & Neimeyer, 2017). This category can also include the bereaved individual’s relationship to the deceased, because some relationships



10.  When Grief Goes Awry

161

EXHIBIT 10.2 ICD-11 CRITERIA FOR PROLONGED GRIEF DISORDER A. At least one of the following: 1. Persistent and pervasive longing for the deceased, or 2. A persistent and pervasive preoccupation with the deceased. B. Intense emotional pain:

Accompanied by intense emotional pain, for example, sadness, guilt, anger, denial, blame Difficulty accepting the death Feeling one has lost a part of one’s self An inability to experience positive mood Emotional numbness Difficulty in engaging with social or other activities. C. Time and impairment criterion

Persisted for an abnormally long period of time (more than 6 months at a minimum) following the loss, clearly exceeding expected social, cultural, or religious norms for the individual’s culture and context. Grief reactions that have persisted for longer periods that are within a normative period of grieving given the person’s cultural and religious context are viewed as normal bereavement responses and are not assigned a diagnosis. Source: From World Health Organization. (2019). International Classification of Diseases (ICD), 11th revision: 6B42 Prolonged grief disorder. Retrieved from https://icd.who.int/dev11/l-m/en#/ http%3a%2f%2fid.who.int%2ficd%2fentity%2f1183832314

tend to be associated more with difficulties in bereavement, such as parental loss of a child, followed by the loss of a spouse, sibling, and a parent (Nolen-Hoeksema, Larson, & Larson, 2013). The second category concerns circumstances of the death itself, such as untimely, unexpected, violent, or seemingly preventable death (Rozalski et al., 2017). And finally, the third category of risk factors focuses on the context in which the death occurs, such as social support that is inadequate or that is problematic in some way (Crunk et al., 2017; Worden, 2018), or concurrent stresses, such as financial concerns or other hardships (Shear, 2015a; Van der Houwen et al., 2010; Practice Example 10.1). Complicated, protracted grief is more prevalent in individuals who have attachment difficulties, or whose models of the self or the world do not allow for the accommodation and integration of significant life events into how they view themselves, others, and the world (Mancini & Bonanno, 2012; Schenck et al., 2016). Who we are shapes how we grieve, and who we are is very much associated with how we relate to others. When we are highly bonded

162

II.  Practice and Process

EXHIBIT 10.3 CLINICAL FEATURES OF COMPLICATED GRIEF

Acute grief symptoms that persist for more than 6 months following the death of a loved one, include: 1. Feelings of intense yearning or longing for the person who died—missing the person so

much that it is hard to care about anything else. 2. Preoccupying memories, thoughts, or images of the deceased person that may be wanted

or unwanted and that interfere with the ability to engage in meaningful activities or relationship with significant others; may include compulsively seeking proximity to the deceased person through pictures, keepsakes, possessions, or other items associated with the loved one. 3. Recurrent painful emotions related to the death, such as deep, relentless sadness, guilt,

envy, bitterness, or anger that are difficult to control. 4. Avoidance of situations, people, or places that trigger painful emotions or preoccupying

thoughts related to the death. 5. Difficulty restoring the capacity for meaningful positive emotions through a sense of purpose in life or through satisfaction, joy, or happiness in activities or relationships with others. Source: Shear, M. K. (2010). Complicated grief treatment: The theory, practice, and outcomes. Bereavement Care, 29(3), 10–14. doi:10.1080/02682621.2010.522373

and possess a significant amount of attachment anxiety, there is a higher tendency toward CG. The outcomes of CG can be very serious, and intervention is required to assist these individuals to counteract the potential negative sequelae that can result from its impact on the lives of these individuals (Parkes, 2014; Shear, 2015a). It is important to be able to recognize when clients are experiencing this type of disabling grief, because it can have a significant negative impact on health and quality of life. CG is associated with the following: ■■

Myocardial infarction (heart attack) and congestive heart failure

■■

Immune system dysfunction, placing individuals at higher risk of infections and illness

■■

Substance use and abuse

■■

Essential hypertension

■■

Functional impairment

■■

Reduced quality of life

■■

Suicidal ideation and suicide attempts (Maciejewski, Maercker, Boelen, & Prigerson, 2016; Shear, 2015a)

On a more practical level, we begin to consider a client to be experiencing a CG response when: (a) the intensity of the grief worsens instead of improving or the individual’s ability



10.  When Grief Goes Awry

163

P R A C T I C E EXAM PLE 1 0 . 1 MULTIPLE RISK FACTORS FOR AND SYMPTOMS OF COMPLICATED GRIEF

Mikaila, a young widow, came for grief counseling after attending a community talk on the topic of grief. She decided that she “needed help” after the death of her husband 9 months prior. When Mikaila came for her first session, she spoke about her husband’s protracted illness and death in a matter-of-fact way. As the session progressed, she also shared that her mother had died of a long bout with breast cancer 4 years ago, and Mikaila had been her primary caregiver. After her mother’s death, Mikaila and her husband had undergone unsuccessful treatment for infertility for 2 years, and what ended their efforts in trying to start a family was her husband’s unexpected diagnosis of cancer. Mikaila described the irony of having to use a good portion of her husband’s life insurance money to pay off the costs of the infertility treatment that was not covered by their health insurance. The counselor noted that when describing all of these events, Mikaila’s demeanor never changed; she recounted each loss in a factual way, paying attention to the details, but not expressing any emotion. Mikaila then began to talk about her dog, which she and her husband had adopted before he was diagnosed with cancer. She stated that she lives in “daily fear” that something might happen to this dog, indicating “I think that would be the final straw.” Mikaila said she goes to work every day and comes home, walks the dog, eats a bowl of cereal, and falls asleep on the couch. She cannot sleep in the bed she shared with her husband, nor can she sit in his recliner chair in the living room. She also cannot eat at their kitchen table because his chair is empty. She also avoids going into the basement because most of his belongings are in boxes there. At the end of the session, Mikaila says, “Maybe I just need to buck up and get on with my life.” To this comment, the counselor replies, “It sounds like you’ve had to be very strong for a long time and you’re exhausted.” Mikaila agreed with the counselor’s comment, and stated, “It’s the first time in my life that I feel completely lost and I have no idea what to do with myself.”

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

164

II.  Practice and Process

OVERLAPS BETWEEN GRIEF AND TRAUMA To some extent, all grief is traumatic, because significant losses require us to rebuild our shattered assumptions about the world that no longer exists as we once thought (Harris, in press). When we lose someone whom we love, we also lose significant aspects of ourselves. Our world is never the same. We may feel frightened, powerless, and void of meaning. As mentioned earlier, the term “traumatic grief ” has been used interchangeably with the term “complicated grief ” because of the mechanism of psychic overload that prevents adequate coping and stress management in the bereaved individual and the resemblance to the models of traumatic stress disorders that are described in the DSM-5 (APA, 2013). In fact, there have been many comparisons made between CG/TG and posttraumatic stress disorder (PTSD), even in the absence of a traumatic event to cause the death. Some researchers have compared normal grief to the DSM-5 criteria for PTSD and found parallels between these two descriptions, indicating that experiencing a significant loss (whether or not it is the result of a traumatic event) can challenge a person’s ability to accommodate what has happened into his or her assumptive world because of the frequent reported disturbances in sleep, concentration, intrusive images, and the avoidance and dissociative responses noted in some bereaved individuals (Frumkin & Robinaugh, 2018). What mainly separates PTSD from CG/TG is the presence of separation distress, including intense yearning for the deceased person, and intrusive thoughts of or pangs for the lost person is the dominant theme in CG/TG reactions (Djelantik, Smid, Kleber, & Boelen, 2017). In contrast to individuals with PTSD who avoid reminders of the trauma, individuals with CG tend to avoid reminders of the absence of the deceased person (Shear, 2015a). It is important to note that traumatic experiences are subjectively assessed by individuals, and how a loss by traumatic means is perceived by an individual will vary, depending on the meaning that the individual attaches to that event and the nature of the relationship to the lost person (Boals, 2018). As counselors, it is important to remember that traumatic material and overlay are interpreted by the client’s perception of the event and not by whether the counselor (or anyone else) believes the event to be traumatic in nature or not. Because this discussion can be confusing, let us make some distinctions between some of the terms that are commonly used. A traumatic loss (death that occurs as a result of an event that would be seen as traumatic, such as a violent act, car accident, or an event in which there may be mangling of the body) is not necessarily going to lead to TG, although it can. Using the term traumatic loss places the focus of the bereaved individual’s experience on the events and the stressors that occurred around the loss and not necessarily on the response of the bereaved individual. The term “traumatic grief ” delineates the degree of the separation anxiety and assault to the assumptive world that is experienced by the bereaved individual (Harris & Rabenstein, 2014). In other words, this term focuses on the experience and response of the bereaved person and not on the events surrounding the death itself. The clinical presentation of an individual with CG is often anxiety based, whereas in normal grief, the presentation is usually more dominated by sadness or anger. The common thread between TG and a traumatic response to an event is found in the propensity for psychological overload that is demonstrated in the similarities between the two responses. This



10.  When Grief Goes Awry

165

distinction can be very confusing, but for practicalities’ sake, if your client describes feeling highly anxious or unsafe, or tends to focus on the events surrounding the loss rather than the person, you are probably dealing with a traumatic overlay of some sort. The presence of CG/TG presents counselors with the need to assess whether or not their training and background is appropriate for working with individuals whose lives are so deeply compromised and whose health and well-being may be at stake. If you are not trained in therapeutic techniques that require skill in both clinical assessment and the processing of traumatic material, a referral should be made to someone with more advanced training in work with grief and trauma. Some of the clinical implications for CG will now be discussed.

The Experience of Loss and Death Can Trigger Old Traumatic Experiences to Surface The common denominator in experiences of grief and trauma is loss of control. When we lose something of value or someone whom we love, the overarching feelings often center on powerlessness, helplessness, and feeling robbed. Of note is that the core features of trauma also revolve around these same feelings. Profound, significant losses may lead to an intensification of feelings of vulnerability and anxiety. In clients with a history of trauma, a significant loss might cause reentry into the traumatic material and the anxiety associated with feeling unsafe. In the diagnostic descriptions that were listed in the beginning of this chapter, a past history of trauma would be seen as a form of pre-existing personal vulnerability in the bereaved individual (Shear, 2015a; Worden, 2018). Counselors must recognize when clients’ former traumatic experiences are “doubling” onto the current loss experience and help clients to learn how to contain the traumatic material while exploring the grief related to the current loss.

There Is Often a “Dance” That Occurs When Trauma and Grief Coexist An important rule to keep in mind is that traumatic material will tend to overshadow the grief-related symptoms at first because clients who are experiencing symptoms related to trauma will not be able to focus on other aspects of their experience until they feel safe, are able to trust the counselor (which may take some time), and have a semblance of control over what to share and how to share it with you. Clients must feel safe and know that there is a “container” for the traumatic material in place before they can do any form of process work, which is the basis for the work with most bereaved individuals. The concept of trauma-informed practice incorporates the core principles of establishing the therapeutic alliance with safety, trust, collaboration, choice, and empowerment as the foundation upon which traumatic material can unfold without causing additional harm to the client (Levenson, 2017). Traumatic material is mediated more by a primitive (primary) system of the brain than grief (Freedy, 2017; Perry, 2005). This primary system controls the fight–flight response, which drives individuals to seek safety and security quickly when activated. In his work with childhood TG, Perry (2005) states:

166

II.  Practice and Process

The key to therapeutic intervention is to remember that the stress response systems originate in the brainstem and diencephalon. As long as these systems are poorly regulated and dysfunctional, they will disrupt and dysregulate the higher parts of the brain. All the best cognitive-behavioral, insight-oriented, or even affect-based interventions will fail if the brainstem is poorly regulated. (pp. 38–39) Clients who are dealing with trauma will often have a sense of unease, and they will often feel vigilant and anxious, but they may not be able to tie these feelings to a specific event, thought, or feeling because the trauma response does not primarily work on cognition but more on instinct and primary drive systems. Counselors can keep in mind that emotional paralysis or an angry demeanor may serve as a form of protection for a client who is feeling highly vulnerable and unsafe emotionally. Pushing or going too deeply before a client feels a sense of containment or control in the sessions may cause the client to emotionally flood, resulting in dissociation or the person feeling violated within the therapeutic setting. Grief is primarily mediated through the attachment system and is tied into cognition, which is related to attributing meaning to events and sequencing events in a certain order (Kosminsky & Jordan, 2016). Thus, grief is usually experienced in a more linear way than traumatic events in isolation (O’Connor & McConnell, 2018). Clients who are experiencing grief will often be able to name the feeling(s) and tie the feeling(s) to an experience (or experiences) directly related to their grief, and they will usually be able to share about their loss experience in a mostly linear and cohesive fashion. You will often hear about the importance of bereaved clients being able to “tell their story,” which involves the ability to describe events in this way. As discussed in the previous chapter, grief is not always expressed as sadness—there is often profound anger at feeling robbed or deprived as a result of a loss, as well as the myriad number of other emotions that have been described previously. Bereaved individuals often go into their grief very deeply, and it can be helpful for the counselor to facilitate this deep exploration, which often involves emotional catharsis. We have also discussed earlier that not all bereaved individuals need to deeply explore their emotional responses to loss and “work them through”; it can probably be assumed that the majority of bereaved clients who seek grief counseling would tend to self-select as more representative of those individuals who find this way of working with grief to be beneficial. This being said, attention to individual differences in client experiences, responses, and expressions is of paramount importance. The “dance” between trauma and grief is obvious. If you try to engage in deep processing of grief-related material when the client is feeling traumatized, you risk the client feeling flooded and shutting down, dissociating, or feeling more out of control and anxious—with the results being that the client may feel worse instead of better afterward. If you try to offer a means of containment to a client who needs to deeply explore the grief, you risk suppressing the experience and encouraging the client to remain superficially engaged or avoidant of grief that may need to be attended at that time. Most likely, effective counselors know when containment is needed, while also having the ability to gently explore and help the client to work through the raw grief when it surfaces.



10.  When Grief Goes Awry

167

OVERLAPS BETWEEN GRIEF AND DEPRESSION Anyone who has experienced grief, personally or professionally, knows that people who are grieving are often extremely sad, weepy, confused, exhausted, and otherwise distressed. These behavioral manifestations of deep emotional pain are present, to one degree or another, in most of the people we see in our offices. So how can we tell the difference between grief that is all-encompassing and depression? Parkes (2014) states that most individuals who experience depression during bereavement will have suffered similar episodes in the past and these individuals may actually be able to identify the difference between their grief and their depression. Other differences may include how grief and depression are experienced, with grief occurring typically in waves or “pangs” (Parkes, 2014), whereas in depression there tends to be consistently a persistent low mood that stays relatively the same all the time. Likewise, grief can be punctuated by times of positive feelings and even laughter, whereas in depression the misery and negative feelings tend to be pervasive and unabating. Finally, whereas a bereaved individual may be focused on thoughts about his or her own death as the possibility of joining a loved one who has died, an individual who is depressed may consider ending his or her own life because of feelings of worthlessness, despair, or inability to cope with the pain of depression (Parkes, 2014; Searight, 2014). Differentiating between CG and depression may be a bit trickier, as both entities share common features such as difficulty functioning, lack of energy, ongoing low mood, and rumination (Figure 10.1). However, in CG, the symptoms are focused upon separation distress from the deceased loved one, with lack of energy and rumination focused upon the loved one and the circumstances of the death. In comparison, depressive symptoms are due to a primary mood disturbance, with diffuse symptoms and low self-esteem that are not typically related to a specific event. The use of medication in CG is equivocal in regard to effectiveness, which will be discussed later in this chapter when we review possible clinical

DEPRESSION

COMPLICATED GRIEF Separation distress primary

OVERLAPS

Low self-esteem primary

Lack of energy related to loss and coping with death

Difficulty functioning

Lack of energy and mood disturbance primary features

Symptoms relate to death of loved one

Lack of energy

Symptoms diffuse; don’t apply to specific events

Suicide thoughts to be with loved one Antidepressant medication equivocal

Pervasive low mood Rumination

Suicide thoughts as relief from pain/distortions Antidepressant medication usually helpful

FIGURE 10.1  Comparison of complicated grief (CG) and depression.

168

II.  Practice and Process

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

SUICIDE BEREAVEMENT There have been many discussions comparing how bereavement after suicide differs from bereavement related to natural causes of death. At face value, it would seem obvious that individuals who are bereaved after the suicide of a loved one would face a very different set of circumstances in their grief. Suicide carries strong social stigma in a society that lauds values of stoicism, self-confidence, and overcoming adversity through personal strength. Likewise, there are underlying assumptions that an individual who dies by suicide is emotionally weak, troubled, or in some way emotionally compromised. There is also considerable evidence that the stigma attached to the person who died will “spill over” onto the family of the deceased as well (Peters, Cunningham, Murphy, & Jackson, 2016; Young et al., 2012). Individuals who are bereaved by suicide may feel the negative attitudes toward suicide in our culture transferred to them. Thus, even if others feel and demonstrate compassion and sensitivity for the mourner, the survivor may assume or fear that others are judging them negatively and therefore withdraw or otherwise act in ways that inhibit social support efforts from others. These aspects of the grief experience after suicide are unique and deserve special attention from clinicians (Practice Example 10.2). Another issue of more recent importance relates to the role of bullying and cyberbullying to suicide in youth. Youth who are bullied, or who bully others, are at an elevated risk for suicidal thoughts, attempts, and completed suicides. The reality of these links has been strengthened through research showing how experience with peer harassment (most



10.  When Grief Goes Awry

169

P R A C T I C E EXAM PLE 1 0 . 2 COMPLEXITIES AROUND SUICIDE BEREAVEMENT

Arthur came to see Jason, a grief counselor, after the death of his wife. In his first few sessions, Arthur focused on what his life had been like for the past several months since his wife died, and how he had been trying to cope with difficulties sleeping and eating. After four sessions together, Jason was aware that Arthur had not really talked about how his wife died, so in their next session, Jason asked Arthur about the circumstances surrounding his wife’s death. Arthur hesitated, and at first said, “It was an accident.” As he said this, he stopped and looked at the ground for a few minutes. Taking a deep breath, he then looked up at Jason and said, “She killed herself. She waited for me to go away for the weekend to close up the cottage, knowing I wouldn’t be home for a couple of days.” He hesitated again. Tears streamed down his face. “I found her when I opened the garage door as I drove my car in. She had run the car with the door down. She must have done it right after I left because she had obviously been dead for a long time.” Arthur then told Jason that he had not told anyone else in her family that she had killed herself, stating, “I didn’t want them to judge her or to think less of me for leaving her alone.” He then told Jason that the main reason he could not sleep at night was due to recurring images of what his wife looked like when he found her. He also felt wracked with guilt for not realizing something was wrong and for leaving her to go to the cottage. He had nobody in his life to share his agony and pain, and he was barraged by intrusive images, feelings of anger and guilt, and a sense of profound isolation. He confessed to Jason that he, too, had considered ending his own life to “finally be free of this horrible situation.”

often as a target but also as a perpetrator) contributes to depression, decreased self-worth, hopelessness, and loneliness—all of which are precursors to suicidal thoughts and behavior. Cyberbullying victims are almost twice as likely to have attempted suicide compared to youth who had not experienced cyberbullying (Hinduja & Patchin, 2018). The popular Netflix series, 13 Reasons Why, had a big impact on youth for many reasons. The story line hinges around a teenage girl who dies by suicide after being bullied by her classmates in various ways. However, she leaves behind tapes for each of the people that she holds responsible for her decision to end her life. The lesson is clear that suicide is portrayed as a viable way to deal with psychological pain as well as a way to “get back” at those who have harmed you (Mueller, in press). While written for entertainment purposes, the underlying theme struck a chord with many young people and there has been concern about the possibility of real consequences of viewing such a program, especially by youth who are considered to be vulnerable or at risk. In one of the first studies of the impact of viewing patterns and reactions to 13 Reasons Why in youth, Hong et al. (2019) found that many young people who watched the series to report increased suicidal ideation. The degree of suicidal ideation was also higher among youth who binge-watched the episodes in a short period of time. This study emphasized the importance of prevention strategies to ameliorate risk among these viewers.

170

II.  Practice and Process

LANGUAGE Consider the language that is often used in referring to death by suicide. For example, the phrase “committed suicide” is frequently used when talking about someone who died by suicide. The word “committed” is also used when talking about a criminal offense, for example, “He committed larceny.” It is true that until a few decades ago, taking your own life was seen as a crime against the church in many countries. Individuals who died by suicide were not granted church-sanctioned religious rites and families were denied the ability to bury the body in a church yard. The thinking was that life is a gift from God, and individuals do not possess the right to choose death for themselves, as this was seen as the purview of the creator of that life. In increasingly secular times, this way of thinking is less relevant to how most people view life and death; however, the stigma associated with suicide continues to carry over into the present. Insurance companies may or may not pay life insurance premiums to survivors if the death was a result of suicide; therefore, there has been pressure upon professionals who complete death certificates to not list suicide as a factor in the death of an individual. The tendency to not identify suicide on documentation is also, at times, seen as a way of being sensitive to the survivors who will carry the stigma of their loved one’s cause of death with them. However, not recognizing suicide also reinforces the social stigma attached to suicide death. As counselors, it is very important to be aware of these issues and to train yourself to use language around suicide bereavement in a way that is correct, direct, and sensitive (Box 10.1).

IMPACT OF SUICIDE ON BEREAVEMENT In addition to the social stigma that surrounds suicide bereavement, there are other issues that are unique to losing someone you love by suicide. Andriessen and Krysinska (2012) describe two unique aspects of suicide bereavement related to survivors feeling anger at the deceased for “choosing” death over life and profound feelings of being abandoned by the individual who chose to leave them behind. This part of the death that is seen as a choice, or volitional, can create profound complications for survivors, who must wrestle with the reality that the person they cared about who died by suicide chose to die, knowing that they would be left behind to deal with this choice. The findings from studies that compare those who are bereaved through natural means to those who are bereaved by suicide indicate that individuals who were bereaved by suicide have a higher incidence of CG, loneliness, and health issues, as well as increased incidence of family dysfunction and conflict afterward (Bellini et al., 2018; Iglewicz, Tal, & Zisook, 2018; Pitman, Osborn, King, & Erlangsen, 2014; Scocco et al., 2019). In a study of individuals bereaved through suicide, Bellini et al. (2018) found that 63% of study participants had elevated scores on a measure of CG, accompanied by high levels of depression and hopelessness. Many studies of individuals who are suicide bereaved indicate a higher degree of personal vulnerability and increased need of special supports than those who are bereaved from natural causes (see Jordan, 2017 for a full review). McMenamy, Jordan, and Mitchell (2008) interviewed individuals who were bereaved after a family member died from suicide. They reported that those who were suicide bereaved experienced exceptionally high levels of distress at many points in their grieving process. For



10.  When Grief Goes Awry

171

BOX 10.1 LANGUAGE AROUND SUICIDE BEREAVEMENT

Following are examples of how language might be stigmatizing, judgmental, or label inappropriately, and how each might be corrected to talk about suicide in a more direct and informed way. Watch out for: Euphemisms “We lost Maddie.” Better to use “Jeff killed himself.” Doesn’t attach judgment; simply statement of fact. Stigmatizing language “Robert committed suicide.” You commit a crime; connects to the idea of criminality or sinfulness; instead, state, “Robert died by suicide.” Labeling the person “Marlon was a 19-year-old suicide.” Identifies the person with the act of suicide and tells nothing further of the person who died. Funny verbs “Jenny suicided last fall.” Not so much offensive, but clunky and misleading/awkward. “Jenny died by an intentional overdose.” Important to not use this language because of stigma or embarrassment. Incorrect terminology “Jasmine’s cause of death was suicide.” Cause of death is more specific, such as suffocation, heart failure, and so on. It may be related to suicide, but the actual cause of death is the physical reason why the person died.

example, the majority of participants reported moderate to high levels of impairment in their daily activities at home or at work, in addition to significant symptoms of depression, guilt, anxiety, and trauma. In this same study, almost one quarter of the participants indicated that they had thought about suicide to a moderate to high degree. Young et al. (2012) state that suicide survivors often face unique challenges that differ from those who have been bereaved by other types of death, citing that in addition to the inevitable grief, sadness, and disbelief that are common to all grief, there is often a prominent sense of overwhelming guilt, confusion, rejection, shame, and anger. Jordan (2017) suggests that suicide bereavement is distinct in three significant ways: (a) the thematic content of the grief, (b) the social processes surrounding the survivor, and (c) the impact that suicide has on family systems. Survivors are often left to struggle with meaning making, wondering (but never fully knowing) why their loved ones chose to end their lives; feelings of guilt and selfblame (i.e., questioning why they were not able to prevent the suicide from happening); and heightened feelings of abandonment and rejection by the person who chose to leave them by suicide. Of great concern is a study of adults who were bereaved by suicide (Pitman, Osborne,

172

II.  Practice and Process

Rantell, & King, 2016), which found that adults bereaved by suicide had a higher probability of attempting suicide than those bereaved by sudden natural causes. Jordan (2017) concludes that “. . . the evidence is now compelling that exposure to suicide carries with it an elevated risk for many negative sequelae, the most important of which is higher rates of suicidality in those exposed to a suicide” (p. 5). Another aspect of suicide bereavement that is unique is that there is sometimes a sense of relief, which may be the case if there has been a long history of problems and worry with the deceased, often involving chronic psychiatric problems with repeated hospital admissions and relapses, difficult or unpredictable behavior, and, in some cases, multiple previous suicide attempts. Feigelman, Jordan, McIntosh, and Feigelman (2012) note that these families would most probably show heightened stress (and elevated levels of symptoms), even if the suicide had not occurred because of these ongoing difficulties and the strain of the uncertainty and intensity of living with a loved one who is greatly compromised. In situations such as this, a sizable number of families would say that the death of their loved one to suicide was not completely unexpected. Important to this discussion is that the families of many suicide completers have experienced a difficult and often lengthy ordeal of living with an emotionally disturbed and self-destructive person, and the exhaustion and roller-coaster ride of the experience will often leave them depleted and conflicted about their loved one’s death.

Supports Individuals and families who are bereaved by suicide often find talking with others who are bereaved by suicide to be beneficial. In light of the unique features of this type of loss experience, referrals to suicide support groups would be highly preferable over referral to general bereavement groups. McMenamy et al. (2008) also found providing educational information about suicide and grief after suicide beneficial as well. Education may help individuals to better understand their loved one’s choice, their process, and their experience within the social context of the stigma that is often part of their grief. Access to this type of information may also be empowering to individuals who have felt powerless in the loss of their loved one. We have stated throughout this book that grief is a normal, adaptive response to loss and we have also reinforced that uncomplicated grief does not warrant formal intervention in most circumstances. However, in light of the intensity of the experience, the social stigma (and self-stigma) that is prevalent, and the high degree of potentially negative sequelae associated with suicide loss, the support and information provided by friends, family, and untrained individuals may not be sufficient. Because suicide survivors are at higher risk for developing CG and may be more susceptible to depression, it is important for clinicians to be cognizant of and address troubling symptoms should they occur. Treatment should include the best combinations of education and specialized support, including specific forms of psychotherapy and/or group support, as well as awareness of when medical assessment for possible pharmacotherapy may be needed to address coexisting symptoms of depression, guilt, and trauma (Young et al., 2012). As counselors, it is important to be aware of the various supports available to survivors of suicide in your community. Online supports and web-based information may also be very useful, especially in areas where communities are



10.  When Grief Goes Awry

173

limited in their offerings. As stated in previous sections about online resources, if you as a professional are recommending websites and online support communities, be sure that you have checked these sources for accurate and current content and a monitor that is regularly present if there are chat or discussion boards.

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

The death of someone was caused by the willful, unexpected, and violent act of another person.

■■

Murder is a public event; thus, family members are robbed of their right to privacy and how they are presented to the public by media.

■■

Because murder is considered a crime against the state, family member’s needs are often placed secondary to those of the legal system and the state.

In addition, language is also important in this experience. Many who have lost a loved one to homicide are frequently referred to as survivors of homicide. This term may seem contradictory because the actual victim of the homicide has died. However, it is considered that every homicide produces two categories of victims: The person who is murdered (the victim) and those associated with the victim, such as family members, friends, and close people (the co-victims/secondary victims, or those who must live with this incident burned into their minds). Bereavement after homicide is not a private matter, and it is often fraught with the painful intrusion of traumatizing media coverage and implicit assumptions that can profoundly affect the grieving process. A major complicating factor in homicide bereavement is the involvement of police, investigators, and the court system. The stigma of homicide is perpetuated and increased when law enforcement personnel must repeatedly examine the scene of the death and question relatives, friends, and neighbors about the decedent and/or death. Family members and their support networks may be exposed to repeated intrusions by the media, each time having to relive the events of the death and circumstances surrounding the homicide of their loved one (Alves-Costa, Hamilton-Giachritsis, & Halligan, 2018). Armour (2002) further aptly states, “The press, criminal justice system, social networks, and the community—as well as social attitudes and the overall climate of investigation, manipulation, speculation, rumor, and delay—give family members less power to direct their fate” (pp. 379–380). In this same study, bereaved family members frequently described feelings of being betrayed by the media and legal process and neglected by those who were expected to provide support. Some described their experience was like a “nightmare that doesn’t end” (p. 374).

174

II.  Practice and Process

Homicide combines elements of traumatic loss (the death carries elements of violence or of events that cause the bereaved survivors to feel distress over what their loved one experienced just before dying) and TG (separation distress that is brought about by the suddenness of the death and feeling robbed of the loved one). Homicidally bereaved individuals are at an increased risk of developing a variety of psychological difficulties, including PTSD, depression, anxiety, substance abuse, and CG (Alves-Costa et al., 2018). Most individuals bereaved by homicide will be bombarded with feelings of powerlessness and helplessness in light of an event that has a painfully devastating impact on them. These individuals will often describe a cascade of horrific images, feelings, and events that begin upon notification that their loved one has been murdered (Rynearson, 2012). After notification, family members may or may not be allowed to view their deceased loved one’s body. If they are able to view the body, they are often closely monitored and prevented from touching the body or clothing because of concerns over “tampering” with evidence. It becomes very clear that the body of the person they loved no longer belongs to them; many family members struggle with the knowledge that the last form of touch that their loved one experienced was of violence and harmful intent. The justice system moves slowly, and it is common for families of homicide victims to have to wait a year or more for a trial to commence. During the time of waiting for the trial, family members exist in a liminal state, unable to move forward because of their need to know the outcome of the proceedings in order to process what has occurred. When the trial arrives, family members are often retraumatized by the testimony and images presented, especially those that are brought up by the defense for the individual charged with homicide. Families will frequently describe feeling victimized all over again when the politics of plea bargaining and sentencing seem to reduce the life of their loved one into a political game. Incidences of secondary victimization in survivors who participated in the legal processes surrounding their loved ones’ deaths have been frequently documented (Cook, 2018; Englebrecht, Mason, & Adams, 2016). Their studies also revealed similar incidences of rejection, unrealistic expectations, and lack of recognition of the impact of the experience upon the survivors by other family members and friends. The amount and quality of social support to family members of those who die from homicide is often based on the circumstances of the homicide. For example, if a family member was killed during a crime committed by an unknown assailant (robbery, burglary, innocent bystander), the survivors are often nurtured and comforted by support systems in the community. However, if the death was related to drugs or criminal acts involving the decedent, the surviving family members are typically isolated and viewed in part as condoning unlawful acts by the decedent (Vessier-Batchen & Douglas, 2006). In these scenarios, family members and friends are often viewed as somehow complicit in the actions of the deceased and may be subjected to scrutiny, judgment, and shaming by others in their community. Despite the high prevalence of poor mental health outcomes of this population, only a small percentage of survivors actually use available services. Barriers to service may be the cost or lack of insurance to cover the costs, availability of transportation, not knowing who to contact, services being offered too far away from home, and not knowing how interventions are offered and by whom (Williams & Rheingold, 2015). Although most governments allocate funding



10.  When Grief Goes Awry

175

to provide assistance and compensation for victims that may help mitigate some of these financial barriers, the application process is often confusing, and survivors may not be aware that such programs even exist. Survivors living in rural areas may also face additional barriers, including having to travel long distances to access specialized services. For counselors working with individuals and families bereaved through homicide, it is important to “hold” all of these issues in mind, validating their presence and normalizing the intensity of feelings that occur in the midst of a very abnormal situation. Homicide survivors will likely find different resources helpful at different times during the bereavement process. For example, in the weeks and months following a homicide, survivors may benefit from having contact with victim services or intensive case management through local law enforcement agencies to help link family members to additional resources (e.g., financial entitlements to help pay for crime-related expenses) more so than mental health treatment. Survivors of homicide have reported a great need to find meaning in the midst of a situation that appears initially to be void of any sense or meaning (Bottomley, Burke, & Neimeyer, 2017). Working with family members together may also provide needed support for the family system and an opportunity to help the family to draw from the strengths and resources of the individual members (Harris & Rabenstein, 2014). It is important for clinicians to understand the legal process, the terminology used in the court proceedings, and the function of the court system. Many families find it very comforting for their counselor to attend portions of the trial for support if possible, or to offer flexible meeting times around the timing of the court proceedings (Hays & Browning, 2017). Armour (2002) reported that family members often felt helped when people from all aspects of the experience demonstrate even small expressions of sensitivity and caring. One participant in this study cited seeing tears in a judge’s eyes when speaking with him about what had happened, noting that this awareness of the judge’s concern for her meant a great deal. I (D.L.H.) have also had family members bring coroner’s reports of their deceased loved one to their sessions to read and review in the presence of a caring witness in a safe place. A special note here is added regarding mass shootings and their coverage by various media outlets, where events typically unfold in seemingly random patterns and with devastating consequences. In many of these instances, social media is used as a vehicle to spread terror, increase exposure to such events by individuals who are not local, and to launch a platform or agenda of those responsible for these events. Haravuori, Suomalainen, Berg, Kiviruusu, and Marttunen (2011) describe the role of the media in further traumatizing high school students after a mass shooting in a high school in Finland: A noticeable feature was the speed of the media response. Within half an hour dozens of journalists were on the scene, filming and photographing escaping students and school workers. The pressure to get information and interviews was such that phone calls and text messages were sent to students who were just rescued or still waiting to be rescued within the school building. News broke online while television and printed news followed later. The role of the Internet communities was unique as they identified the probable shooter and videos posted on the Internet while the police operation was still ongoing. (p. 70)

176

II.  Practice and Process

In this same scenario, the actions of the reporters added pain to the families and impeded the investigation. Many of the interviews were done with students who were in shock without the consent of their parents; many of the students did not even remember they had been interviewed afterwards but would see themselves in video footage or being quoted directly after the event, creating a sense of re-victimization all over again. Vicarious exposure to this type of media coverage increases risk for symptoms of PTSD, exacerbates current symptoms, as well as increases the likelihood of prolonged distress in individuals and communities recovering from these incidents (Fallahi, 2017). Counselors who work with individuals that have lost loved ones to traumatic events may find that even if the client’s story has no overt relevance to a recent publicized mass shooting, feelings of anxiety and vigilance may heighten due to activation of the client’s traumatic experience through vicariously observing media coverage of these events. Individuals who were directly affected by the mass shooting have experienced a seemingly senseless horrific event, where those who died and those who survived appear to have done so by pure random fate. Events of such magnitude have a deep and lasting effect upon those directly affected, the first responders and healthcare providers, as well as the community, which must gather to support those affected even as difficult questions and attributions about the events are voiced.

CLINICAL IMPLICATIONS FOR COMPLICATED GRIEF AND TRAUMATIC GRIEF Counselors Need to Focus on Their Client in Order to Know How to Best Proceed Above all, at this time we wish to reiterate that CG/TG is not evidence of pathology in the client. It is important that the grieving individual be given support and a safe space to explore the meaning of the loss experience and its associated ramifications for that person (Thompson, 2012). Thus, even identifying a client’s presenting issues with the proposed criteria for CG or PGD does not mean that something is wrong with your client; rather, the client may be lacking in something that they need in order to grieve, or there may just be a sense of being overwhelmed by the loss and its consequences. We do not just “flip into” a different mode of being with our clients when we sense the grief is traumatic or complicated. Instead, we continue to be fully present and engaged with our clients and use cues from their story to guide us in the therapeutic process. We would suggest that you use the information from this chapter to know when clients may need more structured support, but you should also always keep in mind the information we presented about the social context of loss and the politics of diagnosis in Chapter 4, “The Social Context of Loss.” Listen to your client carefully. If your client is really mired down in grief, gently assess whether the client’s distress focuses mostly on the loss itself (what/who has been lost), the events that surrounded the loss, and/or the process of grief itself, or a combination of these factors, and use your client’s focus as your guide in the sessions. If your client is sharing more about the event that happened or images of how the person’s body looked or was imagined to look, or seems highly anxious or uncomfortable, go slowly and provide stopping points



10.  When Grief Goes Awry

177

to check in with the client in the session. Feelings of anxiety and vigilance indicate to you that your client is feeling unsafe and unsure. Clients may describe nightmares about what happened to their loved one. These kinds of dreams may involve the context of an event in which the griever felt powerless and the loved one suffered harm, mutilation, or death or in which the person hears or sees the loved one, but there is an ominous overtone or a sense of something being terribly wrong. Many clients describe “searching dreams,” where they are repeatedly looking for their loved one and cannot locate that individual, or they are somehow prevented from finding them.

The Interplay of Grief and Trauma There is often an obsessive quality to what is shared by the client when the grief is complicated or traumatic in nature. Although most people who are bereaved yearn for contact with their deceased loved one(s), those whose grief is traumatic are often obsessed by what happened and the details surrounding the death, and they are often consumed by feelings of anger, rage, fear, or powerlessness. They may have intrusive thoughts that focus on what happened or they may relive the event(s) over and over in their minds. They may experience bodily symptoms either from the stress they are under or similar to those that might have been experienced by the lost person. They may be unable to go to the place where the event happened or find themselves avoiding similar sites (certain roads, certain types of cars, certain buildings or types of buildings). There is also often fear of being triggered by outside stimuli—television programs, songs on the radio, exposure to a similar event—and they may have an aversion or avoidance pattern in their daily functioning, such as a refusal or reluctance to drive through certain intersections or go near certain buildings. They may also feel a sense that they will die soon or have a sense of fatalism about life. In addition, their level of everyday functioning is often profoundly affected; many of these individuals are just getting by in regard to their work functioning and in their everyday routine, which adds another tremendous stress on top of their process. Traumatic loss and TG are often associated with feeling violated, powerless, angry, and out of control. These feelings must first be recognized and validated, and the individual needs to feel a sense of control—even if the control is how they choose to disclose details, or how the sessions proceed. Counselors must be clear in working with individuals who are feeling unsafe and anxious that they only need to know what the client needs to share with them. Be careful about asking too many questions about details. If you want to know about a detail that the client has shared, ask and then wait before asking for more. Pushing for details and content when clients are hesitant or pushing back may be experienced as intrusive and further increase feelings of anxiety. Attempts to minimize or even reframe the magnitude of the client’s feelings, or to act as if the client’s anxiety and hesitancy are not important issues, will only demonstrate to the client that they cannot be open about feelings, thoughts, and difficulties with you. In families and certain groups in which there has been a suicide, there can be higher rates of suicide in the remaining members, so feelings about not wanting to continue living and possible thoughts of suicide should be taken seriously and not dismissed (Jordan & McIntosh, 2011).

178

II.  Practice and Process

Treatment Modalities Traumatic Grief Therapy

One important aspect of working with individuals who are experiencing traumatic overlay to their grief is the need to slow the process down and not to push the person to go deeper into feelings that could lead to flooding with potentially traumatizing images. Slowly allow the person to share about what happened. Focus on breathing, taking breaks, and maintaining a strong presence in the room. Being able to talk about small “chunks” of the bereaved individual’s experience is sometimes referred to as “dosing” the experience—only dealing with small and selected segments of the painful and traumatic aspects of the client’s experience at a time (Jordan & McIntosh, 2011). Rynearson’s restorative retelling model was developed for working with TG. This model builds upon a solid relationship with the therapist that will later foster a sense of safety when the client is invited to engage with the traumatic material in a way. The therapist is trained to assist the client to explore the event narrative in ways that can foster healing and an increased sense of integration with meaning-oriented narratives (Neimeyer, 2012). Complicated Grief Therapy

Developed by Shear (2015b) and Shear and Bloom (2017), complicated grief therapy (CGT) has been proposed as a means to assist bereaved individuals by a series of interventions designed to address some of the specific and more problematic areas of CG. Similar to how we have discussed grief previously, the basic principle underlying CGT is that grief is a natural, adaptive process, and treatment of CG involves removing the impediments to the helpful aspects of the grieving process. CGT incorporates aspects of both interpersonal therapy (“talk therapy”) with cognitive behavioral therapy (CBT). Although CGT can be flexibly applied in clinical practice, the manualized form tested in research studies consists of 16 sessions, each approximately 45 to 60 minutes long. Each session is structured, with an agenda that includes reviewing the previous week’s activities, doing work in session, and assigning tasks for the coming week (see Wetherell, 2012 for detailed descriptions of the weekly work). In CGT, clients are asked to maintain a grief diary and to engage in imaginal exercises that are designed to revisit the death in increments; situational revisiting exercises are used for avoided activities and situations. The revisiting portion of the treatment is similar to a form of exposure therapy that is used with the treatment of PTSD. The advantages of CGT are its high response rate and limited session length (16 sessions; Shear & Bloom, 2017). The disadvantage is that practitioners who wish to utilize CGT have a limited number of offerings for training in the protocol and thus the limited availability of the treatment for people with CG. Cognitive Behavioral Therapy

CBT has also been proposed as a useful technique in working with CG. This approach addresses beliefs that center upon the bereaved individual’s thoughts about the person who died, how they perceive their relationship with that person, and their assessment of their own ability to continue living without the deceased. CBT directly addresses the negative cognitions that have formed around the loss experience, assisting the bereaved person to



10.  When Grief Goes Awry

179

reframe these cognitions in a more realistic and meaningful way. In a review of CBT for CG, Kosminsky (2017) suggests asking clients the following: ■■

Does this way of thinking (about the death, or your life now and in the future) make you feel better or worse?

■■

Does it give you more energy to carry on with your life or does it drain you of energy and hope? (p. 27)

According to Boelen, De Keijser, van den Hout, and van den Bout (2007), the goals of CBT in CG include: (a) integrating the loss with existing autobiographical knowledge, (b) changing unhelpful thinking patterns, and (c) replacing unhelpful avoidance strategies by more helpful actions and coping strategies (for further information about the use of CBT in CG, see Boelen and van den Bout [2012]). CBT is also helpful when there is significant traumatic overlay, as trauma disrupts cognitive processing and survivors of traumatic loss are especially prone to fragmentation of memories, exaggerated beliefs regarding their responsibility for the death, and sustained levels of physiological hyperarousal. Thus, the use of CBT could also be useful in situations where the death was sudden or unexpected (Malkinson, 2012). Similar to CBT is metacognitive therapy (MCT), which focuses more upon modifying unhelpful thinking processes that maintain distress. This aspect of MCT seems to be very helpful in addressing rumination and repetitive negative thinking, which are key components in the descriptions of PGD and CG. Repetitive negative thinking about issues related to past experiences or worries about the future keep the bereaved individual’s attention fixed on distressing information (e.g., the injustice and unfairness of the loss), which impairs the chance of developing coping strategies, promotes maladaptive behaviors, drives away social support, and perpetuates depressive symptoms (Wenn, O’Connor, Breen, Kane, & Rees, 2015). CBT training is widely available in almost every clinical program, so it is readily available for individuals in many different areas. MCT is newer and just beginning to be considered as a helpful adjunct in CG treatment. Meaning Reconstruction Therapy

Meaning reconstruction therapy has also been proposed as a way to reduce debilitating acute grief symptoms, providing clients with the opportunity to address their losses, relationships, and purpose in life in the context of the narrative of their life’s story with the deceased individual and without that same person (Neimeyer, 2016). From a constructivist standpoint, the way in which bereaved individuals construe or “makes sense” of the loss of a loved one and life afterward is directly related to accommodation through the grieving process and adjustment to life after a significant loss. If an individual perceives a loss event as foundational to their identity, this loss experience can serve as a reference point for subsequent experiences as well as memories of past events, potentially leading to greater distress, symptomatology, and other adverse outcomes (Bellet, Neimeyer, & Berman, 2018). The main trigger in CG has been found to be a composite of both traumatic and separation distress, so that meaning making strategies centered on restoring a sense of secure attachment to the memory of the deceased may play a contributing role in mitigating distress over a highly central loss (Kosminsky & Jordan, 2016). The specific goals of meaning reconstruction therapy include the following (Shear, Boelen, & Neimeyer, 2011, p. 154):

180

II.  Practice and Process

■■

Finding a meaningful place for the event story of the death in the client’s ongoing self-narrative

■■

Reviewing and revising the back story of the relationship with the deceased, both to address residual concerns and to reconstruct the attachment bond with the deceased in a way that does not require his or her physical presence

■■

“Re-visioning” life and fostering creative problem solving

■■

Reinforcing dedicated action through legacy work

Meaning reconstruction therapy may utilize many different strategies to foster a restoration to a coherent narrative of self in the context of life for bereaved individuals. For more information, it is suggested that the reader view the Techniques of Grief Therapy series, edited by Neimeyer and published by Routledge. It is important to remember that these descriptions are a very condensed overview of each of these therapeutic approaches, and each of these treatment modalities requires specialized training by a skilled and experienced therapist. These approaches are briefly described here for you to keep in mind if your client is struggling with the basic interpersonal counseling approach to grief that we have described in this book so far.

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



10.  When Grief Goes Awry

181

Important to this discussion is, as was discussed earlier in this chapter, that CG can co-occur with major depressive disorder and post-traumatic stress disorder. Although depressive symptoms may respond to medication, there is considerable controversy as to whether these same class of medications is helpful for CG symptoms in the absence of depression. Neimeyer (2012) aptly states that CG is often associated with intense separation distress, which is on the anxiety spectrum, and not within the range of depressive symptoms, so treating with antidepressant medication might not provide much benefit in this instance. For the purposes of this chapter, it is suggested that counselors pay attention to the level of functionality of the client, along with descriptions of sleep habits and patterns of thinking that tend to “spiral downward” without the client being able to recover in between times of deeper despair and despondency. For clients who, over a period of many months, have been unable to develop more regular sleep patterns and who do not tend to oscillate between grief symptoms and daily functioning, assessment for medication may be of benefit, and the counselor would be remiss in not exploring such a referral in these situations.

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

Advocacy and Empowerment in Complicated Grief Advocacy is often an important way for the individual to feel that what has happened may have some meaning to it. Advocacy can be thought of as a form of “therapeutic activism” (Jordan & McIntosh, 2011, p. 32) and as a means to try to change things that have surfaced as inequities, injustices, or causal elements in the event that has happened. It is also a means for regaining a sense of personal power after experiencing an event where one felt powerless or helpless. Advocacy may also be a way to channel the intense emotions that have arisen as a result of being traumatized and for individuals who have experienced a similar event to support each other through identification with the common cause. The group Mothers Against Drunk Driving was begun by women who lost loved ones because of drunk drivers, and this organization has provided a powerful presence to lobby for stricter laws and penalties for driving while under the influence of substances. Many suicide prevention groups are

182

II.  Practice and Process

formed by individuals who have been personally affected by the suicide of a loved one. The popular television show, “America’s Most Wanted” was hosted by John Walsh to help families find and convict perpetrators of violent crimes after his 6-year-old son was abducted and murdered. With the presence of online groups and Internet-based support, many people find joining online advocacy groups and blogging about their experience to be a way to voice their feelings and concerns so they may be heard and put to use in social contexts (Sofka, 2016). Meaning making through advocacy serves to integrate a traumatic event into one’s existing assumptive world, and it also creates a legacy for the deceased individual.

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

GLOSSARY Complicated grief (CG) Involves prolonged acute grief symptoms, and situations in which the bereaved is unable to rebuild a meaningful life without the deceased person; there is currently a movement toward the development of consensus criteria for CG because of confusion regarding differing terminology to refer to difficult grief, such as CG, TG, and PGD. Dissociation  Although the person remains physically present, there is a sense that emotionally and/or cognitively the person is absent. The continuum may run from daydreaming to actual amnesia about events or conversations. Posttraumatic stress disorder (PTSD)  The presence of a proscribed set of symptoms and behavioral manifestations that are described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) that occur after exposure to a traumatic event and that remain present for at least 2 months after the event. Symptoms may include frequent reported disturbances in sleep, concentration, intrusive images of the event, avoidance, and vigilance.



10.  When Grief Goes Awry

183

Trauma  A deeply distressing or disturbing experience, or a situation that involves a threat of death, serious injury, or significant potential harm to an individual. Trauma may be experienced directly or vicariously. Traumatic grief (TG)  Delineates the degree of the separation anxiety and assault to the assumptive world that is experienced by the bereaved individual. Some losses are traumatic because they focus on the experience and response of the bereaved person and not necessarily on the events surrounding the death itself. For example, a palliative death of a very close attachment figure in certain circumstances may lead to TG if the loss causes the bereaved individual to feel unsafe, threatened, or highly vulnerable. Traumatic loss  Places the focus on the events and the stressors that occurred around the loss, which are usually sudden, unexpected, violent, disfiguring, or out of the normal expectation.

QUESTIONS FOR REFLECTION 1. List and describe client scenarios that would indicate a need for a clinician to have

specific training and expertise in dealing with CG assessment. How would you know when you are “over your head” with a particular client? What would you do if you felt this way?

2. What differentiates the experience of PGD from chronic sorrow that accompanies

nonfinite losses?

3. Individuals with CG are often identified and diagnosed as depressed by some

professionals. What are some of the ramifications for making this diagnosis in individuals with CG?

4. It has often been said that “all grief is complicated.” Explore this statement, using

the information you have read in this chapter.

REFERENCES Allen, J. Y., Haley, W. E., Small, B. J., Schonwetter, R. S., & McMillan, S. C. (2013). Bereavement among hospice caregivers of cancer patients one year following loss: Predictors of grief, complicated grief, and symptoms of depression. Journal of Palliative Medicine, 16(7), 745–751. doi:10.1089/jpm.2012.0450 Alves-Costa, F., Hamilton-Giachritsis, C., & Halligan, S. (2018). “Everything changes”: Listening to homicidally bereaved individuals’ practice and intervention needs. Journal of Interpersonal Violence, 33, 1–21. doi:10.1177/0886260518766558 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Andriessen, K., & Krysinska, K. (2012). Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health, 9(1), 24–32. doi:10.3390/ ijerph9010024 Armour, M. (2002). Journey of family members of homicide victims: A qualitative study of their posthomicide experience. American Journal of Orthopsychiatry, 72(3), 372–382. doi:10.1037/00029432.72.3.372 Bellet, B. W., Neimeyer, R. A., & Berman, J. S. (2018). Event centrality and bereavement symptomatology: The moderating role of meaning made. OMEGA-Journal of Death and Dying, 78(1), 3–23. doi:10.1177/0030222816679659

184

II.  Practice and Process

Bellini, S., Erbuto, D., Andriessen, K., Milelli, M., Innamorati, M., Lester, D., . . ., Pompili, M. (2018). Depression, hopelessness, and complicated grief in survivors of suicide. Frontiers in Psychology, 9, 1–6. doi:10.3389/fpsyg.2018.00198 Boals, A. (2018). Trauma in the eye of the beholder: Objective and subjective definitions of trauma. Journal of Psychotherapy Integration, 28(1), 77–89. doi:10.1037/int0000050 Boelen, P. A., & van den Bout, J. (2012). Changing catastrophic misinterpretations with behavioral experiments. In R. A. Neimeyer (Ed.), Techniques in grief therapy: Creative practices for counseling the bereaved (pp. 125–128). New York, NY: Routledge. Boelen, P. A., van den Bout, J., & van den Hout, M. A. (2006). Negative cognitions and avoidance in emotional problems after bereavement: A prospective study. Behaviour Research and Therapy, 44(11), 1657–1672. doi:10.1016/j.brat.2005.12.006 Bottomley, J. S., Burke, L. A., & Neimeyer, R. A. (2017). Domains of social support that predict bereavement distress following homicide loss: Assessing need and satisfaction. OMEGA-Journal of Death and Dying, 75(1), 3–25. doi:10.1177/0030222815612282 Bruinsma, S. M., Tiemeier, H. W., Heemst, J. V. V., van der Heide, A., & Rietjens, J. A. (2015). Risk factors for complicated grief in older adults. Journal of Palliative Medicine, 18(5), 438–446. doi:10.1089/ jpm.2014.0366 Cook, D. (2018). A qualitative study of secondary victimization of homicide co-victims navigating the juvenile justice system (Doctoral dissertation, Alliant International University). Crunk, A. E., Burke, L. A., & Robinson III, E. M. (2017). Complicated grief: An evolving theoretical landscape. Journal of Counseling & Development, 95(2), 226–233. doi:10.1002/jcad.12134 Djelantik, A. M. J., Smid, G. E., Kleber, R. J., & Boelen, P. A. (2017). Symptoms of prolonged grief, post-traumatic stress, and depression after loss in a Dutch community sample: A latent class analysis. Psychiatry Research, 247, 276–281. doi:10.1016/j.psychres.2016.11.023 Dyregov, K. (2004). Strategies of professional assistance after traumatic deaths: Empowerment or disempowerment? Scandinavian Journal of Psychology, 45(2), 181–189. doi:10.1111/j.14679450.2004.00393.x Eisma, M. C., Schut, H. A., Stroebe, M. S., Boelen, P. A., van den Bout, J., & Stroebe, W. (2015). Adaptive and maladaptive rumination after loss: A three‐wave longitudinal study. British Journal of Clinical Psychology, 54(2), 163–180. doi:10.1111/bjc.12067 Englebrecht, C. M., Mason, D. T., & Adams, P. J. (2016). Responding to homicide: An exploration of the ways in which family members react to and cope with the death of a loved one. OMEGA-Journal of Death and Dying, 73(4), 355–373. doi:10.1177/0030222815590708 Fallahi, C. (2017). Social media and news coverage as vicarious exposure. In L. Wilson (Ed.), The Wiley handbook of the psychology of mass shootings (pp. 136–152). Sussex, UK: Wiley-Blackwell. Feigelman, W., Jordan, J. R., McIntosh, J. L., & Feigelman, B. (2012). Devastating losses: How parents cope with the death of a child to suicide or drugs. New York, NY: Springer Publishing Company. Freedy, J. (2017). Understanding trauma and grief complications. In C. Arnold (Ed.), Understanding child and adolescent grief (pp. 127–142). New York, NY: Routledge. Frumkin, M. R., & Robinaugh, D. J. (2018). Grief and post-traumatic stress following bereavement. In E. Bui (Ed.), Clinical handbook of bereavement and grief reactions (pp. 19–44). Cham, Switzerland: Humana Press. Haravuori, H., Suomalainen, L., Berg, N., Kiviruusu, O., & Marttunen, M. (2011). Effects of media exposure on adolescents traumatized in a school shooting. Journal of Traumatic Stress, 24(1), 70–77. doi:10.1002/jts.20605 Harris, D. (2020). Non-death loss and grief: Context and clinical implications. New York, NY: Routledge. Harris, D., & Rabenstein, S. (2014). Family therapy in the context of traumatic losses. In D. Kissane & F. Parnes (Eds.), Bereavement care for families (pp. 137–148). New York, NY: Routledge. Hays, M. B., & Browning, S. W. (2017). Clinical work with families of homicide. In S. Browning & B. van Eeden-Moorefield (Eds.), Contemporary families at the nexus of research and practice (pp. 184–196). New York, NY: Routledge. Hinduja, S., & Patchin, J. W. (2018). Connecting adolescent suicide to the severity of bullying and cyberbullying. Journal of School Violence, 18(3), 333–346. doi:10.1080/15388220.2018.1492417



10.  When Grief Goes Awry

185

Hong, V., Ewell Foster, C. J., Magness, C. S., McGuire, T. C., Smith, P. K., & King, C. A. (2018). 13 Reasons Why: Viewing patterns and perceived impact among youths at risk of suicide. Psychiatric Services, 70(2), 107–114. doi:10.1176/appi.ps.201800384 Houwen, K. V. D., Stroebe, M., Stroebe, W., Schut, H., Bout, J. V. D., & Meij, L. W. D. (2010). Risk factors for bereavement outcome: A multivariate approach. Death studies, 34(3), 195–220. doi:10.1080/ 07481180903559196 Iglewicz, A., Tal, I., & Zisook, S. (2018). Grief reactions in the suicide bereaved. In E. Bui (Ed.), Clinical handbook of bereavement and grief reactions (pp. 139–160). Cham, Switzerland, Humana Press. Jordan, J. R. (2017). Postvention is prevention—The case for suicide postvention. Death Studies, 41(10), 614–621. doi:10.1080/07481187.2017.1335544 Jordan, J. R., & McIntosh, J. L. (2011). Grief after suicide: Understanding the consequences and caring for the survivors. New York, NY: Routledge. Kosminsky, P. (2017). CBT for grief: Clearing cognitive obstacles to healing from loss. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 35(1), 26–37. doi:10.1007/s10942-016-0241-3 Kosminsky, P. S., & Jordan, J. R. (2016). Attachment-informed grief therapy: The clinician’s guide to foundations and applications. New York, NY: Routledge. Levenson, J. (2017). Trauma-informed social work practice. Social Work, 62(2), 105–113. Maccallum, F., & Bryant, R. A. (2018). Prolonged grief and attachment security: A latent class analysis. Psychiatry Research, 268, 297–302. doi:10.1016/j.psychres.2018.07.038 Maciejewski, P. K., Maercker, A., Boelen, P. A., & Prigerson, H. G. (2016). “Prolonged grief disorder” and “persistent complex bereavement disorder”, but not “complicated grief ”, are one and the same diagnostic entity: An analysis of data from the Yale Bereavement Study. World Psychiatry, 15(3), 266– 275. doi:10.1002/wps.20348 Malkinson, R. (2012). The ABC of rational response to loss. In R. Neimeyer (Ed.), Techniques of Grief Therapy (pp. 129–132). New York, NY: Routledge. Mancini, A. D., & Bonanno, G. A. (2012). The persistence of attachment: Complicated grief, threat, and reaction times to the deceased’s name. Journal of Affective Disorders, 139(3), 256–263. doi:10.1016/j. jad.2012.01.032 McMenamy, J. M., Jordan, J. R., & Mitchell, A. N. N. (2008). What do suicide survivors tell us they need? Results of a pilot study. Suicide and Life-Threatening Behavior, 38(4), 375–389. doi:10.1521/ suli.2008.38.4.375 Mueller, A. S. (in press). Why Thirteen Reasons Why may elicit suicidal ideation in some viewers, but help others. Social Science & Medicine, 232, 499–501. doi:10.1016/j.socscimed.2019.04.014 Neimeyer, R. A. (2012). Retelling the narrative of the death. In R. Neimeyer (Ed.), Techniques of grief therapy: Creative practices for counseling the bereaved (pp. 86–90). New York, NY: Routledge. Neimeyer, R. A. (2016). Meaning reconstruction in the wake of loss: Evolution of a research program. Behaviour Change, 33(2), 65–79. doi:10.1017/bec.2016.4 Nolen-Hoeksema, S., Larson, J., & Larson, J. M. (2013). Coping with loss. New York, NY: Routledge. O’Connor, M. F., & McConnell, M. H. (2018). Grief reactions: A neurobiological approach. In E. Bui (Ed.), Clinical handbook of bereavement and grief reactions (pp. 45–62). Cham, Switzerland: Humana Press. Parkes, C. M. (2014). Diagnostic criteria for complications of bereavement in the DSM-5. Bereavement Care, 33(3), 113–117. doi:10.1080/02682621.2014.980987 Perry, B. D., (2005). Applying principles of neurodevelopment to clinical work with maltreated and traumatized children: The neurosequential model of therapeutics. In N. B. Webb (Ed.), Working with traumatized youth in child welfare (pp. 27–52). New York, NY: Guilford Press. Peters, K., Cunningham, C., Murphy, G., & Jackson, D. (2016). "People look down on you when you tell them how he died": Qualitative insights into stigma as experienced by suicide survivors. International Journal of Mental Health Nursing, 25(3), 251–257. doi:10.1111/inm.12210 Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry, 1(1), 86–94. doi:10.1016/s2215-0366(14)70224-x Pitman, A. L., Osborn, D. P., Rantell, K., & King, M. B. (2016). Bereavement by suicide as a risk factor for suicide attempt: A cross-sectional national UK-wide study of 3432 young bereaved adults. BMJ Open, 6(1), e009948. doi:10.1136/bmjopen-2015-009948

186

II.  Practice and Process

Rozalski, V., Holland, J. M., & Neimeyer, R. A. (2017). Circumstances of death and complicated grief: Indirect associations through meaning made of loss. Journal of Loss and Trauma, 22(1), 11–23. doi:1 0.1080/15325024.2016.1161426 Rynearson, E. K. (2012). The narrative dynamics of grief after homicide. Omega-Journal of Death and Dying, 65(3), 239–249. doi:10.2190/om.65.3.f Searight, H. R. (2014). Expanding the boundaries of major depressive disorder in DSM-5: The removal of the bereavement exclusion. Open Journal of Depression, 3(1), 9–12. doi:10.4236/ojd.2014.31004 Scocco, P., Preti, A., Totaro, S., Corrigan, P. W., Castriotta, C., & SOPROXI Team. (2019). Stigma, grief and depressive symptoms in help-seeking people bereaved through suicide. Journal of Affective Disorders, 244, 223–230. doi:10.1016/j.jad.2018.10.098 Schenck, L. K., Eberle, K. M., & Rings, J. A. (2016). Insecure attachment styles and complicated grief severity: Applying what we know to inform future directions. OMEGA-Journal of Death and Dying, 73(3), 231–249. doi:10.1177/0030222815576124 Shear, M. K. (2010). Complicated grief treatment: The theory, practice, and outcomes. Bereavement Care 29(3), 10–14. doi:10.1080/02682621.2010.522373 Shear, M. K. (2015a). Complicated grief. New England Journal of Medicine, 372(2), 153–160. doi:10.1056/ nejmcp1315618 Shear, M. K. (2015b). Complicated grief treatment (CGT) for prolonged grief disorder. In U. Schnyder & M. Cloitre (Eds.), Evidence based treatments for trauma-related psychological disorders (pp. 299–314). New York, NY: Springer Publishing Company. Shear, M. K., & Bloom, C. G. (2017). Complicated grief treatment: An evidence-based approach to grief therapy. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 35(1), 6–25. doi:10.1007/s10942 -016-0242-2 Shear, M. K., Boelen, P. A., & Neimeyer, R. A. (2011). Treating complicated grief: Converging approaches. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 139–162). New York, NY: Routledge. Sofka, C. (2016). Restorative justice principles and restorative practice: Museums as healing spaces. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 213–224). New York, NY: Routledge. Stroebe, M., Stroebe, W., Schut, H., & Boerner, K. (2017). Grief is not a disease but bereavement merits medical awareness. The Lancet, 389(10067), 347–349. doi:10.1016/s0140-6736(17)30189-7 Thompson, N. (2012). Grief and its challenges. Basingstoke, UK: Palgrave. Vessier-Batchen, M., & Douglas, D. (2006). Coping and complicated grief in survivors of homicide and suicide decedents. Journal of Forensic Nursing, 2(1), 25–32. doi:10.1111/j.1939-3938.2006.tb00050.x Wenn, J., O’Connor, M., Breen, L. J., Kane, R. T., & Rees, C. S. (2015). Efficacy of metacognitive therapy for prolonged grief disorder: Protocol for a randomised controlled trial. BMJ Open, 5(12), e007221. doi:10.1136/bmjopen-2014-007221 Wetherell, J. L. (2012). Complicated grief therapy as a new treatment approach. Dialogues in Clinical Neuroscience, 14(2), 159–166. Williams, J. L., & Rheingold, A. A. (2015). Barriers to care and service satisfaction following homicide loss: Associations with mental health outcomes. Death Studies, 39(1), 12–18. doi:10.1080/07481187. 2013.846949 Worden, J. W. (2018). Grief counseling and grief therapy (5th ed.). New York, NY: Springer Publishing Company. World Health Organization. (2019). International Classification of Disease s(ICD), 11th revision: 6B42 Prolonged grief disorder. Retrieved from https://icd.who.int/dev11/l-m/en#/http%3a%2f%2fid.who. int%2ficd%2fentity%2f1183832314 Young, I. T., Iglewicz, A., Glorioso, D., Lanouette, N., Seay, K., Ilapakurti, M., & Zisook, S. (2012). Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience, 14(2), 177.

CHAPTER 

11

T HE CL I N I C I AN ’ S T O O L B O X : T HERA P E UT I C MOD A L I T I E S A N D T ECH N I QUE S I N T H E C O N T E X T OF  G RIE F

LEARNING OBJECTIVES 1. Describe how rituals and symbolic/linking objects can be helpful to people who are grieving. 2. Discuss specific forms of writing that can assist with the grieving process. 3. Identify what are known as “power therapies” and how they may be used with bereaved clients. 4. Explain how specific types of nonverbal techniques, such as sandtray work and photo narrative, may assist clients with their grief. 5. Relate the concepts of mindful awareness, presence, and compassion-focused therapy to the grieving process.

INTRODUCTION In this chapter, we explore some therapeutic tools and techniques that may be helpful when working with bereaved individuals. We offer these ideas and suggestions with the recognition that there are many diverse ways for bereaved individuals to share their thoughts,

188

II.  Practice and Process

feelings, and stories, and these ideas might help to facilitate this aspect of your work with clients. It is highly apparent that there is no such thing as “one-stop shopping” in grief counseling. Some clients will talk nonstop in a session for almost the entire time, whereas others will say very little and have a great deal of difficulty expressing themselves. Some clients will readily talk about their feelings and will be highly self-reflective in their encounters with you, whereas others may focus more upon events outside of themselves and/or be quite analytically oriented. Your job as a grief counselor is to facilitate your clients’ process in a way that is most congruent to their way of being in the world and aligned with their needs and goals. In this section, we describe some therapeutic adjuncts, or different ways of working with clients and their grief. Some of these techniques require additional training, and we specify suggestions for additional resources and training opportunities for these modalities for your interest. This chapter is by no means an exhaustive review of counseling strategies for adaptation to loss. We have provided descriptions of these modalities because they are the ones with which we are most familiar. If you are interested in a deeper exploration of various exercises and strategies for working with bereaved individuals, we would refer you to Neimeyer’s Techniques of Grief Therapy series (Neimeyer, 2012, 2016, in press). Before introducing work with clients that strays from a classical talk-therapy orientation, we go back to a foundational point in counseling: The relationship that you have with your client is what is most important. We would never encourage a counselor to try an intervention or strategy with a client unless there is a sense of comfort in the relationship, where a sense of trust between the client and the counselor is well established, and the counselor feels that they have a solid grasp of the client’s concerns, values, and sensitivities. Remember, the relationship comes first, as the therapeutic alliance is the foundation for all of the work that occurs. The client must have a good sense of trust in you, an engagement with the process, and a motivation to work before you can introduce an exercise or different way of working together into the sessions. We have found that the well-timed introduction of a therapeutic adjunct can have quite dramatic results with some clients, often providing a catalyst for greater awareness, self-understanding, and reflection in the session and afterward. Thus, we want to share some of the things we keep in our “counselor’s toolkit” for you to consider in your work with your own clients.

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



11.  The Clinician’s Toolbox

189

with the deceased loved one, and it may nourish a sense of the deceased’s presence that is ongoing in some way with the client. The most common ritual in North America is probably the funeral, which serves many purposes: honoring the deceased individual’s life, providing a structured opportunity for social support to be offered to the family and close friends, reaffirmation of values and beliefs, and reintegration of the family into the community without the deceased individual. However, the funeral is a time-limited ritual, and it does not afford an opportunity to be revisited by the bereaved as the grieving process unfolds (Worden, 2018). Certainly, the presence of a grave or marker for a deceased loved one can provide an opportunity for ongoing visitation by loved ones and possibly a sense of connection with the deceased individual or to a higher power. However, in the absence of an avenue for expression, this visitation alone may not actively engage the bereaved individuals into that process. That being said, we might suggest that a bereaved person complete a “rubbing” of a cemetery marker or plaque to bring to the session as a means of sharing this experience with you. For clients who do not live in the same city as where their loved one is buried, or who have difficulties with transportation, a rubbing might be a good way for them to “visit” their loved one’s memorial when they wish to do so but are unable to travel to the site. Rubbings are made by placing tracing paper or thin paper over the marker and then “rubbing” a crayon, pastel stick, or chalk over the surface. The lettering and images of the marker are then transferred onto the paper. Pictures of the marker are often helpful as well, but the physical task of making the rubbing is often therapeutic for the bereaved individual. Sas and Coman (2016) identified three types of rituals, including rituals meant to honor the deceased, to let go of a deceased loved one, and to facilitate self-transformation after the death of a loved one. Ritual activities may include visiting the grave, displaying photographs of the deceased, showing photos and speaking about the loved one to others, taking up an interest the deceased enjoyed, writing letters to the loved one, watching a particular TV program that evokes memories, creating something, wearing or interacting with something that belonged to the deceased, attending a particular event because the loved one would have attended it or honoring the loved one by attending an event (such as a memorial tournament), creating a memorial of some kind, lighting a candle in honor of the deceased person on specific dates and times, creating a memorial trust in the name of the deceased person, and planting a tree or special plant in honor of a loved one (Lewis & Hoy, 2011). There are as many rituals possible as there are individuals on the Earth, and these are just the more common examples that we see in our practices. Keep in mind that rituals can also be used for losses that are not death related and for rites of passage, because the use of ritual provides a symbolic avenue for recognizing significance and to attach meaning to an event from which the individual may feel a loss of parts of himself or herself or of something that is highly significant, but not necessarily related to a death.

Symbolic Objects and Personal Belongings Grieving clients often use special items as a means of maintaining a connection with what they have lost. More than simple keepsakes, these items are often imbued with a great deal

190

II.  Practice and Process

of symbolic meaning to a person, relationship, situation, or a part of themselves. Symbolic objects in grief therapy serve the main function of representing the lost loved one or the relationship with the lost loved one. They also validate the relationship of the bereaved to the deceased, to facilitate remembrance, and to encourage feeling and expression of emotion. Symbolic objects also provide a focal point in which the self-representation of the bereaved merges with that of the dead person. Such objects represent the emotional value invested in the relationship and are used to manage the separation anxiety. Often intimate things that belonged to the deceased are cherished transitional objects that are readily available to the bereaved, to be seen and touched when the need for attachment arises. Often referred to as “linking objects,” clients frequently take items that they associate with their loved one and attach significance to them as reminders, or as a means of feeling connected to their deceased loved one (Harper, O’Connor, Dickson, & O’Carroll, 2011; Sas & Coman, 2016; Volkan, 1981; Practice Example 11.1). Common examples of these items are clothing, photographs, personal items (e.g., a pet’s collar, a child’s stuffed toy, a lock of hair), items associated with a place of significance, such as where someone died or was given the news, and letters and gifts that were from a significant person. These objects are often worn or carried by the bereaved individual throughout the day. One example of this type of object was shared by a mature client who wore a locket that her deceased husband had given to her before he died. She also confided that she had placed a very small pinch of his ashes in this same locket so that he was “always with her.” One client chose to wear his father’s shirts to events where he wanted to sense his father’s presence with him, choosing one of his father’s shirts when going to his first job interview after graduation from university. Clients will often wear jewelry that belonged to their loved one or have jewelry made that represents something that is significant to them. For example, one client whose mother died took her mother’s wedding ring to a jeweler and added her mother’s birthstone as well as the birthstones of her sister and herself to it, and wore it every day as a reminder of the love her mother gave to her family. Many clients will wear the deceased one’s clothing, use everyday objects that the deceased regularly used (like coffee mugs or pens), and keep specific objects on display that remind them poignantly of their deceased loved one, and this will often provide a sense of comfort and meaning for them.

P R A C T I C E EXAM PLE 1 1 . 1 USE OF LINKING OBJECTS

Vanessa’s husband died suddenly several months ago. As she was going through his belongings, she came across his glasses. She remembered him asking her to go to pick out new frames at the optical shop the month before he died. They had joked around with each other as he had tried them on. While this was a bittersweet memory for Vanessa, she felt close to him as she held the frames in her hands. She then decided to take the frames to her optician and had her prescription placed into them. She then wore the glasses every day, feeling that she was looking at the world through his eyes as well, which comforted her.



11.  The Clinician’s Toolbox

191

Although not an object, the rise in popularity of memorial tattoos has recently gained attention. Tattoos may serve many ritual purposes in grief. The act of choosing and getting a memorial tattoo can be therapeutic in that it affirms the desire for an ongoing connection to the person who died, which has the potential to facilitate a continuing bond with the deceased individual (Davidson, 2017). The pain involved in the tattoo act can have a therapeutic component as well, as the pain involved in the creation of the tattoo through the insertion of the needle into the skin is a match for the pain of the grief associated with the loss of a loved one (Cadell et al., 2018). Memorial tattoos often have pictures of the deceased, symbols that represent the deceased or the relationship shared between the bereaved and the deceased, or text that may include names, dates, and phrases that have special meaning to their relationship (Practice Example 11.2). It is often helpful to ask clients if they have any objects of connection that they find meaningful and, if so, to have them bring these objects to their sessions. It can be very powerful for the counselor to validate the existence and value of these objects with the client and can often lead to a deepening of the therapeutic alliance because the client explores the meaning of the object(s) with the counselor (Humphrey, 2009).

Perinatal/Reproductive Loss Mementos It is becoming more common for hospitals and health professionals to recognize the significance of the loss of an unborn child to the parents and family (Tseng, Hsu, Hsieh, & Cheng, 2018). Many clinics and emergency departments offer chaplain support services to women who miscarry or deliver a stillborn baby. These spiritual care providers may offer a blessing or say prayers for the baby and the family, and their presence highlights the recognition by others that a loss of significance has occurred (Kobler, Limbo, & Kavanaugh, 2007). Other

P R A C T I C E EXAM PLE 1 1 . 2 MEMORIAL TATTOOS AS ONGOING CONNEC TIONS TO THE DECEASED

Andrew was a minister for a large Episcopal church in his city. He was devastated when his son died after contracting an obscure infection after traveling to several African countries for charity work with local villages. Andrew’s grief was deep and paralyzing to the point that he was unable to work for many months and he sought assistance with a grief counselor. In counseling, Andrew shared his profound feelings of sadness, anger, and angst. He often brought in pictures of his son and of the two of them together. One day, Andrew came into his session and said he was feeling a “bit” better. He then rolled up his sleeve and showed his counselor a tattoo on his arm. It was a scripture verse that was special to him and his son. It also had the date and his son’s name underneath the verse. Andrew said that having a tattoo was not something that he would normally consider; however, he felt this was a way of acknowledging this special memory of his son, and it also assured him that his son would continue to be a part of him as he continued to live without his presence.

192

II.  Practice and Process

rituals that are now commonly used in this type of loss include taking footprints of the baby and placing them on a card or providing parents with a “memory box” that contains items that were related to their baby, such as any clothing used, baby bracelets, footprints or handprints, and photos taken (if possible). Many of my (D.L.H.) clients have brought these memory boxes into their sessions and painstakingly gone through each item with me, with the presence of something tangible providing a means to physically touch the same materials that were in contact with their baby, or that held significance for them. Another example of the use of ritual in reproductive loss comes from the work of a client who had gone through several years of unsuccessful infertility treatment. After one of her counseling sessions, she made a clay model of her uterus. She then formed several small balls of clay that represented each of the embryos that were transferred into her body during the various infertility procedures. She initially placed all of the “embryos” into the clay uterus, told them that she loved each of them, and then she took each of them out of the clay container, one by one, saying goodbye to the children that she would never bring into the physical world with her. She then buried each of these clay balls to symbolize her desire to recognize the significance of the loss of her children after these treatments were unsuccessful.

Letters, Journals, and Electronic Communication Several of our clients have written letters to their deceased loved ones, talking with them in ways that are similar to how they might interact with them if they were still alive. Often, writing letters helps the bereaved individual to feel connected to the deceased person, while processing the implications of their absence. In essence, the deceased person “hears” about the grieving process from the bereaved individual, who would most likely share this process verbally with the same person if she or he were still alive (Neimeyer & Alves, 2016). There are numerous websites that allow bereaved individuals to post online memorials and notes to their loved ones, including their pets. Several of our clients have stated that these online memorials are very comforting to them and that they have an added bonus of being readily available at all times of the day or night and do not require transportation or venturing into a public place when privacy is desired. More recently, electronic media are becoming a more common form of expression for bereaved individuals (Refslund Christensen & Gotved, 2015). Several clients have shared that they have created a memorial site for their loved one, often using the individual’s social media site to do so. Thus, a Facebook page that belonged to a deceased loved one may turn into a memorial page for that same person. A uniquely creative client established an email account for his deceased wife and wrote to her regularly, using this email account address. Intermittently, he would go into the account he had created for her and read what he had written and then reply back to his own email account what he thought his wife would say to him at various points in time in response to what he had shared.

Use of Ritual With Conflicted Relationships In relationships in which there has been ambivalence or negativity, rituals can still be useful to work through some of the unfinished business that remains after death. In addition to



11.  The Clinician’s Toolbox

193

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

WRITING AND NARRATIVE AS THERAPY Many current bereavement researchers and practitioners argue that meaning reconstruction is the central process involved in grief (Hibberd, 2013; Neimeyer, 2015). In this approach, human beings are seen as the “weavers of narratives that give thematic significance to the salient plot structure of their lives” (Neimeyer, 1999, p. 67). As discussed earlier, when a significant loss occurs, the assumptions that we have made about life can be dramatically shaken to the very core. When these assumptions are violated or shattered by the death of a loved one (or a significant loss event), our life narrative becomes fragmented and incoherent. Significant losses require individuals to rewrite the narrative of their lives in a way that allows for an explanation of what has occurred within a context of personal meaning and congruence with how they now see the world, others, and themselves. Thus, approaches that focus on the person’s life story and the loss that has occurred may assist in creating a new, more meaningful self-narrative that emerges from the loss experience itself (Neimeyer, 2012, 2015). There are several possibilities for assisting clients in telling their stories. As the story unfolds, you may begin to identify where the person’s self-narrative has become fragmented as a result of a shattered assumptive worldview. We briefly discuss a few of the strategies that may be of benefit in helping clients rewrite their life narrative in the context of grief counseling.

Clustering Clustering is a form of brainstorming that may be very useful for clients who feel very stuck or who need to sort through many different competing thoughts and feelings. First, ask the client to think of a central point or aspect of their experience. Write that word in the middle of a sheet of paper and circle it. Then, begin to brainstorm about all of the different tangents that may extend from that central point—draw lines from the central point to a word that

194

II.  Practice and Process

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

Saying no Awkward

Mom health

Saying yes Dating

Travel to visit

My family Alone

Holidays

Neighbors Are they ok?

Change school?

No sleep

Overwhelmed Stress

Children

My health

Money!

Blood pressure No energy Headaches

Tom's death

His parents Family issues

Feeling obligated

Maintenance Contractors

House

Hospital

Stay

Memories

Extra work

Leave

Afraid to go there

Dysfunctional dynamics Angry at MD

Letter?

FIGURE 11.1  Clustering. This example of a cluster was completed with a client after her husband died from a sudden illness 2 years ago. The main (central) oval in the page started with the death of her husband, then the most important issues that were on her mind as a result of losing her husband. She then went to each of these issues and explored each further with more clustering.



11.  The Clinician’s Toolbox

195

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

Use of Metaphor and Story Metaphors allow clients to capture the essence of an experience or feeling through the use of descriptive imagery and symbolism. One suggestion for the use of metaphor is to ask the client to think of his or her loss, grief, or present life situation in terms of an image or an object. For instance, one client described his current situation as feeling like he was in a car that was out of control without a driver, while he was strapped in so tightly with the seat belt in the backseat that he could not breathe. Descriptions such as this provide a rich source of material to explore with the client that can offer meanings on many different levels (Goldberg & Stephenson, 2016; Witztum, 2012). Another exercise that utilizes a similar method is the virtual dream story, which is a story told in figurative language (Exhibit 11.1; Neimeyer, Torres, & Smith, 2011). This exercise may help clients to work with core issues, while using the figurative language to allow some distance from the personal aspects of their experience that may be overwhelming or too intense to discuss directly. In this exercise, clients are assigned a set of six elements (e.g., settings, figures, objects) of the virtual dream and they are instructed to write a story that includes these elements, adjusting them to relate to their loss experience. For example, a client may be asked to write a story with a violent storm, an unearthly light, a dove, a strong man, a mask, and a closed door. After the client finishes writing, ask them to read the story out loud to you and then explore the various elements and their relevance to the client’s current situation. This exercise may take some time and a little bit of coaching, but it can be a powerful catalyst for exploration and meaning-making by the client.

Letter Writing There are many different forms and variations of this exercise. In its simplest form, clients may be asked to write a letter to the lost person (it may not be a loss from death only) to share their thoughts and feelings with that person. The letters typically focus on the expression of thoughts and feelings about the loss and the clients’ grief. If a letter is being written

196

II.  Practice and Process

EXHIBIT 11.1 VIRTUAL DREAM EXERCISE

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

Figures/Voices

Objects

A wasting illness A violent storm A troubled sea An early loss A long journey A secret room A cool book An unearthly light A precipice A cave

A wise woman A mysterious stranger A booming voice A choking sob An angel A dove A serpent A wrinkled elder An overheard song A strong man

A rose A burning fire An ancient chart An ambulance A mask An empty bed A closed door A coffin A naked sculpture A treasure box

Source: Adapted from Neimeyer, R. A., Torres, C., & Smith, D. A. (2011). The virtual dream: Rewriting stories of loss and grief. Death Studies, 35, 646–667. doi:10.1080/07481187.2011.570596

to someone who is still alive, it is important to emphasize that it is being written for the client’s purposes and not for the purposes of the other individual and that the letter should not be sent. Letter writing can become a very process-oriented exercise, with clients writing letters to themselves as they were in the past, perhaps forgiving themselves, or speaking with the voice of experience now to a younger and more naive version of themselves at an earlier time. Clients can write letters to their future selves as well, providing a way to work on past painful events or reminding their future selves about a time in their lives that they will remember forever. In some cases, a ritual to dispose of the letter—such as ripping it up, burning it, or burying it—may offer a sense of resolution to the client regarding issues that have been “hanging” in the client’s mind as unfinished or unresolved material (Humphrey, 2009). AfterTalk (www.aftertalk.com; Bogatin & Lynn, 2016) is an online website that fosters “conversations” with deceased loved ones through a secure aspect of the site entitled private conversations. There is also a section on the AfterTalk site where those who are grieving can “share” their conversations with others and invite their responses and contributions as well.

ENERGY-BASED THERAPIES (“POWER THERAPIES”) We include a brief section here to familiarize readers with energy-based modalities and how they have been used with bereaved individuals. Each of these techniques requires highly



11.  The Clinician’s Toolbox

197

specialized training and supervision, so you would not be able to incorporate them into your practice without first immersing yourself into the understanding and use of each under the direct supervision of certified trainers/practitioners. However, because these modalities are often mentioned in both the scholarly/clinical literature and in popular venues, we think it is a good idea for you to have a basic understanding of them and to know when they may be appropriate for clients in the event a referral to another practitioner might be considered, or a client brings these topics up for discussion with you. These therapies are sometimes referred to as “power therapies,” due to their ability to rapidly assist some clients who are paralyzed by traumatic images and material. Energy therapies do have their detractors. Many mainstream therapists and researchers cite inadequate theoretical grounding and lack of outcome evidence as problematic. The idea of energy in the body and the relationship between how energy in the body is distributed harkens back to traditional Chinese medicine (Chan & Fong, 2016). We have heard several clinicians who work with clients who have debilitating symptoms of trauma and complicated grief describe many benefits of these modalities with their clients, which is why we have included brief descriptions here.

Eye Movement Desensitization and Reprocessing Eye movement desensitization and reprocessing (EMDR) was initially introduced with a controlled study of Vietnam veterans and victims of sexual molestation. It was found that with the use of this procedure, clients could quickly desensitize traumatic memories and restructure irrational thoughts and negative self-assumptions and that there was a significant reduction in debilitating symptoms (Solomon & Shapiro, 1997). Solomon (2018) discusses the use of EMDR with bereaved individuals to assist them in processing and reframing highly disturbing and/or painful material that has been stored in association with their memories of the deceased individual. There is research that has demonstrated the efficacy of using EMDR with clients who are experiencing symptoms of trauma and intrusive grief symptoms (Hornsveld et al., 2010; Pearlman, Wortman, Feuer, Farber, & Rando, 2014). Cotter, Meysner, and Lee (2017) completed a study of bereaved individuals who struggled with intrusive images and memories related to their deceased loved one. In this study, EMDR and cognitive behavioral therapy were randomly assigned to participants. The results demonstrated that both therapies led to improvement; the EMDR participants described a markedly reduced experience of distressing, intrusive thoughts. EMDR is an eight-stage treatment method that involves elements of psychodynamic, interactional, and body-oriented therapies along with cognitive behavioral elements. It is thought that the multimodal approach of EMDR elicits an ability to process traumatic and distressing material at an accelerated pace. It is very important to recognize that EMDR training is an intensive process for counselors who are already very skilled clinicians. EMDR should not be attempted without completion of the training and demonstrated competence in the method under supervision. We offer this brief description as a possible consideration for referral in clients with whom talk therapy does not seem effective, or where talk therapy tends to heighten anxiety.

198

II.  Practice and Process

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

Emotional Freedom Technique The emotional freedom technique (EFT), developed by Craig (1995), takes TFT a step further by using a single comprehensive procedure, thus eliminating the need for a complicated diagnosis and specific treatment protocols. Supporters of EFT state that by tapping on all the meridian points, problems associated with the misdiagnosis of underlying emotional distress due to poor or ambiguous definitions are eliminated. During EFT, clients are instructed to focus on their problematic emotions while they tap different meridians on various parts of their bodies. It is thought that focusing on the distressing emotions while tapping is akin to imaginal exposure and distraction, respectively. EFT incorporates the same fundamental components as systematic desensitization and distraction. Therefore, a decrease in subjective units of distress ratings by group EFT may be due to a combination of exposure and distraction, rather than to the specific tapping locations. Since one of the main steps involved in complicated grief therapy is a form of exposure to distressing images and feelings, we would be interested in research that explores the use of EFT with complicated grief, as EFT also uses the mechanism of exposure to distress within the safe environment of therapy; however, we did not find any studies that specifically explored this topic.

USE OF PERSONALITY AND TEMPERAMENT INVENTORIES Although we do not usually recommend the use of measures and instruments as part of grief counseling practice, we often find that clients who embark upon a process of trying to sort themselves out might benefit from the self-exploration that can be facilitated by the completion of self-scoring personality/temperament questionnaires. We find it helpful, at times, to think of how clients process information and generally prefer to interact with them in ways



11.  The Clinician’s Toolbox

199

that are consistent with their needs and preferences. Most of the inventories that we discuss in this section are available as free online versions (we list the websites at the end of this chapter), allowing clients to complete them at home and to read about their results and absorb the information on their own before doing so with the counselor. In addition to assisting clients to develop a deeper awareness and understanding of themselves, working together on the material that has surfaced after the completion of these inventories can assist the counselor to choose language, imagery, and interactional style, and to offer therapeutic suggestions that might be more congruent with the client’s values, beliefs, and strengths. The Myers–Briggs Type Indicator (MBTI) was developed as a personality measure based upon Jung’s theory of psychological types (Myers, McCaulley, Quenk, & Hammer, 1998). The authors, Isabel Myers Briggs and her mother, Katharine Briggs, built upon Jung’s theory of personality types when they designed the measure. The MBTI sorts psychological differences/preferences into four opposite pairs, or dichotomies, with a result of 16 possible psychological types. None of these types are better or worse; however, Myers and Briggs theorized that individuals naturally prefer one overall combination of type differences (Myers et al., 1998). In the same way that writing with the left hand is hard work for a right hander, so people tend to find using their opposite psychological preferences more difficult. The MBTI is not a tool to assess psychiatric diagnoses or personality disorders; rather, it can be a tool to help individuals better understand themselves and how they perceive their world. It is broken down into four different indices that reflect individual preferences in these various areas. ■■

■■

■■

■■

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

If you look at these four areas, there are conclusions you might be able to make regarding a person who is grieving based upon that person’s type. People who are introverted may need some “down time” to process their grief. Extraverted individuals may find attending a support group with others who are sharing and interacting with them to be highly beneficial. People who tend to score higher on the thinking portion of the scale may have difficulty dealing with strong emotions that arise, or they may feel uncomfortable with others who express emotion. These individuals may also struggle with others who attempt to get them

200

II.  Practice and Process

to emote in order to “feel better.” Individuals who tend to be stronger in sensing scores may have difficulty if they did not get a chance to see the body after death, whereas highly intuitive individuals may be more prone to engaging in a deep quest for existential meaning after a significant loss. Individuals who tend to score higher on the judging portion of the scale tend to appreciate organization and routine; obviously, the disorganization and chaos that is often a part of grief has the potential to be especially distressing for them. These generalizations, of course, have to be checked with the person to make sure they are accurate. However, just thinking in terms of individual preferences and differences takes away the language of grieving in a “right” or “wrong” way and helps to identify both challenges and strengths. These differences may also be a source of stress for family members who are grieving differently because of differences in their personality types. The Keirsey Temperament Sorter (Keirsey, 1998) is very similar to the MBTI and may offer a more simplified way for clients to understand personality typology, and to see how knowing their preferences may assist them in finding their own unique path through their grief. Other inventories we have used that may be helpful in a client’s self-discovery include the True Colors characterization (Kalil, 1998) and the Enneagram of Personality (Riso, 1996).

MINDFULNESS-BASED INTERVENTIONS Although often associated with Buddhist thinking, mindfulness meditation does not require an individual to embrace Buddhist beliefs in order to practice mindful awareness. In therapeutic work, mindfulness practice incorporates elements into the client’s experience that may be of great benefit, including learning to cultivate an intentional focus on the moment-tomoment experience as it is in the here and now; detached observation of thoughts, feelings, and sensations; and nonjudgmental acceptance of one’s experience exactly as it is (Kumar, 2013; Stang, 2018). The mindfulness practice that has been adapted to psychological work in the West is also sometimes referred to as insight meditation, or Vipissana. Rather than teaching clients to shut out their experiences, thoughts, and feelings, the cultivation of mindful awareness allows clients to enter these experiences and states fully, but without being overwhelmed by them. Clients who engage in mindfulness practice often describe feeling that they are very in touch with their direct experiences, but that they no longer find these same experiences as distressing or distracting as they once were. Western therapies, such as Gestalt, psychodrama, and the Internal Family Systems (IFS) model (which is discussed in the next section), draw upon elements of mindfulness, bringing the client into a full awareness of the present experience in order to heal or work through experiences or issues from the past. There are numerous clinical applications for mindfulness practices. We have found Kumar’s book, Grieving Mindfully (2005), as well Stang’s book, Mindfulness and Grief (2018), to be good resources as well. The actual Mindfulness-Based Stress Reduction (MBSR) program was developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center. The MBSR training involves an 8-week introductory program, which includes both didactic training and daily meditation practice (Kabat-Zinn, 1990; Sagula & Rice, 2004). More specific to bereavement is the ATTEND model, which applies the principles of mindfulness to



11.  The Clinician’s Toolbox

201

bereavement therapy (Cacciatore & Flint, 2012). Our chapter on therapeutic presence incorporates many aspects of mindfulness practice, and you may want to revisit it to review the ideas presented for the counselor and adapt them for clients to explore. The advent of many new phone apps for mindfulness, imagery, and relaxation provides wonderful resources for clients to access in between sessions. The most common, basic techniques of mindful awareness used are the body scan technique and following the breath.

Body Scan Technique One of the first techniques learned and practiced in the MBSR program is the body scan. We have a tendency to neglect our body unless there is something wrong with it, which is unfortunate because what is called the “felt body sense”—awareness of body sensations, which are often quite subtle—can give us valuable insights into what is going on not just with our bodies, but with our whole being as well. The body scan is a practice of devoting moment-tomoment attention to our body just as it is. Typically, the body scan is performed lying down but can be practiced in any position. Clients are instructed to first direct broad, expansive attention to the body as a whole and then use very focused attention in a systematic fashion to various regions of the body, and then, once again, do an expansive awareness of the entire body. Through this process, they will often discover much about how the body feels, including its sensations, and their mental reactions to directing attention to various parts of the body. Clients are instructed to pay attention, without trying to fix or change anything, in order to become less critical of their body’s perceived imperfections and responses to the environment and to cultivate greater acceptance and appreciation for their bodies at that very moment (Ditto, Eclache, & Goldman, 2006; Kabat-Zinn, 1990).

Following the Breath In this practice, clients are asked to find a comfortable sitting position and to bring the attention to the sensation of breathing. They should breathe in and out deeply a couple of times, focusing on any spot in the body where the breathing is easy to notice and on which the mind feels comfortable focusing. This could be at the nose, at the chest, at the abdomen, or any spot at all. The client should stay with that spot, noticing how it feels as they breathe in and out. The client should not force the breath or bear down too heavily as they focus. Let the breath flow naturally and simply keep track of how it feels. Savor it, as if it were an exquisite sensation to prolong. Clients will often express that it is difficult to control their thoughts, that their minds wander a lot, and that they find it difficult to stay focused on their breathing. We let them know that this is normal and that if their mind wanders off, simply bring it back. We encourage them and tell them that if their mind wanders 100 times, simply bring it back 100 times. We emphasize being compassionate with themselves as they begin this process and to not be focused on whether they “did it” as much as the process of doing it and learning from it. Many people do have a hard time with their thoughts, and they may get discouraged. We are so used to our hyperactive minds that we barely notice the fact that they are usually churning with activity. So, we tell clients that when they first sit and try to focus, they may be caught off guard by all the activity. Some people find it helpful to use a little imagination

202

II.  Practice and Process

to help themselves meditate. For example, instead of counting or following their breath, they might prefer to imagine a peaceful scene, perhaps floating in a warm lagoon, until the noise inside their minds quiets down (Practice Example 11.3). Clients can experiment with different kinds of breathing. If taking long, deep breaths feels comfortable, they should stick with it. If it does not, they should change it to whatever rhythm feels soothing to the body. They can try short breathing, fast breathing, slow breathing, deep breathing, shallow breathing—whatever feels most comfortable to them at that time. One caution with shallow, fast breathing is that doing so in a prolonged way can heighten anxiety and make the client feel lightheaded, so you may wish to mention this concern before instructing clients about following their breath.

COMPASSION-FOCUSED THERAPY Compassion-focused therapy (CFT) is an integrated model of therapy that draws from social, developmental, evolutionary, and Buddhist psychology, as well as neuroscience. It also draws on many other therapeutic models that have developed interventions for specific types of mental health problems. CFT is founded in the traditions that seek to build a science of therapy that is based on research and understanding how our minds work, rather than being focused on a particular school, model, or process. Initially developed by Paul Gilbert (2009), CFT holds promise as a helpful modality in working with grieving clients. In CFT, compassion is defined as sensitivity to suffering in one’s self and others, with a commitment to try to alleviate and prevent that same suffering. CFT recognizes that compassion flows in three directions: compassion we can feel for another or others, compassion we can feel from others to ourselves, and compassion we can direct toward ourselves (self-compassion; Gilbert, 2014; Nelson, Hall, Anderson, Birtles, & Hemming, 2018). In CFT, clinicians work to normalize painful parts of the human experience by helping clients understand the way their minds work from an evolutionary perspective. Modern

P R A C T I C E EXAM PLE 1 1 . 3 INTRODUCING MINDFUL AWARENESS TO CLIENTS

Sameet was a new counselor who was working with refugee families in his community. Many of the people that came to his office suffered from trauma and grief after being forced to leave their homeland. Sameet was a regular meditation practitioner, and he wanted to use mindful awareness with some of his clients as a way to help them feel more grounded and calmer, but he was struggling with how to introduce the concepts to them. One day, as Sameet was eating his lunch outside by the bank of a river, he noticed the river flowing and realized that watching the river flow could foster a form of mindful awareness. He watched as a single leaf on the top of the water floated away. He also realized that while he was focused on the river, he could choose whether or not to get wet. The example worked well for him, and as he talked about this experience with his clients, they understood the concept readily.



11.  The Clinician’s Toolbox

203

neuroscience research has identified basic emotion systems that have developed throughout the course of human evolution. To make this research clinically useful, the developers of CFT have sorted human emotions into three distinct systems: the threat system, the drive system, and the soothing/safety system. The threat system is what is activated when we experience things like anger, fear, anxiety, disgust, and other emotions that generally invoke struggle. Because of the function these emotions served in our ancestors, these emotions trigger us to act; they urge us to either fight, flee, or freeze. Unfortunately, when our threat system is activated for a longer period of time, our ability to behave flexibly is diminished and we become stuck in a defensive and closed posture. The drive system helps us to get things done and to acquire things that are necessary for our survival; for example, motivating us to go to work, buy a house, find a partner, or accomplish necessary goals. Like the threat system, the drive system can be very activating and motivating and can powerfully focus our attention on what we are pursuing—which can be tricky when the blind pursuit of our goals could be potentially harmful to others or ourselves. The soothing system is different than the other two systems. In the absence of threats or goals to pursue, we are in a resting state in which we feel safe, peaceful, at ease, and content. This system is active when we are experiencing kindness, affection, and belonging among our fellow humans (Figure 11.2). The loss of a significant individual threatens our attachment system, placing us into a defensive and vulnerable place (the threat system). While this system is meant to protect us Three types of affect regulation system Driven, excited, vitality

Content, safe, connected

Incentive/resourcefocused

Non-wanting/ affiliative-focused

Wanting, pursuing, achieving, consuming

Safeness-kindness soothing

Activating

Safety Rest Affiliation with others Peace/contentment

Anger, anxiety, disgust

FIGURE 11.2  Emotion regulation systems as proposed in CFT. CFT, compassion-focused therapy. Source: Adapted from Gilbert, P. (2009). The Compassionate Mind, reprinted with permission from Little, Brown Book Group.

204

II.  Practice and Process

from harm and becomes activated to do just that, over a longer period of time it can prevent us from being able to be open to opportunities for healing, including sharing our pain and receiving support from others. It is thought that the counseling relationship might be able to provide a link to the grieving individual’s soothing system, opening the door for social connection that feels safe, and for healing the attachment wound that has been created by the loss of a loved one. Done skillfully, therapy can be utilized to help clients connect with their soothing system, providing them with the safety and security to help them to approach the emptiness left by the loss of their loved one and face the daunting process of grief that is now before them (which may in itself feel like a threat as well). The compassion aspect of CFT provides a means to acknowledge the presence of suffering—in ourselves and in others, and to seek ways to relieve that suffering in whatever means are available. Suffering and pain in grief are obviously related to the profound absence of presence that is felt when a loved one dies. However, they are also present in the ways that we navigate the grieving process. As discussed in Chapter 4, “The Social Context of Loss,” there are many negative social messages that create a sense of shame in grieving individuals for not being productive or “strong” enough, for being overly emotional, and for not “moving on” after a loss quickly enough. Internalized, these messages create a sense of shame and self-loathing, equating grief and all that accompanies it with weakness or somehow being less than what we should be. Enter compassion, which acknowledges the presence of suffering, and self-compassion, which acknowledges our own suffering and directs kindness to that suffering instead of shame. This form of compassionate approach can be liberating for bereaved individuals who are mired not only in their threat systems, but also in negative selfviews and shame that can be paralyzing. CFT is a relatively new form of therapy. There is currently a great deal of research that demonstrates the powerful healing potential of compassionate presence and intention. Examples of research centers that have emerged for the purpose of studying the role of compassion in many aspects of life include The Compassionate Mind Foundation in England, The Max Planck Institute for Human Cognition and Brain Sciences in Germany, The Schwartz Center for Compassionate Healthcare in Boston, Massachusetts, and The Center for Compassionate and Altruism Research at Stanford University’s School of Medicine. We look forward to further research and clinical applications of compassion to issues related to grief and loss.

THE IFS MODEL 1 The IFS model of therapy (Schwartz, 1995) is one in which treatment is based on an understanding that the personality exists as a system of parts to which compassionate curiosity may be brought in order to facilitate healing. The “parts” in this model may be understood to be autonomous aspects of the personality that have specific roles. Schwartz defines one of these parts as the “exile” or “protector.” The exiled parts hold extreme feelings and/or beliefs about themselves that may threaten to “blend” (i.e., overwhelm and define the system). When this occurs, an individual may identify solely as the blended part (e.g., “I am sad” or “I 1

 Submitted by Derek Scott, RSW.



11.  The Clinician’s Toolbox

205

am ashamed”). When these vulnerable parts get triggered, other parts jump up to distract us from them, and these reactive protective parts are termed “firefighters.” Common firefighter distractions might include using TV, sleep, alcohol, drugs, sex binging, food binging, rage, and so on to keep the system occupied until the agitating energy of the vulnerable parts is no longer as present. The other group of protectors in the system is referred to as “managers,” which seek to ensure that the vulnerable exiles do not get triggered. The managers do this by attempting to manage the outside world and/or other people. For example, in grief, the decision not to visit the gravesite is commonly manager led, that is, seeking to avoid the inevitable triggering of the parts that are holding the distressing affect. In addition to the parts of the personality system, we also have a Self, and the salient aspects of the Self in terms of the therapeutic work are curiosity, compassion, and calmness. It is Schwartz’s (1995) position that everyone has a Self and the work of the IFS therapist is to help the client’s Self to respond to the parts of the system that are holding distress. Once these parts are compassionately witnessed in terms of the burdensome feelings and/or beliefs they are holding, their burdens may be released and they may choose a new role in the system, bringing great relief to the bereaved and helping the system to return to balance. When working with grief, the IFS therapist will become sensitized to the typical burdens held by the cluster of parts connected to attachment and loss, which are typically parts that are holding depression, sadness, missing/yearning, protest (anger), guilt, powerlessness, and despair (Scott, 2016). Many of these parts hold burdens from unresolved losses in childhood, and they are activated by the present loss. Consequently, the feelings have the intensity of a child’s response, and the protective system becomes engaged to prevent the person from becoming overwhelmed. By attending to the typical managing protectors—honoring their strategies of postponing, displacing, replacing, minimizing, avoiding, somaticizing, numbing, and shaming (which is particularly prevalent in disenfranchised losses), and reassuring them that the client’s Self can hear the exiled pain without becoming overwhelmed—the protective parts of the system may then step aside and allow access to the burdened exiled parts. This model is nonpathologizing; every part is recognized for its beneficent intent for the system. Proponents find it to be an efficient, effective, and inherently respectful therapeutic modality. For more information and to witness a role play of working with complex grief, please see the web links and resources listed at the end of this chapter.

CREATIVE/NONVERBAL APPROACHES Sandtray Work Sandtray therapy (or “sandplay”) is a technique based on practical, creative work in a sandtray. Use of sand as a therapeutic method was originally developed by Dr. Margaret Lowenfeld in the 1920s (Lowenfeld, 1979). The current use of the sandtray with adults began with the work of Dora Kalff, a student of Carl Jung who later studied Lowenfeld’s sandtray technique. She recognized that the archetypal content and symbolic process involved in this medium could make it readily adaptable to Jungian theory, and she used the term “sandplay” therapy to distinguish it from Lowenfeld’s work (Kalff, 2004). Sandplay therapy is now used with both adults and children. There is an International Society for Sandplay Therapy and

206

II.  Practice and Process

another organization called the Sandplay Therapists of America, and there is an extensive training and supervision process for therapists to become qualified in the formal modality of sandplay therapy. Most clinicians who use sandplay therapy with adults still use figures as representational models of either intrapsychic processes or of metaphorical situations that are brought up in verbal (talk) therapy prior to the work in the tray. There are two different ways of using sandtrays that may serve as helpful adjuncts in working with bereaved individuals (Harris, 2012). Hands in the Sand

Sand itself has many connotations for individuals. In her book, Healing and Transformation in Sandplay, Ammann (1991) states that, “Sand is matter ground by the infinity of time. It makes one mindful of eternity. Sand is matter which has been transformed and has almost become liquid and spiritual” (p. 22). Sand in its dry form is almost like liquid. It is light and, when we touch it with our hands, it feels soft. In this type of sandtray work, clients are simply asked to immerse their hands in the sand and to work with the sand in whatever way comes to them. The exercise is nonverbal; clients are asked to focus on their hands, the sensations that their hands experience, and what they are feeling as they do the exercise. They are usually given about 5 minutes to work the sand with their hands. When a client’s hands enter the sand, deeper thoughts and feelings often come quickly to the surface. The tactile sensation of the sand may also remind someone of the desire to be touched and to gently touch someone else—something that may be missing after the loss of a loved one. For some, the act of immersing their hands in the sand or feeling it as they lightly touch the surface changes the tone of the session immediately, often intensifying it and focusing it completely on the client’s experience. The use of music during this time can help to foster the process of the client nonverbally. Music can be chosen by the client in advance, or the counselor can choose a piece that may fit the client’s situation or mood. At the end of the session, we “debrief ” the process, with the clients being able to integrate the affective and tactile experience with their own personal stories of loss. Another use of the “hands in the sand” approach is to help clients remain grounded when there has been a tendency to dissociate in the session or the client begins to feel overwhelmed by the material brought up in the session. Several of my (D.L.H.) clients instinctively now reach for the tray in my office and keep it in their laps while we are in the session, often working their hands in the sand while they are talking as a means of feeling “grounded” and more present during the session. This way of using the tray is similar to grounding methods that help clients to remind themselves that the story they are recounting is not happening in the present—methods such as rubbing their feet on the floor or naming objects in the room as a means to stay connected in the present when talking about traumatic material (Figure 11.3). The Tray as Metaphor

The other method for which I (D.L.H.) use the sandtray is similar to how sandplay therapists use the tray—by having a client place representational figures into the tray to better visualize a situation or to better describe it. This method has been very helpful when clients remain “stuck” on a particular issue or situation. However, the use of such representational figures



11.  The Clinician’s Toolbox

207

FIGURE 11.3  Hands in the sand—working the sand nonverbally with the hands. The client places the hands in the sand and works the sand as he or she feels drawn to do so, while the counselor remains silent and fully present to the client’s work. Evocative music is often used in this process. After 5 minutes, the client is gently asked to complete the work and the counselor asks the client to describe the thoughts and feelings that arose during this process.

involves training in the use of the tray for that purpose, so we suggest the use of representational objects that are natural and more symbolic in nature, such as rocks, leaves, pictures, or objects that may be brought in by the client. Clients may choose a particular rock, shell, piece of wood, feather, or other item from a bowl that is kept near the tray, and they usually explain why they chose a particular object to represent a certain person or situation. The tray may be seen as their life, their loss, their family, or whatever topic is the focus of that session (Figure 11.4).

FIGURE 11.4  The sandtray as a representation or metaphor. In the tray at left, the client used the four objects across the middle to represent the four seasons since her husband had died—the gray rock was winter, the silk flower was spring, the shell was summer, and the broken red leaf was fall. Below these four objects represented her life before her husband died—a shell with a deep purple interior, a pink quartz heart, a seed pod, and feathers. The objects at the top represented her life after her husband died—a dark piece of flat slate, a piece of wood that looked like a “woman who was crying,” and a broken piece of dried wood “which is what my life feels like now.” The client worked in this tray off and on for several sessions. The tray at right was done by a mother whose child had died in a car accident. She brought some of the cards that she had received from her daughter’s friends, a few dried flowers from the funeral, a candle, and a poem that was also written by one of her daughter’s friends. After working with the sand in the “hands in the sand” mode, she lifted her hands out of the sand and noticed that the pattern looked like a butterfly. She placed the items around the tray and took this picture when she was done. She described feeling that her daughter would like what she had done and that in doing the sandtray work, she felt closer to her daughter’s presence.

208

II.  Practice and Process

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

Photo Narrative Photo narrative is a method that invites clients to share aspects of their grief journey with you by taking photographs in between sessions and then talking with you about them in their sessions (Böök & Mykkänen, 2014; Kaplan, 2008; Marion & Crowder, 2013). Clients may choose to take photographs of literal, concrete things, such as a picture of their loved one’s favorite chair, or of their grave marker; they may also take pictures that have a more figurative, symbolic, or metaphorical aspect to them. The beauty in this process is that, like the sandtray work, clients are able to access grief in a nonverbal way, relying upon their senses and innate meanings that they find in their everyday lives. Most people own cell phones with cameras and, as a result, have ready access to the ability to take and share pictures in a spontaneous way. The prompt for this exercise might be something like, “Before your next session, take at least five pictures that describe your grief at this time.” The prompt can vary, depending upon the primary issue and concerns that the client raises, making the exercise flexible and relevant to the client’s work and process in the here and now. In the next session, ask clients to show you the pictures that they took, and ask them to describe what the pictures mean to them, how the pictures make them feel, and what the process was like. You may also wish to ask if they have shared the pictures with anyone else, and if so, what that was like for them (Practice Example 11.4). The use of photo narrative can be a way to “give voice” to feelings and experiences that are difficult for the client to discuss in regular talk therapy. They can also elicit deeper feelings and meanings that may have been implicit to the client in the past but can now become explicit and openly discussed in the context of the therapeutic relationship. In workshops, we often ask participants to do this exercise on their lunch break, or after the first day of a workshop if there are 2 days being planned, and then we provide time in the workshop for them to share with each other in small groups. Many participants have been surprised at how profound yet simple this exercise has been for them.

GROUP WORK Talking with others who have experienced loss can help clients to navigate their grief with supportive others who may uniquely understand what they are feeling. Grief support groups



11.  The Clinician’s Toolbox

209

P R A C T I C E EXAM PLE 1 1 . 4 USE OF PHOTO NARRATIVE IN GRIEF THERAPY

Jason came to student counseling center at the university several months after the death of his father. He was having difficulties concentrating and he could not sleep at night. In the first session, Jason struggled to talk about his father’s death and he also had difficulties describing his feelings. At one point, he looked up at the counselor and said, “I’m not very good at talking about this kind of thing.” At the end of the session, the counselor asked Jason to use his phone to take five pictures that described how he was feeling and to bring them to the next session. Jason came into the next session with the pictures on his phone. They were all pictures of dense fog. One showed a football field that was mostly obscured by the fog (Jason said that represented how he could not focus when he tried to attend his football practices). Another picture was fog that made the road in front of his car impossible to see (Jason said that was how he viewed his path in life now, unable to imagine what his future would be like). Each session, Jason was assigned to take pictures that represented different aspects of his grief, his relationship with his father, and his life. Jason found this way of engaging with the counselor to be very helpful, sharing that he had begun to show the pictures to his sister, who was deeply grieving as well. They began to share pictures that they had taken to represent their grief with each other.

offer acceptance, information, connection with others and an outlet for those who are a little further along their path to help others who are new to the grieving process. Many grief support groups are funded or provided as a public service for specific types of loss issues, and so they may provide an affordable option for clients who need additional support. Grief is often viewed as a wound of attachment—we lose someone to whom we have a significant attachment, and there is often a gaping hole and sense of emptiness that is left behind. Being able to share about these feelings with others who understand and empathize relieves some of the emptiness and may foster a sense of hope in clients who feel the despair of going through this process on their own. Grief support groups can decrease clients’ sense of isolation, help to normalize the grieving process and the significance of the loss that has been experienced, and provide opportunities for bereaved individuals to find ways to cope with the complexities associated with a significant loss (Feigelman & Feigelman, 2016). Online support groups are increasing in both availability and popularity and these groups may be a good resource for some clients, especially if transportation or child care responsibilities interfere with attendance at a regular face-to-face group (Hartig & Viola, 2016; Lynn & Rath, 2012). Most grief support groups function on a self-help model, but some are professionally facilitated by an individual who is a counselor or a professional helper. It is beyond the scope of this book to explore all the intricacies of grief support groups. We strongly suggest that you obtain a list of grief support group resources and referrals in your community for your clients,

210

II.  Practice and Process

so that you can make informed suggestions to clients who may benefit from being involved in a grief support group. Often there are groups for particular types of loss experiences, such as the loss of a child, a suicide survivors’ group, widow/widower groups, and groups for various ages, such as specialized children’s groups or groups for seniors. It is important to note that there are no guarantees regarding the quality of these groups and typically there is no form of accountability or monitoring of the Internet sites on a regular basis.

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

GLOSSARY Clustering  A form of therapeutic writing that calls for brainstorming and drawing to make connections between feelings and events in a concise manner. Internal Family Systems (IFS) model of therapy  Based on an understanding that the personality exists as a system of parts to which compassionate curiosity may be brought in order to facilitate healing. The “parts” in this model may be understood to be autonomous aspects of the personality that have specific roles. Linking objects  Items that individuals associate with their loved one and to which significance is attached; may serve as reminders or as a means of feeling connected to the deceased loved one. Metaphor  Literary figure of speech that uses an image, story, or tangible thing to represent a less tangible thing or some intangible quality or idea. Mindfulness practice  Includes learning to cultivate an intentional focus on the moment-to-moment experience as it is in the here and now; detached observation of thoughts, feelings, and sensations, and nonjudgmental acceptance of one’s experience exactly as it is. Narrative  The telling of one’s life story in a way that draws meaning and coherence into difficult events and circumstances. “Power therapies”  Therapies that rapidly assist clients who are paralyzed by traumatic images and material; refers to EMDR, TFT, and EFT. Ritual  Usually involves an action that is initiated on the part of the bereaved individual to give a symbolic expression to certain feelings or thoughts.

QUESTIONS AND ACTIVITIES FOR REFLECTION Complete one of the narrative exercises yourself. After you have completed the exercise, think about how you felt as you were doing it. If there is someone with whom you feel



11.  The Clinician’s Toolbox

211

comfortable sharing the exercise, talk about it with that person, and discuss between yourselves what it was like to complete the exercise that you chose. Was there anything surprising? What types of clients and contexts of counseling do you think might benefit from completing one of these exercises? As the counselor, how would you use these exercises with clients? 1. Awareness exercise2

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

This exercise is done with a partner. Find a quiet space without the possibility

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

After you complete this exercise, share with your partner what it was like to

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

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

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

Raisin exploration. Take a raisin and hold it in your hand. Begin by looking at

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

  Contributed by Derek Scott, RSW.

2

212

II.  Practice and Process

3. Video clips from YouTube and the IFS model

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



https://www.derekscott.co/videos/ifs-grief-and-loss/ (parts 1 and 2)



www.youtube.com/watch?v=qo_DebUQgmA



a. Can you identify the “parts” that arise during the sample session with a grieving client?



b. What did you like/dislike about how this model works with clients?



c. Can you think of some of your own managers, firefighters, and exiles? How do these interact within your own internal system?

4. Personality inventories and self-assessments

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



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



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



Enneagram: https://www.9types.com/rheti/index.php

REFERENCES Ammann, R. (1991). Healing and transformation in sandplay: Creative processes become visible. La Salle, IL: Open Court Publishing. Bogatin, L., & Lynn, L. (2016). AfterTalk. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Assessment and intervention (pp. 323–235). New York, NY: Routledge. Böök, M., & Mykkänen, J. (2014). Photo-narrative processes with children and young people. International Journal of Child, Youth and Family Studies, 5(4.1), 611–628. Cacciatore, J., & Flint, M. (2012). ATTEND: Toward a mindfulness-based bereavement care model. Death studies, 36(1), 61–82. Cadell, S., Lambert, M. R., Macdonald, M. E., Davidson, D., O’Gorman, M., & Baljko, M. (2018, December). "The pain of the tattoo was a relief ": Advancing a theory of embodied pain in a study of memorial tattoos. Journal of Pain and Symptom Management, 56(6), E31–E31/360. doi:10.1016/j. jpainsymman.2018.10.029 Callahan, R. J., & Callahan, J. (1997). Thought field therapy: Aiding the bereavement process. In C. R. Figley, B. E. Bride, & N. Mazza (Eds.), Death and trauma: The traumatology of grieving (pp. 249–266). New York, NY: Taylor & Francis.



11.  The Clinician’s Toolbox

213

Chan, C., & Fong, C. (2016). Meridian tapping. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Assessment and intervention (pp. 139–143). New York, NY: Routledge. Cotter, P., Meysner, L., & Lee, C. W. (2017). Participant experiences of eye movement desensitisation and reprocessing vs. cognitive behavioural therapy for grief: Similarities and differences. European Journal of Psychotraumatology, 8(Sup 6), 1375838. doi:10.1080/20008198.2017.1375838 Craig, G. (1995). Emotional freedom techniques: The manual. Sea Ranch, CA: Author. Davidson, D. (2017). Art embodied: Tattoos as memorials. Bereavement Care, 36(1), 33–40. doi:10.108 0/02682621.2017.1305055 Ditto, B., Eclache, M., & Goldman, N. (2006). Short-term autonomic and cardiovascular effects of mindfulness body scan meditation. Annals of Behavioral Medicine, 32(3), 227–234. doi:10.1207/ s15324796abm3203_9 Feigelman, B., & Feigelman, W. (2016). Co-facilitating bereavement support groups. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Assessment and intervention (pp. 303–305). New York, NY: Routledge. Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15(3), 199–208. doi:10.1192/apt.bp.107.005264 Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6–41. doi:10.1111/bjc.12043 Goldberg, R. M., & Stephenson, J. B. (2016). Staying with the metaphor: Applying reality therapy’s use of metaphors to grief counseling. Journal of Creativity in Mental Health, 11(1), 105–117. doi:10.1080/ 15401383.2015.1113396 Harper, M., O’Connor, R., Dickson, A., & O’Carroll, R. (2011). Mothers continuing bonds and ambivalence to personal mortality after the death of their child—An interpretative phenomenological analysis. Psychology, Health & Medicine, 16(2), 203–214. doi:10.1080/13548506.2010.532558 Harris, D. L. (2012). Hands in the sand. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Creative practices for counseling the bereaved (pp. 61–66). New York, NY: Routledge. Hartig, J., & Viola, J. (2016). Online grief support communities: Therapeutic benefits of membership. OMEGA-Journal of Death and Dying, 73(1), 29–41. doi:10.1177/0030222815575698 Hibberd, R. (2013). Meaning reconstruction in bereavement: Sense and significance. Death Studies, 37(7), 670–692. doi:10.1080/07481187.2012.692453 Hornsveld, H. K., Landwehr, F., Stein, W., Stomp, M. P., Smeets, M. A., & van den Hout, M. A. (2010). Emotionality of loss-related memories is reduced after recall plus eye movements but not after recall plus music or recall only. Journal of EMDR Practice and Research, 4(3), 106. doi:10.1891/19333196.4.3.106 Humphrey, K. (2009). Counseling strategies for loss and grief. Alexandria, VA: American Counseling Association. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Bantam. Kalff, D. (2004). Sandplay: A psychotherapeutic approach to the psyche. Cloverdale, CA: Temenos Press. Kalil, C. (1998). Follow your true colors to the work you love. Laguna Beach, CA: Author. Kaplan, I. (2008). Being "seen" being "heard": Engaging with students on the margins of education through participatory photography. In P. Thomson (Ed.), Doing visual research with children and young people (pp. 175–191). London and New York: Routledge. Keirsey, D. (1998). Please understand me II: Temperament, character, intelligence. Del Mar, CA: Prometheus Nemesis. Kobler, K., Limbo, R., & Kavanaugh, K. (2007). Moments: The use of ritual in prenatal and pediatric death. American Journal of Maternal Child Nursing 32(5), 288–295. doi:10.1097/01. nmc.0000287998.80005.79 Kumar, S. (2005). Grieving mindfully: A compassionate and spiritual guide to coping with loss. Oakland, CA: New Harbinger. Kumar, S. M. (2013). Mindfulness for prolonged grief: A guide to healing after loss when depression, anxiety, and anger won’t go away. Oakland, CA: New Harbinger. Lewis, L., & Hoy, W. G. (2011). Bereavement rituals and the creation of legacy. In R. Neimeyer, D. Harris, H. Winokuer, & G. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 315–323). New York, NY: Routledge.

214

II.  Practice and Process

Lowenfeld, M. (1979). The world technique. London, UK: Allen & Unwin. Lynn, C., & Rath, A. (2012). GriefNet: Creating and maintaining an Internet community. In C. Sofka & K. Gilbert (Eds.), Dying, death, and grief in an online universe: For counselors and educators (pp. 87–102). New York, NY: Springer Publishing Company. Marion, J. S., & Crowder, J. W. (2013). Visual research. A concise introduction to thinking visually. London, UK: Bloomsbury. Myers, I. B., McCaulley, M. H., Quenk, N. L., & Hammer, A. L. (1998). MBTI manual: A guide to the development and use of the Myers-Briggs Type Indicator (3rd ed.). Mountain View, CA: Consulting Psychologists Press. Neimeyer, R. A. (1999). Narrative strategies in grief therapy. Journal of Constructivist Psychology, 12, 65–85. doi:10.1080/107205399266226 Neimeyer, R. A. (Ed.). (2012). Techniques of grief therapy: Creative practices for counseling the bereaved. New York, NY: Routledge. Neimeyer, R. A. (2015). Meaning in bereavement. In R. E. Anderson (Ed.), World suffering and quality of life (pp. 115–124). New York, NY: Springer Publishing Company. Neimeyer, R. A. (Ed.). (2016). Techniques of grief therapy: Assessment and intervention. New York, NY: Routledge. Neimeyer, R. A. (Ed.). (2020). Techniques of grief therapy: Bereavement and beyond. New York, NY: Routledge. Neimeyer, R. A., & Alves, D. (2016). Seeking meaning in loss: An online narrative constructivist intervention for complicated grief. Grief Matters: The Australian Journal of Grief and Bereavement, 19(3), 68. Neimeyer, R. A., Torres, C., & Smith, D. A. (2011). The virtual dream: Rewriting stories of loss and grief. Death Studies, 35, 646–667. doi:10.1080/07481187.2011.570596 Nelson, J. R., Hall, B. S., Anderson, J. L., Birtles, C., & Hemming, L. (2018). Self-compassion as self-care: A simple and effective tool for counselor educators and counseling students. Journal of Creativity in Mental Health, 13(1), 121–133. doi:10.1080/15401383.2017.1328292 Norton, M. I., & Gino, F. (2014).Rituals alleviate grieving for loved ones, lovers, and lotteries. Journal of Experimental Psychology: General, 143(1), 266–272. doi:10.1037/a0031772 Pearlman, L. A., Wortman, C. B., Feuer, C. A., Farber, C. H., & Rando, T. A. (2014). Treating traumatic bereavement: A practitioner’s guide. New York, NY: Guilford Press. Refslund Christensen, D., & Gotved, S. (2015). Online memorial culture: An introduction. New Review of Hypermedia and Multimedia 21(1–2), 1–9. doi:10.1080/13614568.2015.988455 Riso, D. (1996). Personality types: Using the enneagram for self-discovery. New York, NY: Houghton Mifflin. Sagula, D., & Rice, K. G. (2004). The effectiveness of mindfulness training on the grieving process and emotional well-being of chronic pain patients. Journal of Clinical Psychology in Medical Settings, 11(4), 332–342. doi:10.1023/b:jocs.0000045353.78755.51 Sas, C., & Coman, A. (2016). Designing personal grief rituals: An analysis of symbolic objects and actions. Death Studies, 40(9), 558–569. doi:10.1080/07481187.2016.1188868 Schwartz, R. C. (1995). Internal family systems therapy. New York, NY: Guilford Press. Scott, D. P. (2016). Healing through internal compassion. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Assessment and intervention (pp. 186–189). New York, NY: Routledge. Solomon, R. M. (2018). EMDR treatment of grief and mourning. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 15(3), 173–186. Solomon, R. M., & Shapiro, F. (1997). Eye movement desensitization and reprocessing: A therapeutic tool for trauma and grief. In C. R. Figley, B. E. Bride, & N. Mazza (Eds.), Death and trauma: The traumatology of grieving (pp. 231–247). New York, NY: Taylor & Francis. Stang, H. (2018). Mindfulness and grief: With guided meditations to calm the mind and restore the spirit. New York, NY: Ryland Peters & Small. Tseng, Y. F., Hsu, M. T., Hsieh, Y. T., & Cheng, H. R. (2018). The meaning of rituals after a stillbirth: A qualitative study of mothers with a stillborn baby. Journal of Clinical Nursing, 27(5–6), 1134–1142. doi:10.1111/jocn.14142



11.  The Clinician’s Toolbox

215

Volkan, V. (1981). Linking objects and linking phenomena: A study of the forms, symptoms, metapsychology, and therapy of complicated mourning. New York, NY: International Universities Press. Witztum, E. (2012). Metaphorical reframing. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Creative practices for counseling the bereaved (pp. 172–174). New York, NY: Routledge. Worden, W. R. (2018). Grief counseling and grief therapy (5th ed.). New York, NY: Springer Publishing Company.

CHAPTER 

12

E THI CA L I S S UE S I N G R I E F C O UNS E L I N G P R AC T I C E

LEARNING OBJECTIVES 1. Explain why ethical practice is so important in the counseling relationship. 2. Describe why counselor self-awareness is so important in the counseling process. 3. Discuss the role of boundaries in the counseling relationship, and how the counseling relationship differs from other types of relationships. 4. Identify guidelines and procedures for protecting client confidentiality. 5. List general guidelines that are identified with counselor competence.

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

218

II.  Practice and Process

of professional standards and mores. To do so, the grief counselor must start from a position of personal integrity and responsibility and then be aware of and follow ethics codes, statutory regulations, and case law that pertain to their realm of practice. (p. 1) We form relationships with clients that are dynamic and that engage our personal feelings and reflections. Clients entrust us with their deepest feelings, thoughts, dreams, and fears, which then places them in a position of vulnerability with us. This concept of trust is essential for understanding the context of the therapeutic relationship. Inherent in that trust is the dynamic of a power differential, where the therapist has the power to betray or abuse the trust of a client, with serious implications for how that trust and power are handled. The training and perceived expertise of the counselor, and the willingness of the client to choose to be open to the process with the hopes of improvement, imbue the counselor with a great deal of power and authority, no matter how much the counselor may ascribe to an empowerment-based or egalitarian person-centered approach. Therapeutic relationships are unique because they exist for the benefit of the client. Many bereaved individuals are at a vulnerable place in their lives, and our adherence to ethical standards of practice ensures that this vulnerability will be respected and protected within the therapeutic relationship that is established. In this chapter, we explore some of the ethical issues that are pertinent to the counselor, the therapeutic relationship with clients, and the profession of grief counseling.

COUNSELOR ISSUES The Shadow Side of Counseling Many authors have written about what we would refer to as the “human” side of helping professionals and how these human aspects of the counselor can affect the therapeutic relationship and the counselor’s everyday decision-making and interactions with clients. Egan and Reese (2019) describe the “shadow" side of helping as, “All those things that often adversely (and sometimes constructively) affect the helping relationship, process, and outcomes, in substantive ways but that are not identified and explored by helper or client or even the profession itself ” (p. 40). These authors describe the most common flaws of counselors to be manifested in: (a) lack of knowledge of ethical practice standards, (b) being unaware of personal biases toward specific types of individuals that will have an impact on interactions with certain clients, (c) lack of reflection upon the therapeutic process and recognition of when there is a problem in the therapeutic alliance, (d) lack of self-awareness in thoughts and feelings about specific clients, (e) lack of transparency and disclosure about the helping process with clients, which keeps the counselor in an elevated status as one who possesses “secret knowledge” and promotes client dependency rather than independence, and (f) rigid adherence to a specific approach in counseling without a willingness to assess whether this approach is actually appropriate or effective with a client. Page (2002) describes the “shadow” of the counselor as those darker aspects of the counselor’s personality, role, and experiences that emerge in the context of working with clients that may potentially affect the client in a way that can be harmful.

12.  Ethical Issues in Grief Counseling Practice



219

Gamino and Ritter (2009) refer to the presence of “blind spots,” where the counselor can get in a hurry, skip an important step, make an erroneous assumption, overlook a conflict of interest, neglect to consider a consequence, or rationalize an action as good for the client when it is really the counselor’s own interests that are being served. (p. 3) These lapses in awareness can be the source of a great deal of harm to a client, and so we once again emphasize the importance of regular supervision and self-reflection for the counselor to protect the interests of the client. Pope and Vasquez (2016) cite many examples where breaches of the client’s trust may occur as a result of treating the therapeutic relationship too casually, or of not maintaining rigorous standards of ethical practice. These authors discuss common breaches in ethical practice because of lack of self-awareness, failure to recognize the influence and importance of the innate power differential in the therapeutic setting, lack of application of codes of ethics to client interactions, and failure of counselors to engage in ongoing professional development and training to maintain competency in practice (Practice Example 12.1). The influence and impact of the personal issues and needs of the counselor are discussed in more detail in Chapter 13, “Caregiver Issues for Grief Counselors.” However, it is important to keep in mind that most individuals who enter the profession of counseling typically enjoy being with people and wish to help others. As a result, there is often a very strong inherent desire to be liked by others, to be seen as helpful by clients, and to be respected by colleagues in the field. The shadow side of these good intentions is that if they are not placed in their proper perspective, they have the potential to lead to unhealthy and potentially damaging patterns, such as avoidance of difficult topics with clients, use of their work with clients to try to impress

P R A C T I C E EXAM PLE 1 2 . 1 THE IMPORTANCE OF COUNSELOR SELF-AWARENESS

Anna is a grief counselor. Her client Shaila came to counseling after her 6-year-old son died in a car accident. Her husband had been driving the car when the accident happened. Their marriage had been difficult prior to the accident, but since the death of their son, things became worse and they separated. Since that time, they have been involved in a fierce legal battle over the custody of their 8-year-old daughter. Unbeknown to Shaila, Anna and her husband separated 6 months ago and have been involved in court proceedings regarding custody of their children. As Shaila talks in one of her sessions, Anna begins to feel anxious and keyed up. She realizes that Shaila’s lawyer is the same one who is representing her husband in their custody issues. She knows the way this lawyer works and is triggered as Shaila continues to talk about the legal issues with her husband. At one point, Anna interrupts Shaila with advice and instructions about the legal process. Shaila did not seem to notice, but Anna is very aware that she needs to clear her own issues so that she doesn’t end up “doubling” onto Shaila’s situation again. After the session is over, Anna calls her supervisor and sets up an appointment to talk about what happened.

220

II.  Practice and Process

others, allowing perfectionistic tendencies and unrealistic expectations to drive the process and take over the needs of their clients, and setting up situations that could contribute to the misuse of the client–counselor relationship to fulfill unmet personal and social needs.

Counselor Self-Awareness In order to practice with competence, counselors must know themselves and be familiar with their own needs, feelings, thoughts, behaviors, and sensitivities. If you do not have this awareness of yourself, you will have difficulties separating out your personal needs and feelings from your client, which could result in harm to your client. Counselors who are not self-aware will not have an understanding of how they may influence clients in ways that are unhealthy or even potentially manipulative (Jackson & Slater, 2016; Page, 2002). Often, these counselors’ nonverbal responses to clients convey bias, judgment, or discomfort. They may avoid particular topics, or they may attempt to control the session in ways that prevent the client from exploring necessary topics or material, resulting in the client essentially being manipulated by the unconscious needs of the counselor. See Exhibit 12.1 for an overview of how counselor self-awareness or lack of awareness can affect the client.

ISSUES RELATED TO THE THERAPEUTIC RELATIONSHIP Boundaries The relationship between the counselor and the client is unique, although there are similarities to other types of relationships. Because of the unique boundaries and purpose of the counseling relationship, the process of counseling should be discussed with clients as you begin your initial sessions together. It is important for you to be transparent with your clients in regard to the therapeutic relationship. Clients need to understand how the process works, what the expectations are of them, what they can expect from you, and how the relationship parameters are defined. We cannot always assume that a client knows what the counseling process entails; therefore, it is important that it be explained and discussed as you begin your work together. The therapeutic relationship is very complex, and sometimes it is the relationship itself that forms some of the material of the counseling process (Yalom, 2009). Keep in mind that no matter what theory of therapy to which you ascribe or how many tools or interventions you use with clients, the therapeutic relationship itself is of paramount importance. Think of the things a client needs to know at the beginning and how you would explain the process to a client. Here are some possible examples of what might be helpful: “I believe deeply that you are the one who knows what is best for you.” “My role is to help you understand what you want more clearly.” “This is what you can expect from me . . .” (time, attention, availability). “What I would hope is that you . . .” (can try to be as open as possible, attend to yourself and your needs, let me know if something does not feel right as we work together, be honest with me about how you think things are going in our sessions).

12.  Ethical Issues in Grief Counseling Practice



221

EXHIBIT 12.1 COMPARISON OF COUNSELOR SELF-AWARENESS WITH LACK OF AWARENESS

Counselors With Self-Awareness

Counselors Without Self-Awareness

Recognize and identify when their feelings arise Are able to recognize when their personal feelings are triggered by the client’s story and/ or feelings

Avoid or are unaware of their feelings

Understand how their own personal values and experiences may have an impact upon the counseling relationship Are aware of their own self-talk, feelings, and areas of vulnerability Have the ability to attune to themselves as well as the client, adjusting their responses to ensure they place the client’s needs first Able to cultivate a sense of value and worth from personal practices and relationships Able to set healthy boundaries without feeling guilty or responsible for what is not their responsibility or within their ability to control Able to accept constructive feedback from peers, supervisors, and clients and modify approach as needed for the client’s best interests Aware of professional and personal strengths and limitations

React to client’s stories and feelings out of their own needs and inability to compartmentalize their personal feelings when sharing space with clients React emotionally to their clients, but do not understand why or how Unconsciously use clients to work out their own personal issues Unable to attune to both self and client; may be oblivious to client’s cues and responses to their engagement in the therapeutic relationship Need clients to affirm personal value/self-worth, skill, and/or competence Unable to set appropriate boundaries with ­clients; feel personally responsible for the client’s process and ashamed if client does not improve Become defensive, angry, or argumentative in response to constructive feedback

Blind to or tendency to distort professional and personal strengths and limitations

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

222

II.  Practice and Process

The therapeutic relationship differs from other relationships in regard to: ■■

■■

■■

■■

■■

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

Following are some comparisons between the counseling relationship and other types of relationships that the client may consider to be similar. Similarities and differences to a friendship or an intimate relationship: ■■

Clients may feel the counseling relationship is an intimate one because they share deeply of themselves with the counselor and often feel a sense of closeness with the counselor that they may not have experienced in their other relationships.

■■

The counseling relationship is one-sided, oriented toward the client’s needs, and not two-sided, as would be expected in an intimate relationship.

■■

Advice is given in friendships and intimate relationships, but not in the counseling relationship.

■■

The counselor’s personal issues and needs would be out in the open in a friendship or intimate relationship but shared in very limited amounts with a client for the purpose of therapeutic self-disclosure for the client’s interests and not the needs of the counselor.

■■

The therapeutic relationship involves expectations of confidentiality that are not explicit in a friendship or intimate relationship.

■■

The professional relationship has an ending—the goal of counseling is to end the relationship and for clients to be able to continue with their lives without the need for professional assistance, which is different from the goal of a friendship or intimate relationship.

Similarities and differences with a parent–child relationship: ■■

Similar in that the client is sometimes seeking guidance in the counseling setting.

■■

Different in terms of power and the goal of allowing the client to no longer need you are similar to a parent; however, in the counseling relationship, the counselor tries to equalize the power and give control over to the client.

■■

The unconditional positive regard of a counselor is similar to a parent’s love for a child.

12.  Ethical Issues in Grief Counseling Practice



223

■■

Differs in that there is no ongoing relationship after the client–counselor relationship ends.

■■

The feeling of safety is common in both relationships.

■■

The counselor often provides mirroring to a client in a similar way that a parent might; in so doing, client may be better able to see who they really are, especially in clients with very poor self-image and who have never had a chance to know themselves well.

■■

The client takes the lead in the counseling relationship; whereas in a parent–child relationship, the parent directs the child.

■■

We do not tell clients what to do and do not impose rules on clients as a parent might with a child.

■■

The goal of counseling is to help clients to parent themselves if there have been deficits or inadequate parenting in the client’s past.

■■

Although the counselor’s values are often explicitly stated in regard to the process, the counselor’s personal values are not imparted to the client in the way they are by parents, because the goal is for clients to become aware of their own values and to be able to respond in ways that are congruent with these values rather than those of the counselor.

Similarities and differences with teacher–student relationship: ■■

Imparting knowledge is often an aspect of both relationships.

■■

Modeling is a form of teaching, which can also occur in counseling.

■■

The client is not being judged or graded by the counselor as a student might by a teacher; you cannot do it “wrong.”

■■

In the counseling relationship, clients are the experts in their lives, not the counselor; whereas the teacher is seen as being the expert in a particular area that is being taught.

■■

In counseling, the topic is the client’s life and feelings, not an extraneous subject.

■■

Both relationships are structured and have boundaries that are different from friendships.

■■

Boundaries around the teacher–student relationship are probably not as rigid as those in a counselor–client relationship due to the greater vulnerability and personal involvement of the client in the latter relationship.

■■

The teacher–student relationship can lead to collegial relationships later on; however, the counselor–client relationship is a distinct relationship that will not evolve into another type of relationship after completion of the counseling sessions.

We think it is very important to think about how the counseling relationship can be confusing to some clients and to be prepared when clients misunderstand the boundaries and the unique structure of the counseling sessions. A client may not understand why you do not

224

II.  Practice and Process

accept an offer to attend a social function to which they invite you, or they may mistakenly believe that the intimacy of the counseling relationship indicates that your relationship is also one of friendship or another type of relationship. Because the counseling relationship involves a power differential, even if the counselor attempts to equalize the power, there is the potential for abuse of that power, with the potential for harm to the client. The role of a counselor is one that involves a sacred trust, with clients willingly sharing their deepest selves and most personal vulnerability. This vulnerability and openness must be protected and safeguarded by the counselor (Practice Example 12.2).

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

You ask me to share information with another professional, and you specify in writing what information is to be shared, to whom, and in what context.

■■

I, or my records, are subpoenaed by a court of law for court proceedings.

P R A C T I C E EXAM PLE 1 2 . 2 BOUNDARIES AND THE COUNSELING RELATIONSHIP

John comes to see William, a grief counselor, after the death of his 35-year-old daughter from suicide. After William has seen John for a couple of sessions, his wife comes home from work and talks about the death of one of the people in her office. His wife tells him that the young woman died by suicide and that her family is known to be very dysfunctional, and she discloses information about John that William did not know. As she is talking, William realizes that she is talking about John and that John’s daughter worked in his wife’s office. William did not tell his wife that John is his client. However, he now feels differently about John after hearing his wife talk about the family.

12.  Ethical Issues in Grief Counseling Practice



225

■■

If I have concerns for your safety or the immediate safety of another person that might involve life-threatening harm, I will have to share information about you for your protection or the protection of another person.

■■

If in the process of your sharing, I am given information that causes me to feel concern that a child under the age of 16 is in a situation where there may be abuse or neglect, I am required to report these concerns to the local child welfare authorities.

All jurisdictions in North America have legislation that requires counselors to report suspicions of child abuse and neglect to the appropriate authorities. We will also sometimes discuss how clients may wish to handle a scenario if they see us in a public place, offering that we would let the client decide whether he or she wishes to acknowledge us and/or introduce us to others in their presence. For example, the client may choose to introduce you as their friend rather than as a professional. Another aspect of confidentiality is the disclosure of supervision and how that is sought by the counselor. You do not need to identify the individual who functions as your clinical supervisor, but you may tell the client that you regularly seek supervision to discuss issues that occur in your practice where you feel it is best to obtain support, additional resources, and clinical recommendations. You should clarify that you do not share the client’s name or identifying information with your supervisor and that the supervisor is bound by the same constraints of confidentiality as you. Another important caveat to this discussion is the recognition that clients are not bound to the same adherence to confidentiality as the counselor. Thus, if you choose to self-disclose to a client because you believe this disclosure may be beneficial to the client in some way, be aware that the client is not bound to confidentiality with you. One additional aspect of confidentiality is the disclosure of how you keep your records, and who has access to these records/files. In most situations, you would be the only person who would have access to files, and they should be kept in a locked drawer or as a password-protected file if they are digital. However, if you work in a team in which other individuals have access to any information that you have written, or if you discuss client cases with other team members, then the client has a right to know that. Another place where confidentiality may become an issue is with phone and email contact. Clients should be asked whether they are comfortable with the counselor leaving a voice message for them if there is a need for contact or if they are returning a call made by a client, because not all clients disclose that they are seeing a counselor to other members of the household. In addition, if clients use email to contact the counselor, then the counselor must use a secure email address that is private and for which the counselor is the only one with the password to the email account. Once again, clients should be asked whether their e-mail address is private, and if they are comfortable with the counselor sending a reply back to that email account. In addition, some professional regulatory bodies require counselors to print off any electronic communication to include into the client’s file. If that is the case with your registration requirements, then clients need to be informed that their emails will become part of your documentation in their file. Finally, the setting where the counseling sessions occur must provide privacy and be soundproof so that others who are outside the room where you are meeting with the client cannot hear what is being said. Calls to clients should not be returned in an area where others may overhear

226

II.  Practice and Process

the conversations, and if there is any possibility that a client who is leaving your office may be familiar to another client in your waiting area, either provide an alternative exit for the client or adjust the scheduling of appointments so that these two clients will not be placed in an awkward position of undesired disclosure. If the phone used for your client work has call display that stores caller information, this information must be cleared before leaving your office each day. See Box 12.1 for a summary of confidentiality guidelines. Many clients will describe complicating issues in their lives and in their relationships, such as secrets that they have long held close, situations that cause them embarrassment, or things they have said or done that cause them to feel a great deal of pain or discomfort. It is vitally important that clients understand that you will not disclose these stories or situations to anyone else so that they will feel a sense of safety and trust in sharing such vulnerable material with you.

Dual Relationships A dual relationship is one that involves both a counseling relationship and another type of relationship (e.g., friendship, business relationship, supervisory capacity). Dual relationships have the potential to place the client at risk by imposing another set of values that may not be congruent with the therapeutic relationship and where the needs of the client may not be foremost, which is one of the primary definitions of a therapeutic relationship. The client may

BOX 12.1 CONFIDENTIALITY GUIDELINES ■■

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

■■

Be aware of relevant legal statutes that may limit confidentiality (such as child abuse reporting and necessity of disclosure in the event of potential imminent harm to the client or another individual)

■■

Be familiar with codes of ethics in your professional association and adhere to these guidelines

■■

Protect client records with secure filing systems and/or password protection on electronic files. Do not access phone messages or electronic messages in a place where they may be overheard or seen by others

■■

Seek regular supervision with a trusted colleague or mentor in a private and formalized setting. Do not discuss client situations or information with anyone in a social gathering or in a public place

■■

Ensure that the setting where you meet with clients is private and free from interruptions

■■

Disclose to clients if you are working as a team with other professionals, and in that context, specify who will have access to information about them and what they share with you

12.  Ethical Issues in Grief Counseling Practice



227

be placed in a position of compromise with self-disclosure, negating the core conditions of safety and nonjudgment in the counseling relationship. In dual relationships, the counselor has a personal interest that may not be consistent with the client’s interests. This alternative focus may lead to intended or unintended exploitation, harm, manipulation, or coercion of clients (Herlihy & Corey, 2015; Shebib, 2014). Many scholars and clinicians believe that some dual relationships are unavoidable, because of location (such as in a small community where interactions with others may be limited geographically), specialty, or happenstance. Instead of advising complete avoidance of dual relationships, Herlihy and Corey (2015) suggest that counselors learn how to manage their occurrence, especially when they are unavoidable. The terms multiple roles and nonprofessional interactions may also be used to describe these types of relationships and encounters. Although there are few specific guidelines in various codes of ethics in professional organizations and memberships, all agree that any form of sexual contact between a client and counselor is strictly prohibited and morally unethical, even after the client is no longer seeing the counselor for assistance. The most common form of dual relationship that we encounter is that a former client may choose to take a course in which we are instructors. Because the counseling relationship has revolved around a stance of nonjudgment and nonevaluation of the client’s material, the immediate issue of duality is that the counselor is now placed in a position of having to evaluate a former client’s learning and that the instructor knows very personal information about one student in the class that may place the client or the other members of the class at a disadvantage. In situations such as this, in which no other faculty member is teaching the same course, we often meet with the student and suggest that another faculty member read and mark the assignments for that student, and we discuss concerns about the dual relationship to see what types of accommodation should be made for the former client who is now a student (Practice Example 12.3).

P R A C T I C E EXAM PLE 1 2 . 3 MANAGING DUAL RELATIONSHIPS

Mariah is a grief counselor who teaches classes on grief and bereavement part time for a university-based social work program in her community. Mariah had just started teaching an online section of the course when she received an email from one of the mature students in her class. It turned out that this student was a grief counselor for a local hospice, and two of the other students in the class turned out to be her clients at the hospice. The course required considerable interaction and sharing through the online discussion boards, and this participation counted for a good portion of their grade for the course. The student felt compromised in being able to share openly on the discussion boards because of the client–classmates who would be reading her posts. She could not tell Mariah who the other students were because of confidentiality for their identities. Mariah spoke with her supervisor about the situation. They decided that the student who is the counselor would send her discussion postings directly to Mariah, and she would be relieved from either posting or reading the discussion boards for the course.

228

II.  Practice and Process

Another relational conflict may arise if a counselor is asked to see another member of the same family, where disclosure by one member may compromise the therapeutic relationship that is established with the other family member(s). Some counselors may adamantly refuse to see members of the same family individually, whereas others may agree to do so, as long as there is an understanding among the family members regarding the sharing of common information. This can be a very tricky scenario to navigate, because even if the issue seems to be clearly identified by all of the family members (such as the death of a family member), there are often secrets in families that are kept by members, and the counselor could be in a very difficult position of holding multiple confidences that are relevant to each of the clients that are being seen, without these individuals being aware of the counselor’s knowledge. This “insider knowledge” could compromise the counselor’s relationship with all the individuals involved. For further reading about the complexities of dual relationships within therapeutic encounters, we refer the following books to the readers: Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey, 2015) and Multiple Relationships in Psychotherapy and Counseling: Unavoidable, Common, and Mandatory Dual Relations in Therapy (Zur, 2017; Practice Example 12.4).

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

P R A C T I C E EXAM PLE 1 2 . 4 TRICKY SITUATIONS

Sierra was a grief counselor for a downtown counseling agency in her city. Her best friend, Margaret, had gone through a difficult divorce last year and Sierra had been her main source of support during this painful time. One day, Margaret called Sierra and told her that she had met someone through a professional workshop, and she wanted Sierra to meet him. They arranged for Sierra and her husband to meet them for dinner. When they arrived at the restaurant, Sierra was shocked—the person that Margaret had met was one of her former clients whose wife had died 2 years previously. She excused herself to the restroom to try to figure out what to say and do. She could not act like she did not know Margaret’s date, but she also could not disclose that she knew him or how. She was also very uncomfortable having a former client join her and her husband for an intimate dinner together.



12.  Ethical Issues in Grief Counseling Practice

229

(CCPA), and it provides general guidelines for working with competence (CASW, 2015; CCPA, 2014; Shebib, 2014): 1. Counselors should offer services that are within the limits of their professional

competence, according to their level of education, training, and professional standards. Competent counselors know that the support and assistance of other professionals are necessary for issues that exceed their expertise and training.

2. Counselors should monitor their work and seek supervision, training, or consulta-

tion in order to evaluate their effectiveness. Continued professional development should be pursued in order to increase competence and to remain current with best practices, research, and literature in the field.

3. Counselors should not work in specialized areas of practice without proper train-

ing and acquisition of the specialized body of knowledge for that area.

4. Counselors should seek to base their work and practice on accepted theory and

empirical knowledge (see the discussion following).

5. When access to other professionals is limited or unavailable, such as in rural

settings or in centers where there are long waiting lists, the substitution of other services that are not equal in comparison to access to a professional in a formal setting is not a viable or sound practice.

6. Counselors need to know when particular topics or problems are sensitive or deli-

cate for themselves. They need to be aware of when their clients’ problems are similar to sensitive or difficult areas in their own lives. This knowledge is of paramount importance for counselors to know when to seek consultation or supervision, when to refer clients to another counselor, and when to enter counseling to address their own needs. Clients have a right to expect that their counselor’s judgment and abilities to work with them will not be impaired by unresolved personal problems or issues.

Issues that may interfere with counselors adhering to these guidelines could include lack of time or lack of available programs to engage in professional development that would enable the counselor to remain current in best practices, heavy caseloads that do not provide an opportunity to reflect upon counselor–client interactions and to have regular access to supervision and consultation, and inadequate training or preparation to work with a specific client or clientele. In many of the previous chapters, we discussed newer ways of thinking about grief and bereavement, based on current literature and research. In her review of counselor practices, Breen (2010–2011) found that the majority of the grief counselors that she interviewed based their practices on theories and research that were outdated and no longer considered relevant to the profession. Indeed, in the last 5 years alone, the amount of research and discussion on the topical areas of complicated grief, when grief counseling is appropriate, and the diversity of grief responses has dramatically changed what would have been considered sound and competent practice in the specialized area of grief counseling in the past. Although we think it is probably not feasible to always be able to provide evidence-based practice in a field in

230

II.  Practice and Process

which many of the constructs involved are not concrete and readily measured/operationalized, it is unethical to continue to practice with clients in a way that may have been cautioned as potentially harmful in current research that has been reported with this clientele. The only way to know how to identify when clients need additional resources and whether your work with clients is truly from a place of best practices is to remain current in the field, within both the domains of counseling practice and bereavement research and theory.

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

GLOSSARY Boundaries  Limits or guidelines that define the counseling relationship and denote the limits of acceptability in the therapeutic relationship. They outline the expectations in the therapeutic space and mark the point beyond which neither party is expected to go. Competence in counseling  Includes accurate representation regarding the limits of scope of practice, involvement in ongoing and continuing education in the field, maintenance of accurate knowledge and expertise in practice, and the ability to address personal issues that could potentially hinder effectiveness. Confidentiality  The ethical principle or legal right that a physician or other health professional will hold secret all information relating to a patient, unless the client gives consent permitting disclosure; confidentiality can be broken in a number of circumstances, including: consent/request from the client, if the information is already in the public domain, when referring to another professional (with the client’s consent), when the interest to protect another outweighs confidentiality, prevention of terrorism, instruction by a court, or during supervision. Dual relationship  One that involves both a counseling relationship and another type of relationship (e.g., friendship, business relationship, supervisory capacity). Sometimes also referred to as multiple relationships/encounters and nonprofessional interactions. In small communities, encounters such as this may be inevitable and will need to be negotiated carefully.

QUESTIONS FOR REFLECTION 1. Joanne, a client who comes to talk with you after the loss of her husband from a

traumatic accident, discloses in her first session with you that not just her husband

12.  Ethical Issues in Grief Counseling Practice



231

died from a very tragic incident, but his best friend, Steve, also died in this incident. When she tells you his best friend’s name, you recognize that Steve was a client of yours in the previous year, and you did not know he had died. Joanne then proceeds to tell you that she knew that you had seen Steve for counseling and that he spoke of you often to her husband. She then begins to ask you questions about Steve and details regarding his life and his relationship to her husband. How would you respond to this scenario? 2. You have been seeing Carol for about 6 months to help her as she grieves the loss

of her son 2 years ago. Carol has good supports in place, and she is feeling better, although she still feels deep grief frequently. She tells you that she thinks she is ready to finish her sessions with you. You review your time together and Carol shares that your assistance has been invaluable to her being able to get through this time, but she also says that she will miss the ability to keep in touch with you, and she asks whether you could meet her for coffee sometime to catch up. How would you respond?

3. Think of the following personal needs that many people who are counselors have.

As a counselor, look at each of these needs and think of how each could be potentially harmful to your clients: a. Need to be liked and to be helpful b. Need for status, prestige, or recognition from others c. Need for control d. Perfectionism e. Need for relationships/need for connection with others

4. Use the ethical guidelines that were posted in this chapter to discuss the following

situations:

a. A client who has been seeing you after the death of his wife asks you to talk to his adult daughter when he begins dating someone. b. You have just had a very difficult session with a client who is very depressed and angry. He directs some of his anger at you, saying that you really do not care about him and that you just see him because you are being paid to do so. After the session, you go into the lunchroom of the counseling center where you work. One of your colleagues is eating her lunch and when she sees you, says, “Wow, you look awful. What just happened in there?” How should you respond? c. Your client asks whether you are in a relationship. d. You are invited by a friend to a dinner party. When you arrive, you are introduced to the other guests, including a woman who is your client. How would you handle this situation? e. As your last client of the day leaves your office, it begins to pour rain and thunder. You know that she does not have a car and that she will be walking

232

II.  Practice and Process

for blocks in the pouring rain to get to the bus stop. She asks whether you could give her a ride to the bus stop. How would you respond? f. Your client shares a very moving story about her relationship with her deceased son. She is crying as she tells you this story, and you realize that you have tears spilling onto your cheeks as you listen. 5. The following questions are to help you to explore your values, beliefs, and sensi-

tivities. You may want to work with a small group to discuss your answers to these questions. a. Do you think people are basically good or bad? b. What do you think motivates most people? c. Should people have the right to take their own lives? d. What kinds of clients would you like to work with the most (include information about age, gender, personality type, culture, religion, ethnic background)? e. What kinds of people do you find most problematic for you personally? f. When you die, how would you most like to be remembered? g. Are some religions better than others? h. Should counselors discuss their personal religious beliefs with clients? i. Do you often feel responsible for the feelings, thoughts, or behavior of others? j.

Imagine that you are a client. What would your counselor need to know about you in order to work effectively with you?

6. Write a two-page summary that answers the question, “Who am I?” 7. Write a summary of your personal philosophy of counseling practice.

REFERENCES Breen, L. J. (2010–2011). Professionals’ experience of grief counseling: Implications for bridging the gap between research and practice. Omega, 62(3), 285–303. doi:10.2190/OM.62.3.e Canadian Association of Social Workers. (2015). Code of ethics. Retrieved from https://www.casw-acts .ca/sites/default/files/attachements/casw_code_of_ethics.pdf Canadian Counselling and Psychotherapy Association. (2014). Code of ethics. Retrieved from https:// www.ccpa-accp.ca/wp-content/uploads/2014/10/CodeofEthics_en.pdf Egan, G., & Reese, R (2019). The skilled helper: A problem-management and opportunity-development approach to helping (11th ed.). Boston, MA: Cengage. Gamino, L. A., & Ritter, R. H. (2009). Ethical practice in grief counseling. New York, NY: Springer Publishing Company. Herlihy, B., & Corey, G. (2015). Boundary issues in counseling: Multiple roles and responsibilities. New York, NY: Wiley. Jackson, M. A., & Slater, S. (2016). 28 Hidden biases in counseling women: Balancing work and family concerns. In M. Kapala & M. Keitel (Eds.), Handbook of counseling women (2nd ed., pp. 340–351). Thousand Oaks, CA: Sage. Page, S. (2002). The shadow and the counselor: Working with the darker aspects of the person, role and profession. New York, NY: Routledge.



12.  Ethical Issues in Grief Counseling Practice

233

Pope, K. S., & Vasquez, M. J. T. (2016). Ethics in psychotherapy and counseling: A practical guide (5th ed.). Hoboken, NJ: Wiley. Shebib, B. (2014). Choices: Interviewing and counselling skills for Canadians (5th ed.). Toronto, Canada: Prentice-Hall. Yalom, I. R. (2009). The gift of therapy: An open letter to a new generation of therapists and their patients. New York, NY: Harper Collins. Zur, O. (Ed.). (2017). Multiple relationships in psychotherapy and counseling: Unavoidable, common, and mandatory dual relations in therapy. New York, NY: Taylor & Francis.

PART III CURRENT ISSUES AND TRENDS

CHAPTER 

13

C A REG I V E R I S S UE S F O R GRI EF  C OUN S E LOR S

LEARNING OBJECTIVES 1. Identify three different sources of occupational stress in helping professions. 2. Explain how the counselor’s personal experiences of loss can be both a strength and a potential liability in working with bereaved clients. 3. Distinguish between the experiences of burnout and secondary traumatic stress in helping professionals. 4. Identify guidelines for reflective practice and self-care strategies in grief counselors. 5. Define what is meant by self-compassion for counselors and identify three components of self-compassion.

INTRODUCTION Every form of helping and caring is accompanied by its own unique emotional burden. For counselors, not only is caring a motivation and a desire, but it is also a requirement in order to work effectively with clients. In essence, a counselor’s livelihood is dependent upon the ability to profoundly engage with this capacity for caring and empathy without losing these abilities along the way. Grief counselors are especially prone to the accumulation of occupational stress with the subsequent loss of their caring capacity as they repeatedly witness people’s deep pain and despair, are exposed to their clients’ traumatic images and material,

238

III.  Current Issues and Trends

and are often thrust into their clients’ intense emotional states. An additional drawback to the counseling profession is isolation. Even though they may be seeing clients all day, there is often a sense of seclusion that counselors describe in their work, as contact with other clinicians and colleagues is often limited by differing work schedules and the fact that most of the work occurs behind a closed door in private with their clients. To many counselors, the “work” of counseling is a natural extension of who they are. In addition to typically being highly empathetic and caring, most grief counselors identify at a deep level with the choice to work in this field. People who are drawn to this field are well acquainted with personal experiences of loss and pain; their desire to do this type of work is often an outgrowth of these experiences. Thus, it may be impossible to separate the person who is the grief counselor from the profession of grief counseling. This unique blending of who you are with what you do can be incredibly rewarding. However, it can also have unique drawbacks, as being so highly identified with your work can lead to difficulties with boundaries, a strong need to be valued in your work in order to feel validated as a person, and difficulties with balance in other areas of life. Implicit in this statement is that some counselors will attach great value to their caring role, and when this role is impaired by stress or when there is frustration with one’s work environment, significant damage can occur to the counselor’s assumptive world.

SOURCES OF OCCUPATIONAL STRESS Osipow, Doty, and Spokane (1985) describe three different dimensions of occupational stress in individuals who work in helping professions: 1. Internal stressors, including internalized attitudes toward work and how problems

are perceived and interpreted by the individual.

2. External stressors, which include the individual’s experience of stress in the work

environment itself.

3. Coping resources available to counter the effects of the occupational stresses, and

the individual’s ability to draw upon these inner resources at various times.

Internal Stressors Stresses that come from internalized sources may be the most difficult to identify, because they are often not readily apparent, are typically not seen as problematic by the person, and counselors may not necessarily be aware of their presence and influence upon their choices and experiences. Some of the more common internal stressors for counselors include having unrealistic expectations of themselves, or a need for this type of work to provide completion of unfinished business from the past. In grief counseling especially, a history of significant losses and a high degree of emotional investment in clients coupled with feelings of powerlessness and lack of control in regard to life events can take a big toll over time. Caregivers may also struggle with self-induced stress, which can include tendencies toward perfectionism, fear of failure, and the need for approval. Counselors’ needs for success and approval



13.  Caregiver Issues for Grief Counselors

239

in the client setting may interfere with their ability to be totally present and attentive to the needs of their clients. These unmet needs are often manifest in difficulties with boundaries in working with clients. Signs that the counselor’s needs are driving the process rather than the client’s needs may include some of the following examples: ■■

Excessive self-disclosure on the part of the counselor, including detailed discussions of the counselor’s personal problems or aspects of intimate life.

■■

Beliefs in the indispensability of the counselor to the client that are perpetuated by the counselor.

■■

Encouraging personal communication and dependence by the client upon the counselor, including the counselor giving out personal information.

■■

Repeated or lengthy calls to clients outside of the session times.

■■

Giving preferential treatment to a client to the detriment of others.

■■

Buying gifts or accepting gifts from clients that are more than token or symbolic gestures.

■■

Lending money or personal belongings to clients.

■■

Flirtatious behavior with a client or a member of the client’s family.

■■

Failure to seek supervision when a boundary has been crossed or is being “skirted” by the counselor (Egan & Reese, 2019; Herlihy & Corey, 2014; Wogrin, 2013).

It is these often unspoken but very real issues that can cause counselors to alienate themselves from others, which then means they do not receive the needed peer support or supervision to ensure that they do not inadvertently allow their needs to usurp those of the client. Herman (1997) refers to the problem of unrealistic expectations in counselors as narcissistic snares. The most common “snare” includes the counselor’s aspiration and expectation to heal all, to know all, and to love all. The author also discusses the concept of traumatic countertransference, in which the counselor can become overwhelmed by bearing witness to the client’s intense emotional experiences. She states that any person who thinks they can work with people who have undergone traumatic experiences without having a good support system and time for personal care is setting up an unsustainable scenario for doing this type of work over the long term. Counselor self-awareness is a key component of the work of grief counseling. In fact, we think self-awareness and self-care are professional competencies that good counselors must cultivate and practice on a regular basis. Think about why you wanted to do this type of work. What draws you to this field? We mentioned earlier that the field of grief counseling often tends to attract people who have experienced significant losses in their own lives. Working through such experiences can enable you to enter into practice as the wounded healer, which can be a very powerful and effective place from which to work with the bereaved (Nouwen, 1996). However, it is important for counseling professionals to have examined the impact of these wounds and to experience a sense of healing from them before attempting to engage with another person’s rawness and open wounds. We have all known individuals who mean well and who truly wish to help others in this field, but who would be more aptly described

240

III.  Current Issues and Trends

“Wounded Healer” (loss experiences deepen empathy and resilience)

“Walking Wounded” (loss experiences are still raw and will seek attending)

“Damaged Goods” (loss experiences are felt as shameful and a sign of weakness)

FIGURE 13.1  Differentiating how personal loss experiences may affect counselors.

as the walking wounded, because their wounds are still readily apparent and need tending. Others, who take on the identity of being damaged goods as a result of their wounds, may continue to need others’ validation to feel better about themselves because of the overlay of shame onto their experience(s). If these latter scenarios are actively engaged for a counselor, there is the potential to bring harm upon clients, because it would be impossible to completely focus on the client’s issues and experiences when wounds such as these in the counselor are still glaring and prominent (Figure 13.1). Worden (2018) states that working with bereaved individuals may affect counselors by (a) making them more aware of their losses, (b) causing them to be more “tuned in” to losses that they might fear (such as losing a child), and (c) heightening awareness of their personal mortality and existential anxiety. When working so closely with clients who are dealing with significant loss experiences, it is important for counselors to be very aware of their own loss history and to be able to identify any topics that may present an especially difficult challenge due to personal experiences or vulnerabilities. This personal inventory should also include whether or not the counselor can be fully present to the feelings of powerlessness, helplessness, and frustration that can arise in working with bereaved individuals. In this field, you will encounter situations that seem to lack sense or reason. You will be exposed to a great deal of suffering that defies alleviation. And any notions of fairness, justice, and order will be repeatedly challenged in deep and often troubling ways. As we highlighted in an earlier chapter: You cannot take away the pain, you cannot bring back the loved one who died, and you cannot change what has happened. Counselors can be triggered into their personal pain when they witness deep pain in their bereaved clients, and this discomfort can cause them to shut down emotionally, or worse, attempt to shut the client down to stop this discomfort



13.  Caregiver Issues for Grief Counselors

241

(Worden, 2018). Both Worden (2018) and Wogrin (2013) suggest that counselors complete a personal loss history (Exhibit 13.1) and that they share this history with a friend, colleague, or supervisor to ensure that there are no “lurking shadows” that may impede their ability to work effectively with bereaved clients.

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

EXHIBIT 13.1 ELEMENTS OF A PERSONAL LOSS HISTORY

Ask yourself the following questions. Then take the time to review your responses with a trusted friend or colleague. Think about the ways that these losses and your responses to them might affect your interactions with bereaved clients, or clients who are struggling with loss issues. 1. Complete a loss line of all the losses that you have had in your life (death and nondeath

related). 2. What are the most significant losses that you have experienced? How are these losses more significant to you? 3. How did you react to these losses? Do you tend to have similar reactions to loss

experiences? 4. How did the people around you react to these losses and to you during these times? 5. What have you learned about death, grief, and life from your experiences? 6. What are your religious or spiritual beliefs about death? About life events? 7. What are your cultural beliefs and assumptions about the expressions of grief, especially in

regard to feelings and social obligations? 8. Based upon your own experiences, what do you believe people typically need from others as

they attempt to cope with grief and loss?

242

III.  Current Issues and Trends

Vachon (2014) found that contrary to what had been expected, directly working with terminally ill patients and families did not cause the majority of the stress that the staff reported. Instead, the main sources of stress for caregivers were unrealistic workloads, low consideration of the input of caregivers in decision-making, and little time for staff to offer support to each other. Previously, Vachon (1987, 2004) noted that much of the stress experienced by caregivers who worked with this population was related to their work environments and what they felt were unrealistic expectations by supervisors and administration, rather than their work with individuals and family members who were terminally ill or bereaved. Working environments that create a sense of depersonalization, demoralization, and moral distress can deeply challenge the assumptive world of those who practice in such an atmosphere. In essence, work situations in which there are unrealistic demands and expectations such as these can lead counselors to question the reasons why they entered this profession, whether the work they do really has any meaning or purpose, and whether or not they really do help others. It is almost impossible to be person centered in your counseling practice if you, the counselor, are being objectified in the environment where you practice.

Coping and Internal Resources The concept of coping implies some attempt at adaptation, either by the reappraisal of stressful or negative experiences in some way, or by reintroducing aspects of benevolence, meaning, and self-worth into situations that may otherwise challenge the existence of these values. Coping can be viewed as a process of attempting to deal with challenges to one’s assumptive world in situations that are perceived by the individual as stressful or even threatening. It is important to note that coping strategies may or may not be successful. Perhaps, the most important point to make about coping strategies in stressful work environments is the ability of the counselor to (a) identify the source of the stress, (b) explore if there is anything that can be done to either eliminate the stress or to change one’s relationship to the stress, and (c) to know when a situation has reached a “critical mass,” where ongoing attempts to grapple with a situation that is draining precious internal resources will eventually deplete the counselor of the ability to work competently and with a sense of integrity. The ability to clarify how to respond to a stressful work environment requires the counselor to be comfortable recognizing when personal limits can be pushed and expanded, yet to also be realistic in regard to personal limits that should not be compromised. The difficulty here is that the longer you are exposed to ongoing stress and pressure in a situation, the more exhaustion you will experience, and this exhaustion can have a profound impact on your ability to decide how you need to respond to the ongoing and significant stress in the work environment. Thus, a vicious cycle can be set up where you are chronically exposed to stress, and you become so depleted that you lose your ability to see yourself and the situation clearly, lessening your ability to know how to respond in a way that is congruent with your original intentions and values. Losing yourself in this way only adds more suffering to a stressful situation; thus, it is important to know yourself, to be able to discuss issues and concerns with colleagues who are not in the same environment, and that you maintain a healthy and realistic view of your expectations of yourself and your workplace.



13.  Caregiver Issues for Grief Counselors

243

SPECIFIC MANIFESTATIONS OF OCCUPATIONAL STRESS Many counselors enter the field with very good but perhaps overly idealistic hopes about helping others and being successful in their chosen profession. Very few would probably even consider the possibility that they could experience negative repercussions from doing work that they have envisioned as highly rewarding. In fact, many individuals consider their profession of counseling as something akin to a “calling,” which implies that a high degree of investment and sacrifice are expected as part of being a good counselor (Figley & Ludick, 2017; Harris, 2016; Yalom, 2009). This desire to help others and to be so deeply identified with the profession is both laudable and concerning, because a high degree of commitment and a deep capacity for empathy usually allow the counselor to be effective with clients, but these same attributes can set up the counselor for unique forms of personal harm that are insidious in nature. In this section, we explore how exposure to certain stressful situations in counseling can deeply affect the assumptive world of the counselor, with the potential to harm the counselor personally and professionally. We will specifically discuss burnout and secondary traumatization (sometimes referred to as compassion fatigue). Burnout occurs as a result of cumulative and ongoing emotional drain, trauma, and disappointments associated with an imbalance between the counselor’s resources and the demands (both internal and external) placed upon them. Burnout is seen as an evolutionary, cumulative process that starts with this imbalance and progresses to chronic emotional strain and exhaustion, depersonalization, and a sense of reduced personal accomplishment and satisfaction (Maslach, 1982). Counselors who experience burnout typically begin to cope with the emotional overload by distancing themselves from those who need help in order to feel more protected emotionally. What eventually happens is that counselors can end up being and doing the very opposite of their primary motivation for entering the profession in the first place, and a devastating form of indifference and loss of human warmth begins to preside where there used to be empathy and concern. In addition, there may be personal shame and fear of the judgment of others about this change in attitude, which may prevent the counselor from being able to reach out and get the support and care that he or she needs from others. An unrelenting cycle can become established in which the needs and expectations that the counselor has are compounded by the needs and demands of clients and/or the work environment, within a vacuum of resources for the counselor’s renewal and energy, triggering the counselor to “try harder” to overcome the obstacles alone. This effort only results in further, deeper depletion of the limited resources that are present. Burnout is a state of physical, emotional, and mental exhaustion. The symptoms are caused by the ongoing stress that caring professionals can experience in their careers, which is cumulative and often predictable (Maslach, 1982). Burnout tends to occur when professionals experience a low level of control over decisions regarding how they will provide care, whether it is because of autocratic/bureaucratic factors, lack of input into how their workload and responsibilities are assigned, or being given more responsibility or a higher work volume than a person feels is possible to handle (Harris, 2016). Recognizing and addressing burnout may involve looking at both internal and external factors. Professionals who are passionately devoted to their work often have a strong desire to be successful, and feelings of repeated disappointment

244

III.  Current Issues and Trends

or inadequacy may foster high levels of stress and burnout. What is more common is an interaction between these factors, especially when high workload demands are in conflict with the time requirements and needs of people who are in emotional pain and crisis (Harris, 2016). Vicarious trauma (sometimes referred to as secondary traumatic stress or compassion fatigue) is the natural byproduct of bearing witness to and empathetic engagement with those who suffer, especially if the individual who is empathetically engaged feels a sense of powerlessness or hopelessness in the process. This exposure leads to changes in the caregiver’s worldview, as well as their psychological, spiritual, and physical well-being. Secondary traumatic stress can be related to the cumulative, potentially traumatizing effect of working with those who are suffering (Jones & Remke, 2016). In secondary traumatic stress, the practitioner adapts to the suffering of others, which affects their identity, worldview, and ability to engage meaningfully with others. The effects of secondary traumatic stress or vicarious stress can become permanent, altering the manner in which the practitioner engages and interprets the world (Rossi et al., 2012). Pearlman, Pomeroy, and Garcia (2009) define vicarious trauma as “the negative transformation that takes place in a therapist through empathic engagement with traumatized clients and a commitment or sense of responsibility to help” (p. 254). Ironically, it is those counselors who have the greatest capacity for feeling and expressing empathy that tend to be at highest risk for compassion fatigue. Professional work that is focused on the emotional suffering of clients means the counselor is often exposed to information that is deeply troubling, which may also lead the counselor to absorb the suffering as well (Figley & Ludick, 2017; Pearlman et al., 2009). In addition, the “work” of counseling involves the opening of one’s self to another, which could increase counselors’ sense of personal vulnerability as they open themselves to the pain and suffering of their clients. Factors that can affect the counselor’s level of vulnerability to vicarious traumatization may include the amount of experience of the counselor, the counselor’s previous history of trauma (all types), the presence of concurrent stressors, the counselor’s attachment style (as well as the attachment style of the client), perceptions of the therapeutic alliance with specific clients, and the percentage of clients in the caseload that are perceived as “difficult” for a number of reasons (Hunter & Schofield, 2006; Practice Example 13.1). The variety of symptoms associated with vicarious trauma include re-experiencing the patient’s/client’s story in a way that is intrusive, personally traumatizing, or overwhelming; a feeling of dread when faced with working with certain people; difficulty separating work from personal life; and guilt for being free of pain or suffering. Secondary traumatization implies a physical, emotional, and spiritual exhaustion with a decline in the ability to experience joy as the body becomes exhausted. Pearlman et al. (2009) refer to the disruption in spirituality as a hallmark of vicarious trauma, meaning a loss of connection to a sense of meaning, loss of hope, and loss of coherence with the bigger aspects of life. Those who experience secondary traumatization may have associated feelings of hopelessness, blame, anger, and physical fatigue, and they may also engage in substance abuse to deal with these difficulties. They may feel irritable and have difficulty sleeping. Lack of sleep, along with the other symptoms, may put not only their jobs in jeopardy but also their clients’ well-being. Counselors who experience secondary traumatization are at a higher risk for depression, anxiety disorders, avoidance, and decisions to leave the profession in order to control symptoms (Showalter, 2010).



13.  Caregiver Issues for Grief Counselors

245

P R A C T I C E EXAM PLE 1 3 . 1 MANIFESTATIONS OF SECONDARY TRAUMATIZATION

Carole worked as a social worker in a cross-cultural learning center. Recently, a group of Syrian refugees came to her city, and the center was given funding to assist the families as they adjusted to life far away from their homeland. Carole’s office became very busy with the details involved in assisting the families with housing, employment, schooling for the children, and filling out mounds of government forms. Many of the immigrants did not speak English; however, those who did described the devastating events in their homeland and what they had left behind. Carole was deeply moved by these stories, and sometimes also deeply troubled. She would sometimes picture what these families had endured before fleeing from their country. She would also see images of horrible things that happened to the people who were left behind. Carole began having incapacitating headaches. She noticed that her back was also sore, and she was having a hard time concentrating. One day when she was walking into her office, she was overcome with a terrible sense of dread and foreboding. Carole was taken aback by these symptoms. At first, she just decided she was working too hard, so she asked for a couple days of vacation. She spent her time off in bed, with her head and her body aching all over. She finally realized that the intense work she had been doing with these refugee families was overwhelming her and she made an appointment with her supervisor, who told her that she had experienced secondary traumatization. Together they explored the impact of the intense distress that Carole had been exposed to while working with these families. Her supervisor also made suggestions for Carole to help her to stay focused in the present and to ground herself when she was aware of feeling distress or discomfort at work.

The type of stress encountered with secondary traumatization is different than what is experienced in burnout in that it is a result of vicariously experiencing the pain and trauma that your clients may share with you. Although secondary traumatization is detrimental to personal and professional functioning, it is preventable. If the counselor is highly self-aware and knows how to remain grounded even when in the presence of situations that are empathically challenging, they will know when a client has shared something that is personally challenging or that leads to feelings of helplessness, hopelessness, and/or powerlessness. At these times, if the counselor readily addresses what has been taken in from the client and has cultivated the ability to quickly become grounded in these moments, traumatic overlay is much less likely to occur (Butler, Carello, & Maguin, 2017).

SELF-CARE AND SELF-COMPASSION AS PROFESSIONAL COMPETENCIES Since our most important asset as counselors is our ability to care and to share in human compassion, it is of vital importance that these aspects of ourselves be nurtured, guarded, and

246

III.  Current Issues and Trends

protected, so they will be available when we want and need them in our lives, both professionally and personally. We write this chapter with the assumption that in order for self-care to have any benefit, it must be recognized as a professional competency for effective counseling practice. It is not an option or something you do only when you have time. In the helping professions, there is always the need to establish a functional balance between taking care of others and taking care of self. Others’ needs tend be apparent, insistent, and pressing and can easily overshadow the needs of the self. Rigorous self-awareness and contemplative practices help to maintain a balance between caring for others and caring for ourselves and these practices may also buffer clinicians from the onset of burnout, secondary traumatization, and/or debilitating numbing/flooding (Halifax, 2013; Pomeroy & Garcia, 2009). Self-care for counselors and the regular seeking of peer support are imperative when your everyday practice involves intensely working with individuals who are suffering, or whose situations evoke your own feelings of helplessness and powerlessness. Helping others to help themselves requires counselors to accept their own needs as well as the needs of others. The greatest resource that counselors have available to them is the ability to relate on a human level with their clients. In order to do this, counselors must be comfortable with their own “human-ness,” which includes having needs and recognizing limitations. In fact, many counselors would say that the degree to which we take care of ourselves often reflects directly on our ability to foster the well-being of our clients. Preventing burnout requires counselors to be self-aware, attuned to their own needs, and proactive in taking care of these needs in a healthy and constructive way. Unrealistic expectations, unmet needs, unfinished business, and the “need to be needed” must be addressed in an accepting and open way that allows counselors the opportunity to explore their own motivations and wounding in order to come to a place of healing and balance. Counselors need to cultivate a personal philosophy that will allow empathetic involvement with others while maintaining individuality and clear boundaries between the needs of self and the needs of others. Professional peer support groups for helping professionals are excellent opportunities to provide a place for the development of self-awareness, self-care, and interactions with others who are like-minded and share similar values. Being engaged in peer support with other clinicians counteracts the isolation and alienation that can occur from working with clients, and it also provides a place to receive much needed support and validation. Our society values the highly individualistic, self-sufficient “superman/superwoman” image. However, this image is completely unrealistic and denies our human need to both give and receive from others. Counselors must recognize that being able to find support and receive it from others is in itself a strength that can be cultivated in the presence of a supportive network. Counselors also need to be able to find supportive persons in their lives that will allow them to ventilate feelings, share frustrations, find successful coping strategies, and observe positive role models in order to become empowered providers. The following are guidelines for counselors to assist them in engaging in reflective practice with necessary support and self-care strategies: ■■

Recognize and honor your limitations; you are a human being whose capacity to care for others hinges upon your ability to care for yourself.

■■

Have a place to go for support and debriefing that will respect the confidentiality of you and your clients.



13.  Caregiver Issues for Grief Counselors

247

■■

Have regular supervision with someone who is experienced in this type of work.

■■

Cultivate self-awareness of your issues, feelings, and values so that you will be able to separate them from those of your clients.

■■

Engage in a regular contemplative practice that allows you to disengage from being mired down in feelings of powerlessness, helplessness, and reactionary feelings and that supports your ability to reflect and tap into your deepest intention toward yourself and your clients.

■■

Take advantage of professional development opportunities, such as workshops, courses, reading journals, and new materials.

■■

Align yourself with a professional code of ethics and standards of practice within a counseling-related field.

■■

Monitor your own health and well-being. Develop your private world in a way that is nurturing to you.

■■

Give yourself permission to not always work well with everyone.

■■

Monitor your working hours and time spent focused on client-related topics.

■■

Recognize your own philosophy of life and how that impacts your work as a counselor.

■■

Be aware of the unique signals from your body that may indicate your need to attend to work-related stress, such as disturbed sleeping patterns, changes in eating patterns, bodily aches and pains, and frequent illnesses that may indicate your immune system is being challenged.

Halifax (2013) has proposed the ABIDE model of compassionate response to suggest a way of working with others that is self-sustaining and energizing rather than depleting and potentially traumatizing. Defining compassion as “the capacity to be attentive to the experience of others, to wish the best for others, and to sense what will serve others” (Halifax, 2014, p. 121), compassion is viewed as a natural outcome that arises from the interaction of a number of interdependent processes that are somatic, affective, cognitive, and attentional in nature, and all of which are amenable to development through training. Halifax’s focus is upon cultivating aspects in the caregiver that would be protective in potentially traumatizing situations, while at the same time enabling helpers to deeply engage with the suffering of others. The foundational cornerstone of this model is for the caregiver/helper to regularly engage in some form of contemplative practice that allows for the cultivation of a sense of perspective. In addition, such types of practice serve to remind caregivers of their deepest intentions to be present to the suffering of others, and the ability to see the “real-world” experiences of injustice without getting caught up in unrealistic expectations or clinging to outcomes that cannot be obtained. Contemplative practices can vary widely, and individuals who wish to explore these practices may need to try various modalities to see which are a good “fit” and are realistic for regular engagement. Examples of contemplative practices may include meditation, journaling, yoga, tai chi, immersion in the arts, retreats, and specific rituals (see Figure 13.2 to explore some of these practices; see also Practice Example 13.2).

248

III.  Current Issues and Trends

FIGURE 13.2  The Tree of Contemplative Practices. Source: With permission from The Center for Contemplative Mind in Society.

Perhaps, even more important than the desire to help to alleviate the suffering of others is the recognition that we also must commit to alleviating our own suffering in whatever ways are possible. There is no distinction between us and those in our care; we are all human and we are all imperfect. We must apply the motivation to relieve suffering not just in others, but also inwardly toward ourselves. Self-compassion involves being touched by and open to one’s foibles, failures, and flaws, addressing these with kindness and nonjudgmental understanding. Self-compassion has been linked to increased resilience, enhanced distress tolerance, greater life satisfaction, and healthier responses to stress (Bluth & Neff, 2018). Neff and Germer (2017) describe the three facets of self-compassion as self-kindness (being sympathetic to our shortcomings versus harshly judging or shaming ourselves), mindfulness (which allows us the opportunity to be fully present and aware in any given situation), and common humanity (recognizing that being human automatically means that we are definitely “works in progress,” something that is shared by all of us). Sometimes, the



13.  Caregiver Issues for Grief Counselors

249

P R A C T I C E EXAM PLE 1 3 . 2 GROUNDING IN THE HERE AND NOW

Aviv and Rena sought assistance from Brynah, a grief counselor, after the sudden death of their 9-month-old baby, Samuel. Rena described Samuel as healthy and happy; he was their first child, and they adored him. Rena had taken a leave of absence from her work in order to spend time at home with Samuel for a while. Her face then changed, and she began to share about what happened when Samuel died. Rena had put the baby down for a nap and was doing things around the house. The baby monitor was quiet, with the exception of the light music that she put on when he was sleeping. He usually woke up around the same time each afternoon, and when he was sleeping longer than usual, Rena went to check on him. To her horror, she realized that Samuel was not breathing. Brynah listened intently. She had a child who was 3 years old and could relate to Rena’s story. When Rena shared the details about finding her baby not breathing, Brynah began to feel acutely anxious. She felt a strong impulse to check on her child. Her thoughts began to race. She could vividly picture the limp baby in Rena’s arms, as well as Rena’s screams as she dialed 911 for help. At that moment, Brynah realized that she was no longer separating the experience of Rena from her own. She began to focus on her breathing and she rubbed her feet on the floor. In her mind, she said to herself, “I am here right now,” which was a phrase she would sometimes use in her meditation practice to help herself to feel grounded. As she was aware of her breath, she was then able to be more present to Rena and Aviv as they shared their grief and pain with her.

practice of self-compassion begins with learning new self-talk, considering how much of our “inner voice” is actually a very sharp critic and unrelenting taskmaster. Neff (2003) asks us to consider how our best friend might respond to us in situations of disappointment or failure and to begin talking to ourselves with the same voice as someone who might be our best friend. This change in our inner dialogue may take a great deal of time and practice, and we might find it helpful to seek out a supervisor or counselor whose work centers upon the principles of compassionate response. Some possible ways to re-frame our inner dialogue are provided in Table 13.1. Self-compassion is not the same as self-esteem. It also is the opposite of narcissism, as it takes humility to lovingly accept ourselves in the midst of our flaws. Indeed, self-compassion truly “sets the stage” as a habit that we learn to cultivate with ourselves, that is then readily applied to those around us. As this chapter has explored the potential pitfalls and personal toll associated with being a grief counselor, we feel it is imperative that grief counselors understand the cultivation of self-compassion as an essential component of good practice. For more information about self-compassion, we suggest the following website: www.selfcompassion.org.

250

III.  Current Issues and Trends

TABLE 13.1  Cultivating Self-Compassion in Our Inner Dialogue Learning a New Language . . . If you are thinking . . .

Say to yourself . . .

“I am useless”

“Not everything I do happens the way I would like”

“I’m stupid!”

“I can learn to do things differently”

“What was I thinking?”

“I will do it differently the next time”

“I should have known better”

“This was a learning for me”

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

GLOSSARY Burnout  Occurs as a result of cumulative and ongoing emotional drain, trauma, and disappointments associated with an imbalance between the counselor’s resources and the demands (both internal and external) placed upon him or her. Burnout is seen as an evolutionary, cumulative process. Contemplative practices  Various practices that allow practitioners to reflect and connect with their intention and a sense of presence in a moment-to-moment way. Contemplative practices may assist counselors to remain grounded when bearing witness to painful or potentially traumatic material from clients and can be protective in situations where a sense of powerlessness, helplessness, or injustice could otherwise overwhelm both the counselor and the client.



13.  Caregiver Issues for Grief Counselors

251

Coping  The process of attempting to deal with challenges to one’s assumptive world and situations that are perceived by the individual as stressful or even threatening, although coping strategies may or may not be successful. “Narcissistic snares”  Unrealistic expectations by counselors to heal all, know all, and to love all. Secondary traumatization (also sometimes referred to as vicarious traumatization or compassion fatigue)  A state of tension and preoccupation with the individual or cumulative trauma of clients. Traumatic countertransference (also called vicarious trauma)  A state in which the counselor can become overwhelmed by bearing witness to the client’s intense emotional experiences.

QUESTIONS FOR REFLECTION 1. After reading through this material, allow yourself to think of the following ques-

tions. If you have a trusted peer or colleague, see if you can answer these questions and review your answers with each other.

■■

How would you know if you are burned out or if you are too involved in your work?

■■

What are appropriate boundaries with others in this work?

■■

How much of yourself that is personal do you share in the professional setting?

■■

Why are you doing this work? What are you getting from it or what is in it for you?

■■

If you are an “innate helper,” have you explored what may be the reason for your being this way?

■■

Does your work give you a sense of belongingness or a sense of meaning?

■■

What “feeds” you in your life?

■■

Are you able to attach comfortably at times and also detach comfortably when you need to do so?

2. The Professional Quality of Life Scale (ProQOL; see Appendix 13.1) was developed

to measure compassion fatigue, burnout, and compassion satisfaction (Stamm, 2005). Fill out the scale and then score it. What do you think about this scale and the items listed on it? Are there areas where you are aware that you may have some vulnerability as an individual who works with individuals facing death, loss, and grief on a regular basis?

3. Awareness exercise:

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

252

III.  Current Issues and Trends

In pairs, face your partner and take 5 minutes to share what you are aware of

by saying, “Now I am aware . . .,” then switch. As your partner is sharing with you, simply nod and offer nonverbal encouragement.

Debrief: How was that to do? What were you aware of? Was there laughter?

If so, what was it about? Did you find yourself censoring anything? If so, do you know why?

4. Meditation exercise:

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

After a while, start to imagine or feel energy coming into the center of your

chest on the inbreath. As you experience this energy say to yourself, “I am loved.” Now with your outbreath, imagine it leaving your body from your perineum and going straight into the Earth. As this energy flows from your body, say the words to yourself, “I belong.” Maintain this gentle, deep relaxed breathing for 5 minutes.

Gradually return your attention to the room, what you notice from your

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

REFERENCES Bluth, K., & Neff, K. D. (2018). New frontiers in understanding the benefits of self-compassion. Self and Identity, 17(6), 605–608. doi:10.1080/15298868.2018.1508494 Butler, L. D., Carello, J., & Maguin, E. (2017). Trauma, stress, and self-care in clinical training: Predictors of burnout, decline in health status, secondary traumatic stress symptoms, and compassion satisfaction. Psychological Trauma: Theory, Research, Practice, and Policy, 9(4), 416. doi:10.1037/tra0000187 Egan, G., & Reese, R. (2019). The skilled helper (11th ed.).Boston, MA: Cengage. Figley, C. R., & Ludick, M. (2017). Secondary traumatization and compassion fatigue. In S. N. Gold (Ed.), APA handbooks in psychology. APA handbook of trauma psychology: Foundations in knowledge (pp. 573–593). Washington, DC: American Psychological Association. Halifax, J. (2013). Understanding and cultivating compassion in clinical settings: The ABIDE compassion model. In T. Singer & M. Bolz (Eds.), Compassion: Bridging practice and science ebook (pp. 208–226). Munich, Germany: Max Planck Society. Halifax, J. (2014). G.R.A.C.E. for nurses: Cultivating compassion in nurse/patient interactions. Journal of Nursing Education and Practice 4(1), 121–128. doi:10.5430/jnep.v4n1p121 Harris, D. L. (2016). Care for the caregiver: A multilayered exploration. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 251–264). New York, NY: Routledge. Herlihy, B., & Corey, G. (2014). Boundary issues in counseling: Multiple roles and responsibilities. New York, NY: John Wiley & Sons. Herman, J. (1997). Trauma and recovery. New York, NY: Basic Books. Hunter, S. V., & Schofield, M. J. (2006). How therapists cope with challenge: Personal, professional, and organisational strategies. International Journal for the Advancement of Counselling, 28(2), 121–138. doi:10.1007/s10447-005-9003-0



13.  Caregiver Issues for Grief Counselors

253

Jones, B. L., & Remke, S. S. (2016). Self-care and sustainability for pediatric oncology providers. In A. Abrams, A. Muriel, & L. Weiner (Eds.), Pediatric psychosocial oncology: Textbook for multidisciplinary care (pp. 367–377). Cham, Switzerland: Springer. Maslach, C. (1982). Burnout: The cost of caring. Englewood Cliffs, NJ: Prentice-Hall. Neff, K. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85–101. doi:10.1080/15298860309032 Neff, K., & Germer, C. (2017). Self-compassion and psychological well-being. In E. Seppala, E. SimonThomas, S. Brown, M. Worline, C. Cameron, & J. Doty (Eds.), The Oxford handbook of compassion science (pp. 371–385). New York, NY: Oxford. Nouwen, H. J. (1996). Ministry and spirituality: Creative ministry, the wounded healer, reaching out. New York, NY: Continuum. Osipow, S. H., Doty, R. E., & Spokane, A. R. (1985). Occupational stress, strain, and coping across the life span. Journal of Vocational Behavior, 27, 98–108. doi:10.1016/0001-8791(85)90055-7 Pearlman, L., Pomeroy, E. C., & Garcia, R. B. (2009). The grief assessment and intervention workbook: A strengths perspective. Belmont, CA: Brooks/Cole. Pomeroy, E. C., & Garcia, R. C. (2009). The grief assessment and intervention workbook: A strengths perspective. Belmont, CA: Brooks/Cole. Rossi, A., Cetrano, G., Pertile, R., Rabbi, L., Donisi, V., Grigoletti, L., . . ., Amaddeo, F. (2012). Burnout, compassion fatigue, and compassion satisfaction among staff in community based mental health services. Psychiatry Research, 200, 933–938. doi:10.1016/j.psychres.2012.07.029 Showalter, S. E. (2010). Compassion fatigue: What is it? Why does it matter? Recognizing the symptoms, acknowledging the impact, developing the tools to prevent compassion fatigue, and strengthen the professional already suffering from the effects. American Journal of Hospice and Palliative Medicine, 27(4), 239–242. doi:10.1177/1049909109354096 Stamm, B. H. (2005). The ProQOL manual: The professional quality of life scale: Compassion satisfaction, burnout, and compassion fatigue/secondary trauma scales. Baltimore, MD: Sidran Press. Vachon, M. L. (1987). Occupational stress in the care of the critically ill, the dying, and the bereaved. Washington, DC: Hemisphere. Vachon, M. L. (2004). The stress of professional caregivers. In D. Doyle, G. Hanks, N. Cherny, & K. Calman (Eds.), Oxford textbook of palliative care (3rd ed., pp. 992–1004). New York, NY: Oxford University Press. Vachon, M. L. (2014). Staff stress in hospice care. In G. Davidson (Ed.), The hospice: Development and administration (2nd ed.; pp. 111–127). New York, NY: Routledge. Wogrin, C. (2013). Professional issues and thanatology. In D. Meagher & D. Balk (Eds.), Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement (2nd ed., pp. 395–410). New York, NY: Routledge. Worden, W. J. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (5th ed.). New York, NY: Springer Publishing Company.. Yalom, I. R. (2009). The gift of therapy: An open letter to a new generation of therapists and their patients. New York, NY: Perennial.

254

III.  Current Issues and Trends

APPENDIX 13.1: PROFESSIONAL QUALITY OF LIFE SCALE (ProQOL) COMPASSION SATISFACTION AND COMPASSION FATIGUE (ProQOL) VERSION 5 (2009) When you [help] people you have direct contact with their lives. As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a [helper]. Consider each of the following questions about you and your current work situation. Select the number that honestly reflects how frequently you experienced these things in the last 30 days. 1=Never

2=Rarely

3=Sometimes

4=Often

5=Very Often

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



13.  Caregiver Issues for Grief Counselors

______ 27. ______ 28. ______ 29. ______ 30.

255

I have thoughts that I am a “success” as a [helper]. I cannot recall important parts of my work with trauma victims. I am a very caring person. I am happy that I chose to do this work.

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

YOUR SCORES ON THE ProQOL: PROFESSIONAL QUALITY OF LIFE SCREENING Based on your responses, place your personal scores below. If you have any concerns, you should discuss them with a physical or mental healthcare professional. Compassion Satisfaction _____________ Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective caregiver in your job. The average score is 50 (SD 10; alpha scale reliability 0.88). About 25% of people score higher than 57 and about 25% of people score below 43. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 40, you may either find problems with your job, or there may be some other reason—for example, you might derive your satisfaction from activities other than your job. Burnout_____________ Most people have an intuitive idea of what burnout is. From the research perspective, burnout is one of the elements of compassion fatigue (CF). It is associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be associated with a very high workload or a nonsupportive work environment. Higher scores on this scale mean that you are at higher risk for burnout. The average score on the burnout scale is 50 (SD 10; alpha scale reliability 0.75). About 25% of people score above 57 and about 25% of people score below 43. If your score is below 43, this probably reflects positive feelings about your ability to be effective in your work. If you score above 57, you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.

256

III.  Current Issues and Trends

Secondary Traumatic Stress_____________ The second component of compassion fatigue (CF) is secondary traumatic stress (STS). It is about your work related, secondary exposure to extremely or traumatically stressful events. Developing problems due to exposure to other’s trauma is somewhat rare but does happen to many people who care for those who have experienced extremely or traumatically stressful events. For example, you may repeatedly hear stories about the traumatic things that happen to other people, commonly called vicarious traumatization. If your work puts you directly in the path of danger, for example, field work in a war or area of civil violence, this is not secondary exposure; your exposure is primary. However, if you are exposed to others’ traumatic events as a result of your work, for example, as a therapist or an emergency worker, this is secondary exposure. The symptoms of STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event. The average score on this scale is 50 (SD 10; alpha scale reliability 0.81). About 25% of people score below 43 and about 25% of people score above 57. If your score is above 57, you may want to take some time to think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a healthcare professional. © B. Hudnall Stamm, 2009-2012. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). www.proqol.org. This test may be freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test should visit www.proqol.org to verify that the copy they are using is the most current version of the test.

WHAT IS MY SCORE AND WHAT DOES IT MEAN? In this section, you will score your test, so you understand the interpretation for you. To find your score on each section, total the questions listed on the left and then find your score in the table on the right of the section. Compassion Satisfaction Scale Copy your rating on each of these questions on to this table and add them up. When you have added them up, you can find your score on the table to the right

3. ____ 6. ____ 12. ____ 16. ____ 18. ____ 20. ____

The sum of my Compassion Satisfaction questions is

So My Score Equals

And my Compassion Satisfaction level is

22 or less

43 or less

Low



13.  Caregiver Issues for Grief Counselors

22. ____ 24. ____ 27. ____ 30. ____

Between 23 and 41

Around 50

Average

42 or more

57 or more

High

The sum of my Burnout Questions is

So my score equals

And my Burnout level is

43 or less

Low

Total: _____ Burnout Scale On the burnout scale, you will need to take an extra step. Starred items are “reverse scored.” If you scored the item 1, write a 5 beside it. The reason we ask you to reverse the scores is because scientifically the measure works better when these questions are asked in a positive way though they can tell us more about their negative form. For example, question 1. “I am happy” tells us more about the effects of helping when you are not happy so you reverse the score

*1. ____ = ____ *4. ____ = ____ 8. ____ 10. ____ *15. ____ = ____ *17. ____ = ____ 19. ____ 21. ____ 26. ____ *29. ____ = ____ Total: _____ 22 or less

You Wrote

Change to

Between 23 and 41

Around 50

Average

1

5

42 or more

High

2

4

57 or more

3

3

4

2

5

1

257

258

III.  Current Issues and Trends

Secondary Traumatic Stress Scale Just like you did on Compassion Satisfaction, copy your rating on each of these questions on to this table and add them up. When you have added them up, you can find your score on the table to the right

2. ____ 5. ____ 7. ____ 9. ____ 11. ____ 13. ____ 14. ____ 23. ____ 25. ____ 28. ____

The sum of my Secondary Trauma questions is 22 or less Between 23 and 41 42 or more

So My Score Equals

And my Secondary Traumatic Stress level is

43 or less Low Around Average 50 57 or High more

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

CHAPTER 

14

C U RREN T I S S UE S A N D T R E N D S F O R GRI EF C OUN S E LOR S

LEARNING OBJECTIVES 1. Discuss the implications for a strengths-based approach to grief and identify when grief counseling is indicated. 2. Describe current issues related to competence and maintain currency in the field for grief counselors. 3. Identify aspects of neurobiology that are relevant to the study of grief and grief counseling practice. 4. Discuss the diverse ways that grief can be manifest and the implications for counseling practice. 5. Identify various ways that technology is being used to support grieving individuals, along with ethical concerns regarding the use of technology in grief counseling.

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

260

III.  Current Issues and Trends

ACKNOWLEDGE INNATE RESILIENCE; OFFER APPROPRIATE SUPPORT There are several criticisms of the development of grief counseling as a unique area of specialization in clinical practice. At face value, it makes sense for clinicians who work primarily with bereaved individuals to have in-depth knowledge and understanding of the wealth of literature and research on bereavement that would be difficult for a generalist to achieve. It also would follow that a high degree of experience with bereaved individuals through a specialization in grief counseling would likely hone the skills of the counselor in working with the unique clinical features that may accompany grief in clients. However, the result of the development of grief counseling being identified as a unique specialization is the tendency to focus on the negative aspects of grief—those aspects that require intervention—or to see grief as something to be “treated,” rather than an adaptive process that usually does not require professional intervention (Granek, 2016; Neimeyer, 2014). Most research focuses on problematic adaptation to loss and grief, and yet we know that this type of difficult grief occurs with a minority of bereaved individuals, thus skewing expectations of difficulties inadvertently onto individuals who are coping adequately with their loss. In addition, research measures that track the grief experience of participants are typically designed to identify problematic areas rather than good coping, growth, and resilience. Few, if any, grief measures will ask about laughter and moments of joy, but almost all of them will ask about sadness, crying, and loneliness (Bonanno, Westphal, & Mancini, 2011). Even when clients contact a grief counselor for assistance because they are having difficulties with their grief, there are innate strengths and resilience that can be identified, and upon which the client can learn to draw upon in the counseling process. Grief counseling needs to be focused on the client’s positive coping and inner resources, while recognizing that there are aspects to this experience that challenge the bereaved individual’s view of the world and that do cause distress as well. It is very important to keep in mind that the majority of individuals who experience a significant loss will eventually continue with their lives in ways that will be fulfilling and meaningful. Because the overall conclusions of the recent research on the efficacy of grief counseling have indicated that the majority of bereaved individuals possess a good degree of innate resilience and do not require the intervention of a professional for support, how do we know when grief counseling should be sought? As stated previously, approximately 10% to 15% of bereaved individuals will experience symptoms of prolonged, ongoing grief that can be debilitating and cause significant health problems and higher rates of mortality. Thus, it is very important for professionals whose counseling practice includes working with bereaved individuals to become very familiar with the symptoms of complicated grief/prolonged grief (CG/PG) disorder so that individuals who have this form of debilitating grief will be able to access intervention that is appropriate for their distress (refer to Chapter 10, When Grief Goes Awry, for a review of CG/PGD). Most of the literature does not support preventive or proactive grief counseling; that is, offering unsolicited support and counseling services to those who may be newly bereaved but are not requesting professional support (Gamino, Sewell, Hogan, & Mason, 2010; Stroebe, Stroebe, Schut, & Boerner, 2017). Individuals who seek counseling on their own or who



14.  Current Issues and Trends for Grief Counselors

261

are referred by another clinician, such as a family doctor, tend to benefit from therapeutic support, much in the same way that individuals with other issues benefit from interpersonal therapy (Larson & Hoyt, 2009). Of further interest is Altmaier’s (2011) premise that empirical research cannot “capture” some of the variables in the therapeutic relationship that are dependent on client and counselor attributes. She states, The background of best practices is important in selecting counseling approaches for a grieving client, keeping in mind that there is controversy over whether grief counseling is appropriate for everyone, only for the persons seeking treatment, or only for persons experiencing complicated grief. Moreover, though in general some counseling approaches may seem to be effective, research should not imply that the personhood of the counselor, the relationship of client and counselor, or the client’s own self-healing processes are insignificant aspects of change. (p. 35) In other words, she cautions about empirical studies that focus on client symptoms and effects of specific interventions without taking into account aspects that are relevant to the therapeutic relationship and the characteristics of both the client and the counselor in the process. At this time, the current thinking based on research findings is that: (a) there is no evidence that preventive or proactive grief counseling in individuals who are adequately coping with their loss is beneficial, (b) grief counseling may be helpful to clients with normal, uncomplicated grief in the same way that other counseling therapies benefit people with generalized, everyday stresses and problems, and (c) there is support to indicate that specifically designed grief counseling/therapy support is for individuals who experience symptoms of complicated or prolonged, debilitating grief (Neimeyer & Currier, 2009; Simon, 2013; Worden, 2018).

PROFESSIONAL CURRENCY AND COMPETENCE Unlike any other field in counseling, grief counseling tends to draw people who have experienced significant losses in their lives to become “helpers” to others who are facing loss and grief. Indeed, the helper-therapy principle is a well-known phenomenon, and this personal experience by grief counselors may be of benefit for the cultivation of empathic connection between the counselor and a client (Folgheraiter & Raineri, 2017). However, it can also be fraught with many drawbacks. For instance, what actually qualifies someone to be a grief counselor? If you lost your child and attended a self-help or support group and then “graduated” from that group, are you now qualified to counsel other bereaved parents? When I (D.L.H.) took my first university course on the dynamics of grief support groups, I was taken aback when the instructor, a widow of 5 years, indicated that it was her belief that only another widow could be effective with newly bereaved widows. I did some checking on the background and training of this “professor” for the course. She had a bachelor’s degree in English, and she had taught high school until her husband died. She then quit her job with the school board and began running grief support groups for widows out of her home. Because she was recognized in the community as someone who worked with bereaved widows in a group format, she was asked to teach a university level course for professional clinicians on this topical area. However, she was not familiar with the current research or literature on

262

III.  Current Issues and Trends

group dynamics and had no formal training in counseling or group work. She did not know about the writings of some of the main scholars or clinicians in the field, nor did she incorporate alternative views related to group dynamics and grief support into the course. This instructor’s experience was valuable for us to hear and understand, but we left that course with a very limited understanding of the ways that grief could be expressed (based on a feminine view of a widow’s experience), and a sense of despair that if we had not experienced the same loss as a client, we would be unable to be fully effective with that client—a view that is certainly not supported in the literature in counseling practice, nor upon accounts of clients’ descriptions of what they found most helpful in their counseling sessions (Altmaier, 2011; Norcross, Beutler, & Levant, 2005; Practice Example 14.1). A study by Ober, Granello, and Wheaton (2012) explored the issue of grief counselors’ training, experience, and competencies. Professionals who self-identified as specializing in grief counseling were interviewed to ascertain their background and currency in the field. More than half of the respondents indicated that they had never taken a course or program that focused on the foundational understandings of grief or grief counseling. Similar to the experience of the university instructor cited earlier, several of the grief counselors cited that their own experiences of personal loss were what informed their practice. In another study of grief counselors’ descriptions of their work with clients, Breen (2010–2011) interviewed

P R A C T I C E EXAM PLE 1 4 . 1 ETHICAL ISSUES RELATED TO COMPETENCE

Raina was a grief counselor in the community. Her first client of the day, Alexis, came to see her to talk about the loss of her 30-year-old husband when he died after being involved in a car accident on a major highway during a snowstorm. As Alexis was recounting her feelings and experiences as a young widow, she mentioned that she had attended a widow’s group in the community that she had found through a community public service online bulletin board. She told Raina, “This was not a great experience. The group facilitator kept interrupting us and telling us about her grief experiences. It’s as if she needed us to help her with her grief and she couldn’t handle if someone in the group had an experience that was different from hers.” Raina felt concerned as Alexis continued to share about this group; Raina was aware of this individual in the community and had heard similar stories about her groups from other clients. Alexis then proceeded to mention, “We realized something was wrong, and so we began to meet on our own at each others’ homes and at coffee shops without her knowing about it.” Raina realized that Alexis was able to recognize that something was wrong with this grief group facilitator’s work, and she was relieved that Alexis was able to set healthy boundaries for herself in the situation. However, Raina wondered if others who have attended these groups could have possibly been harmed. She was aware that this facilitator was not affiliated with any professional or regulatory body, so there was no place to report her concerns.



14.  Current Issues and Trends for Grief Counselors

263

clinicians who currently had counseling practices that specialized in grief/bereavement. In her study, most of the grief counselors who were interviewed were not informed of current best practices in grief counseling, with many citing adherence to stage theories of grief and a continued belief in the “grief work” hypothesis for all of their clients, emphasizing the need for all bereaved individuals to talk about their loss and their emotions in order to “recover” from their grief. These findings were very troubling, as there is lack of empirical data and anecdotal relevance of grief stages to the actual experience of most bereaved individuals. The grief work hypothesis, which we also discussed earlier, has not been proven applicable to many bereaved individuals and has not been validated by empirical studies; in fact, it is now known that imposing “grief work” onto some clients may actually be harmful (Stroebe & Schut, 2010). However, many clinicians have not availed themselves of this current research in bereavement, and they will still insist on the necessity of emotional catharsis and confrontation with the loss for bereaved individuals to “recover” from a significant loss. This type of theory-bound, cookie-cutter approach to grief counseling can cause more harm than good, completely undermining the unique needs and personal characteristics of the bereaved individual who may seek assistance through grief counseling. Some studies have identified that some individuals actually fare better by not talking about their feelings or the loss itself (Beckett & Dykeman, 2017; Stroebe, Schut, & Stroebe, 2005). Probably what is most important in this discussion is the need to recognize that there are many variables that affect the experience and needs of bereaved individuals, and an effective grief counselor will assist clients to find ways to recognize and cope with loss that are congruent with the individual client’s personality, strengths, and needs as they are identified and stated by the client. The need to stay current in the field of grief counseling is of paramount importance, because there is a great deal of research and writing about when grief counseling is helpful and, when it is not, what approaches may or may not be indicated for which groups, and when further referrals for other professionals are indicated. Many counselors cite problems with accessing research findings because they are not affiliated with institutions that carry scholarly journals that would report the most current findings in the field and their lack of time to read published research (Altmaier, 2011; Breen, 2010–2011). Recently, the Association for Death Education and Counseling (ADEC) negotiated with publishers to be able to include subscriptions to several of the most well-known journals in thanatology as a benefit of membership in order to address this issue of difficulty in access to current literature and research that has been raised by clinicians who wished to have access to scholarly writings in the field. Some grief counselors have formed professional online networking groups to share and discuss current information and controversial issues that are relevant to practice. The availability of such online networking and sharing may be of benefit to counselors who might otherwise not have the time to seek out these resources during their everyday working hours. In the past few years, various professional groups have suggested that there should be published standards of practice for grief counselors, and we are frequently asked about what credentials and training are appropriate for someone to provide grief counseling. The first issue to be addressed is for anyone who is interested in becoming a grief counselor would be to see what laws and restrictions apply to individuals who are counselors, as well as what organization holds jurisdiction over counseling practice in their locale. The requirements

264

III.  Current Issues and Trends

for someone to practice counseling and/or therapy will vary from state to state and from province to province. Most states/provinces will specify a minimum level of education necessary for clinical practice. Another issue pertains to the recognition of credentials by insurance companies to qualify for reimbursement for services. This recognition usually includes affiliation and/or licensure with a regulatory body of some type (e.g., College of Therapists, American Psychological Association, College of Social Workers), and as part of your membership with this regulatory body, minimum standards for licensure are usually specified. These standards would most likely include the level and type of education and preparation required, continuing education requirements and compliance with ongoing standards of current practice, in addition to adherence to ethical standards of practice that are developed from the membership or regulatory body. There are difficulties in standardizing credentials (e.g., requirement of a graduate degree in a clinical area) because some very rigorous clinical training programs are offered through non-degree granting institutes, and although they are equivalent to postgraduate training, they are not recognized because they are not affiliated with a university setting. Programs that train in psychoanalysis, Gestalt, and the Internal Family Systems model are such examples. This can be a very tricky and controversial topic, because having an advanced degree (such as a doctorate degree) does not necessarily mean you will be the most effective clinician to work with a certain population. However, the valid issue of protection of the public and the adherence to ethical standards of practice somehow needs to be addressed. Because there are many different forms of education about grief, and the information that is offered can range from a weekend workshop to undergraduate and graduate degrees in thanatology or related fields, it is important to be informed about the requirements in the area where you plan to practice in order to know what educational process would be the best to provide you with the necessary training and experience to be a competent practitioner. Currently, most people who provide grief counseling have advanced degrees in fields that provide training in clinical work, such as nursing, psychology, pastoral care, social work, and medicine. Once this training is completed, these students usually engage in another program of study that will immerse them into current theory, research, and practice related to death, dying, and bereavement, which provides a more specialized form of learning and training to focus on issues related to grief and loss. We sometimes tell our students that obtaining a clinically based degree provides them with their “driver’s license,” and the additional education in thanatology serves as a specialization onto their foundational clinical work. There is much confusion over the titles and terms that are used to describe people who provide bereavement support. Konigsberg (2011) expounds on this confusion, stating difficulties differentiating among individuals who call themselves “grief specialists” and “grief facilitators,” along with “grief counselors” and “death educators.” Generally, individuals who volunteer or who do not have formal education in counseling or bereavement theory provide peer support. These individuals may assist as lay volunteers in their faith communities to provide outreach and visitation to bereaved individuals whose needs focus mostly on activities of daily living, sharing experiences, grassroots support, and faith-based companioning. Individuals who provide peer support have often moved further down the road



14.  Current Issues and Trends for Grief Counselors

265

in their grief and use their experiences to assist in the organizing and running of grassroots support groups, with the self-help model in mind. It is our view that once someone is providing a service in which there is a referral base, receiving a fee for service, and the focus is on a skilled helper model, the individual providing that service should have basic training in a counseling-related field, be affiliated with a regulatory body for ongoing competency requirements, and have some form of accountability with established ethical standards of practice. Psychotherapists typically have graduate-level training in a counseling-related field, along with a minimum number of supervised clinical hours while in training, in addition to affiliation with a regulatory body (usually in the form of licensure). ADEC has introduced a certification program to designate individuals who have demonstrated that they possess a foundational body of knowledge in the field of thanatology (identified as “certified in thanatology,” with the initials “CT”). Individuals who apply for the CT credential with ADEC are required to have a minimum of a bachelor’s degree, to have completed a minimum number of hours working in a relevant area in thanatology, provide two letters of reference from individuals who have been in close proximity to their work, and pass a written examination to demonstrate proficiency with the current understandings and principles of practice within thanatology. Unfortunately, this credential is often misunderstood as the completion of a training program, an indication of clinical competence, or as a certification with a clinical component, and none of these assumptions is reflected in the purpose behind the CT designation. The CT credential simply indicates that the individual has demonstrated competence with a foundational body of knowledge related to death, dying, and bereavement and has completed formal or informal education in a relevant area for a minimum number of hours. We strongly suggest that if you wish to be a grief counselor then you must consider how you will obtain the relevant training and education in order to ensure you are providing best practices and the best care for your clients. Please see Box 14.1 for suggested qualifications and requirements for grief counselors.

THE NEUROBIOLOGY OF GRIEF In the past few years, there has been a great deal of interest in the application of neuroscience to experiences that were previously explored only in psychological venues. Likewise, although grief has been described primarily as a psychological phenomenon, there is evidence to suggest that grief also has physiological correlates and that these biological aspects of the process may have consequences for health and the quality of life in bereaved individuals. One example of how understandings about neurobiology have been useful relates to the impact of trauma in early life, and the associated changes in certain structures and alterations in chemical activity in the brain, leading to heightened reactivity and impaired relational capacity in these children, lasting into adulthood (Phillips & Shonkoff, 2000). The physiological/neurological mechanisms that may accompany bereavement and the impact upon morbidity/mortality are an important area of inquiry because understanding these mechanisms may lead to better identification of those who are most likely to experience untoward outcomes as a result of bereavement. Neuroscience-based information also

266

III.  Current Issues and Trends

BOX 14.1 SUGGESTED QUALIFICATIONS FOR GRIEF COUNSELORS

We think that counselors who specialize in working with individuals who are grieving should, at the minimum, have the following: ■■

Knowledge of current theory and research in grief/bereavement, as well as awareness of the current issues in the field

■■

Understanding of the unique aspects of grief counseling that make this form of practice different from other forms of therapeutic support

■■

Recognized training and demonstration of competence in counseling skills under supervision

■■

Affiliation with a professional body that includes adherence to a standardized code of ethics, as well as the provision of and documentation for continuing education in the field

■■

Ability to recognize when grief is complicated and requires further assessment and intervention

■■

Awareness of issues related to diversity and cultural sensitivity in the provision of grief counseling

■■

Provision for supervision from a qualified colleague who is involved in the field

■■

Recognition of the role of self-awareness, reflective practice, and self-care in professional competence

focuses on the neurobiology of distressing events and the subsequent impact upon social functioning, which in turn may directly affect the ability to receive crucial social support in bereavement. Reviewing current research in the area of grief and neurobiology can be challenging for those who are not well versed in neuroscience and neuroanatomy. Rather than giving specific details that identify particular portions of the brain and complex neurochemical processes, we summarize some of the current research that explores the relationship between grief and physiological processes. Some studies have explored the various areas of the brain that are stimulated by specific aspects of the grief response, such as yearning (Freed, Yanagihara, Hirsch, & Mann, 2009; O’Connor et al., 2008). Others have focused on the role of the brain in the regulation of the immune system and inflammatory responses through various biomarkers after the death of a significant attachment figure, finding evidence of increased release of hormones in the body related to immune function and inflammatory responses when the individual was presented with grief-laden material (Miller et al., 2008; O’Connor, Irwin, & Wellisch, 2009; O’Connor, Wellisch, Stanton, Olmstead, & Irwin, 2012). In reviewing three studies of bereaved individuals, Kersting et al. (2009) noted that when bereaved participants were shown images



14.  Current Issues and Trends for Grief Counselors

267

that elicited grief, areas of the brain that are implicated in the experience of physical pain were also activated, providing a biological correlate to the emotional pain of grief. One study (O’Connor et al., 2009) suggested that the major difference between complicated and uncomplicated grief is that reminders of the deceased may activate the neural reward system in individuals with complicated grief. The implications of this study suggest that bereaved individuals with both complicated and uncomplicated grief feel pain upon presentation of grief-related stimuli, but in those with complicated grief, an area important for reward processing was also activated when there was exposure to cues of the deceased. The reward system remained activated while the bereaved individual recalled memories of the deceased, very similar to how the reward centers in the brain may be activated in addiction behaviors. The addiction-relevant aspect of this neural response may help to explain why it is hard for these individuals to resist reminiscing and ruminating about the deceased even though engaging in these activities may prevent those with complicated grief from adjusting to and coping with the realities of the present. Although not trying to imply that the unrelenting grief is pleasurable, these authors surmise that actively reminiscing and thinking about the deceased loved one may serve as a craving response that may make adapting to the reality of the loss more difficult in individuals with complicated grief. Biomarkers are also studied because they may relate to the grieving process. Biomarkers are biological molecules that are found in blood or other body fluids or tissues that may provide an indication of various processes in the body. The study of biomarkers may help to better understand the physiological variables in the similarities and differences between acute uncomplicated grief and complicated grief. Similarly, studying the underlying aspects of the body’s stress response to a death event may reveal distinctions between complicated grief and posttraumatic stress disorder (PTSD) or major depressive disorder. It is hoped that studying biomarkers may help to understand how the death of a loved one can lead to the “broken-heart phenomenon” or the unexpected death of a recently bereaved individual (Mughal & Siddiqui, 2018; O’Connor et al., 2012). Given that morbidity and mortality are physical events, some interaction is obviously occurring between the individual’s knowledge of the loss and the physical response of the body, and although the mechanisms linking them are not well understood, the immune system is seen as a likely intermediary. It is also thought that biological markers potentially associated with grief might help to better understand the mechanisms of complicated grief, which may lead to improved treatment for this disorder. Although the development and use of medication/pharmacological treatments seems like the most obvious way to use this information, psychological treatment that takes advantage of these biomarkers may also be possible (O’Connor, 2013). For example, O’Connor (2012) cites that psychotherapy for PTSD has taken advantage of the discovery that when a patient’s heart rate is high at the beginning of the first exposure treatment, therapy outcomes are better. Although the exploration of the neurobiology of grief is certainly in its infancy, there may be significant implications for the treatment of various forms of difficult grief as these studies progress. A note of interest pertains to the recent research in compassion-based approaches to distress, where the focus is upon the response of the autonomic nervous system to threat (Gilbert, 2009; Siegel, 1999). The autonomic nervous system, which functions outside of conscious control, entails the sympathetic nervous system and the parasympathetic nervous

268

III.  Current Issues and Trends

system. The sympathetic nervous system is responsible for taking quick action through the well-known fight-flight-freeze response (which can lead to hyperarousal), and the parasympathetic nervous system tends to have a calming function, allowing for rest and maintenance of reparative and sustaining processes (which can also lead to hypoarousal). Typically, these two branches of the autonomic nervous system are in balance with each other, creating a “middle ground” of functionality where the individual is alert but not hyperaroused, and relaxed enough that basic functions are sustained, but not to the point of being closed down, hypoaroused, or unable to respond to environmental stimuli (Corrigan, Fisher, & Nutt, 2011). The work of Siegel related to therapy with survivors of trauma addresses the activation of the sympathetic and parasympathetic nervous systems of individuals who struggle with intrusive or overwhelming traumatic symptomatology. Siegel described a “window of tolerance” that demonstrates the relative balance between hyperarousal and hypoarousal and offers several therapeutic suggestions for helping clients to maintain living within this “­window” as much as possible (Siegel, 1999; 2010). The applicability to acute grief, and especially to complicated grief, could be relevant to understand the physiology of acute grief, and to suggest potential therapeutic interventions to assist grieving clients to increase their tolerance to distress and to explore strategies that might enable healthy emotional regulation in the face of acutely distressing losses (Exhibit 14.1).

EXHIBIT 14.1 THE WINDOW OF TOLERANCE IN DISTRESSING SITUATIONS

Hyperarousal “Fight/Flight/Freeze” Response Emotional Flooding/Reactivity

Window of Tolerance Optimal Arousal/Functioning Emotions Processed Information Integration and Cognitive Processes Engaged

Hypoarousal Emotional Numbing Shutting Down Inability to process cognitively Source: Adapted from Corrigan, F. M., Fisher, J. J., & Nutt, D. J. (2011). Autonomic dysregulation and the window of tolerance model of the effects of complex emotional trauma. Journal of Psychopharmacology, 25(1), 17–25. doi:10.1177/0269881109354930



14.  Current Issues and Trends for Grief Counselors

269

GRIEF AFTER MEDICAL ASSISTANCE IN DYING Currently, there are many countries that allow for various forms of medically assisted death in various circumstances. Canada decriminalized assistance in dying performed by physicians, nurse practitioners, and pharmacists in 2016. In the United States, several states have enacted legislation allowing for various forms of medical assistance in dying, including euthanasia and physician-assisted suicide. Many countries around the world have laws that allow for medical assistance in dying, with the trend toward an increase in the numbers of countries that are actively considering this legislation or that are in the process of formulating legislation for active and passive euthanasia. With these changes occurring, it is interesting to consider the impact of choosing to die through government-sanctioned assisted death upon bereaved loved ones. Because this legislation is relatively new in many countries, the research on this topic is just beginning to emerge in places where legalized euthanasia/assisted death is a recent phenomenon. Though assisted death and active euthanasia are different, both involve persons deciding to end their lives in a legally sanctioned way, and this appears to be the underlying dynamic of both the decision-making and the family’s response in both scenarios. Since euthanasia has been legal in The Netherlands since 1984, most of the research that explores the impact upon family members and loved ones left behind originate there. A large study of older adults in The Netherlands completed by Bruinsma, Tiemeier, Heemst, van der Heide, and Rietjens (2015) explored the relationship between factors at the end of life and bereavement outcomes for surviving spouses. Many different variables were assessed, including end of life care and decision-making. In this study, accessing state-sanctioned euthanasia did not demonstrate any increase in adverse bereavement outcomes in spouses. In a systematic review of studies from 1980 to 2017 that explored issues related to death from euthanasia, Roest, Trappenburg, and Leget (2019) found that family members often struggled with conflicting feelings during euthanasia decision-making. While they wished for the patient’s suffering to end, and (regardless of personal views on euthanasia) they often considered the decision by their loved ones to end their lives to be too early or too definitive. Some studies described family members who had been aware of their own exhaustion due to caregiver responsibilities during euthanasia decision-making, and as a result, they opted out of euthanasia decision-making, or they doubted their role in it. For others, euthanasia was seen as a means to both end the patient’s suffering and to provide a specific time when all family members could be present and involved at the time of the patient’s death and funeral. Overall, positive experiences seemed to prevail in bereaved family members; despite the feelings of grief and loss, many family members mentioned that they felt relieved that the suffering had ended, that the patient’s wish had been fulfilled, and that it had been a peaceful deathbed surrounded by loved ones, and these feelings provided comfort in the midst of their grief. In a Swiss study, some families reported feeling isolated due to concerns about the stigma of the cause of death in their loved ones (Gamondi, Pott, Forbes, & Payne, 2015). In another Swiss study that explored bereavement outcomes, family members or close friends who were present at a loved one’s assisted death had no difference in the reporting of complicated grief symptoms than the general populations grieving a nonassisted death (Wagner, Muller, & Maercker, 2012).

270

III.  Current Issues and Trends

In a study on the impact of Oregon’s assisted death legislation on the grief of family, Srinivasan (2018) found that participants’ bereavement experiences following an assisted death overlapped with bereavement experiences of families following a terminal illness. In both cases, people have the opportunity to say goodbye, to prepare for the death, and to experience anticipatory grief. However, when comparing bereavement experiences from an assisted death with bereavement experiences from a nonassisted death from a terminal illness, participants reported that certain aspects of an assisted death brought greater ease in the grieving process, including a feeling of relief that their loved one was no longer suffering, and the aspect of control preserved their dignity. Where this study differs from the European studies is the degree of concern by family members of stigma and disenfranchisement related to controversy over the choice to end one’s life, as in some communities the choice for assisted death was equated with death by suicide. We anticipate further study on the impact of medically assisted death in a variety of countries to help inform our support of those who grieve after loved ones die in this way. Based upon the current available studies, we think the following implications are relevant for grief counselors who offer support to the bereaved loved ones after death by medical assistance: ■■

Listen carefully to how your client describes the process of decision-making around the choice for medical assistance in dying. Normalize the ambivalence that is likely to be present; your cue on how to best offer support will be in the way your client describes this aspect of their loved one’s trajectory.

■■

Be aware that while the decision to seek medical assistance in dying is legal in many countries, the legal right to end one’s life may be in conflict with certain groups over moral, ethical, and legal concerns. Bereaved clients are vulnerable and in need of support; being judged and criticized for a loved one’s choice to access medical assistance in dying adds a dimension of shame and disenfranchisement to their grief that you may need to debrief in your sessions.

■■

Ascertain if there was family disagreement or conflict surrounding the decision-making process or the choice to seek assistance in dying itself. Families may be united by their love and concern for the deceased family member, but the diversity of opinions, expressions of grief, and the underlying family dynamics may be intensified by this choice.

Above all, we have repeatedly reminded counselors to be fully present, nonjudgmental, and open to their clients’ experiences, and this situation is certainly no different. Clients may really need a safe place to explore their feelings and to debrief their experiences in order to honor their grief and their relationship with their loved one.

EFFECTS OF THE OPIOID CRISIS In the past few years, a very troubling rise in deaths related to opioid overdose has occurred in countries around the world. According to the World Health Organization (WHO), roughly 450,000 people died as a result of opioid drug use in 2015. In the United States of America alone in 2017, there were an estimated 70,237 deaths due to drug overdose, which is a 25%



14.  Current Issues and Trends for Grief Counselors

271

increase from previous years (Centers for Disease Control and Prevention [CDC], 2019). Certainly, this issue is relevant to many overlapping areas of care, including end of life care, where patients routinely require opioids to manage pain from their terminal disease, and also to bereavement in families whose loved ones became severely compromised or died after an opioid overdose. We will briefly explore these scenarios. In response to the increasing death toll, many governmental measures have recently been implemented, including new requirements for prescription drug monitoring programs (PDMPs) in most developed countries, as the origin of many addictions to opioids start with medications that are prescribed by physicians after surgery and for injuries that are associated with intense pain. Patients can become addicted after using these medications for these conditions, and when they are no longer able to renew prescriptions from their doctors, they begin to resort to illicit drugs to satisfy the addiction. As a result, prescription guidelines and educational sessions for physicians related to opioid prescribing have been issued by multiple organizations, including the CDC) in the United States, and similar monitoring programs are being endorsed by the United Nations and WHO in other countries around the world. Bruera (2018) describes how these and other educational and regulatory measures have resulted in a reduction in the quantity of opioids prescribed, but there have been unintended consequences. The first problem is that physicians are now under intense scrutiny for their prescribing habits. Many also face additional paperwork for the completion of required assessments of patients when prescribing opioids, resulting in an increased use of less effective non-opioid prescriptions for pain control in instances of severe chronic pain and pain from cancer and terminal illnesses. In addition, pharmacies are not stocking the same amounts of these medications due to government-mandated reductions in their production, resulting in shortages and lack of availability of opioid medications for the patients who require these prescriptions to manage pain and breathing difficulties in palliative care scenarios. Another complication is related to patients who have severe chronic obstructive pulmonary disease (COPD) and the intense shortness of breath that can accompany this disease, which can be managed with the use of opioid medications (Rocker, Bourbeau, & Downar, 2018). However, while opioid use for the control of pain in terminal cancer is understood to be useful, the use of these medications with advanced COPD does not garner the same widespread understanding. As a result, patients with conditions that involve refractory respiratory distress may struggle with intense breathing difficulties and the accompanying anxiety that accompanies air hunger if denied access to this class of medication for these symptoms. On a more personal level, patients who are prescribed these medications may now be affected by the new rules that govern how much of a specific medication may be dispensed at a time. One family member in my (D.L.H.) practice, who took care of her father after he was diagnosed with a form of bone cancer, spoke about having to go to the pharmacy every few days with a new prescription for her father’s pain medication because they could no longer receive an amount that would last for several weeks. Each time, she had to go to the doctor’s office to pick up the prescription, then to the pharmacy and wait for the prescription to be filled. And each time, she had to pay for someone to be with her father because he could not be left alone. Scenarios where family members are forced to watch their loved one suffer due to inadequate

272

III.  Current Issues and Trends

pain relief or whose caregiving burden has been increased due to situations similar to the scenario described here will have an impact upon the grieving process of the family afterward. The second relevant issue with the opioid crisis pertains to the grief of loved ones whose family members overdosed on opioid medications. It is important to note that the main focus of the media and studies of the opioid crisis has been upon the increasing number of deaths related to overdose. However, a large number of individuals who overdose on opioids are found before they die, typically being resuscitated and/or placed on life support when they are taken to medical centers. While it is true that many individuals die from opioid overdose, the issue of significant permanent functional impairment is important to recognize. Common residual effects of an opioid overdose that was survived may include significant brain damage (ranging from nontransient amnesia to a vegetative state), liver toxicity and damage, and kidney failure, requiring lifelong dialysis (Butler et al., 2019; Morrow, Bassett, Maclure, & Dormuth, 2019). Many of these individuals are young, in their 20s and 30s, and they are ending up in long-term care facilities because their families are either unable to care for them due to their complex medical needs, or they have no friends or family available. In a study of grief after overdose, Templeton et al. (2017) describe how bereavement following an overdose differs from bereavement following other deaths associated with alcohol or drug use, indicating complications in the grieving process are often related to the unknown intentionality by the deceased (e.g., was this a chosen death by suicide or an accidental overdose), and the compounded social stigma attached to drug use that then extends to the bereaved family members afterward. Stigma is a particularly important issue for those grieving a substance-use related death, with drugs being associated with criminal, and therefore unacceptable, behavior. Such stigma tends to be reinforced by the way in which these deaths are discussed, managed, and institutionalized in Western societies, including the involvement of police and the criminal justice system. Stigma can extend to family members who may be viewed as somehow responsible or complicit in some way. Templeton et al. (2017) relate further complications to bereavement related to the history of drug use by the deceased, and the impact of the addiction on the family over time. Such experiences, coupled with the other common challenges of having a relative or friend with a drug problem, had a significant impact on the grief of loved ones after the death. Participants in this study talked about grieving for a person who they felt they had already lost, which at least one described as a ‘‘living bereavement,’’ (p. 61) and of being aware of the possibility that the drug use would ultimately lead to the person’s death. The grief after an overdose death usually involves complex emotions such as guilt, self-blame, and a sense of unworthiness to grieve. These factors could significantly affect the bereaved survivors in how they manage their emotions, cope with their experience, seek support, and remember the deceased. The previous discussion of disenfranchised grief from Chapter 4 might be very useful in approaching the needs of this population. Family members of those who survive an opioid overdose but who are left with significant cognitive deficits, organ failure, and/or an inability to function normally face a very complicated scenario of ambiguous loss, where a loved one is no longer the person he or she once was, and whose physical presence now is accompanied by the need for ongoing care, often with great expense, and with an intensification of family dynamics that have most likely already been fractured by the drug use of the affected family member.



14.  Current Issues and Trends for Grief Counselors

273

RECOGNITION OF DIVERSITY WITHIN GRIEF AND GRIEF COUNSELING It is important to keep in mind that the predominant views about grief and grief counseling come from research and literature that are published predominantly in the United States, followed by sources from mostly Western-oriented industrialized countries. The problem is that there is a tendency to apply the descriptions of grief and appropriate expectations and interventions related to grief to individuals in societies and cultures that may not share the same values and experiences. Konigsberg (2011) brings this point well to the forefront as she explores how individuals in Western society tend to view grief practices in non-Western cultures, implying that we “export” our grief theories and impose Western norms onto these cultures. Her descriptions are reminiscent of colonialist practices, where the invading group would claim dominance over the local culture and norms to establish a “better” and more “moral” life for the indigenous population. However, in the area of grief counseling, the “better” way is sometimes imposed on the indigenous culture without acknowledgment that these cultures may already have an effective way of approaching loss and grief; thus, the teaching of bereavement theory and practice in this way, without cultural awareness and sensitivity, has a distinctly narcissistic tone to it. Many cultures do not see sadness or suffering as entities to be rallied against; rather, these experiences may be quietly accepted as just a part of life. Even within Western cultures, there is a great deal of diversity regarding the expressions and rituals surrounding death. The Irish wake can be a celebration of the life of the individual who died, which can be punitively misinterpreted by outsiders as a grand form of denial and an excuse for a party, whereas the British emphasis on stoicism may be judged by others as a socially sanctioned form of suppression. In addition to cultural differences and variations, much is written on the influence of gender socialization on the grieving process, which explores variations between how men and women grieve (Doka & Martin, 2011; Golden, 2001; Lund, 2001; Versalle & McDowell, 2005). Although gender socialization is still a very strong influence on men and women in Western societies related to expression of affect and the cultivation of relationships, the changing roles of both women and men in the last generation in regard to work, education, and income means that there may now be more similarities than differences in grieving patterns and styles with both men and women (Practice Example 14.2). It is important to note that most of the research on grief is still influenced by the fact that more women than men tend to volunteer for research studies, and that the majority of bereavement research still draws heavily upon participation by individuals from middle-class/upper-middle-class, Western-oriented cultures. What is most important to consider here is that our tacit understandings of what constitutes “normal” grief are often based on descriptions and research from samples that cannot be readily generalized across cultures into a wide-ranging global context. As we have stated previously, the focus in grief counseling needs to be on congruence for the individual—can individuals experience and express their grief in a way that feels consistent with their personality, beliefs, culture, and experiences?

274

III.  Current Issues and Trends

P R A C T I C E EXAM PLE 1 4 . 2 SOCIAL EXPECTATIONS VERSUS THE INDIVIDUAL EXPERIENCE OF GRIEF

Brenda was an upper level manager in a large insurance company. On Christmas Day, two police officers appeared at her home to notify her of the death of her 25-year-old son the night before when he was attending a party. Apparently, many of the people at the party had been drinking heavily and using drugs. A fight broke out, and her son was knifed in the abdomen by one of the other young men who was there. Nobody realized that he had gone outside after the fight and died on the front lawn. Brenda was devastated by the loss of her son through such a senseless act. She kept picturing what might have happened in her mind over and over again. At his funeral, she felt like she was in a fog. Brenda hated being home and found being alone made things much harder for her, so she returned back to work a few weeks later. She took comfort in the structure and routine of the workplace, and many of the other managers were her friends as well. One day, Brenda was in an adjacent office when she heard two secretaries talking about her situation. Both were talking about how uncaring she seemed, and that something must be wrong with her if she wasn’t grieving the loss of her son because she returned back to work so soon. “I wouldn’t be able to function if that happened to me. I guess her work is more important to her than her son.” Brenda was deeply hurt by hearing these comments. Brenda was referred for grief counseling by the victim assistance program at the courthouse as the case was being brought to trial. She relayed this incident from work to her counselor, who discussed how her grief differed from the social expectations for women, and especially in this case, mothers. The counselor then explained that Brenda was the only person who would know what is best for herself in her grief.

TECHNOLOGY AND GRIEF COUNSELING The rapid growth of the use of technology in almost every sector of life has also had a big impact on how grief is studied, experienced, and supported. Many university-based programs are offered through an online interface and almost all journals and most of the books that have been published in the past 5 years are available in both hard copy and electronic versions for easy access. The ability to find current literature and research with (literally) the push of a button allows us to overcome many logistical barriers to current knowledge that were common in the past. As stated in the previous section, some professional organizations provide electronic access to important journals for their members. There truly is a knowledge explosion in general, and the ability to stay current in the field is now quite easy with this accessibility made possible through technology. The practice of grief counseling has certainly been affected by this burgeoning technological access. Not only do professionals have access to information and continuing education online but clients also have access to a wealth of material and information. In our practices, we try to keep abreast of good online resources that our clients might be able to utilize. These resources include information web pages that are written about various aspects of grief,



14.  Current Issues and Trends for Grief Counselors

275

online support groups, forums, blogs that provide solid and monitored assistance for specific types and aspects of grief, videos that are posted about grief and aspects of the grieving process, and links to self-assessment measures that may be used to heighten self-awareness or provide further groundwork for discussion in the counseling session. Another aspect of technology is the widespread use of social media that is often used by clients to process their grief. Many of our clients maintain their deceased loved ones’ Facebook sites, using them as a memorial sites and discussion boards for themselves and those who were close to their loved ones. Hieftje (2012) cites the importance of the use of social media and social networking online in the grieving process for emerging adults, functioning much like a virtual ongoing support group among those who knew the deceased individual. These online social networking sites allow bereaved individuals to feel connected to others who share their loss and, similar to forum sites and blogs, they have the added benefit of being available at any time of the day and are readily accessed from anywhere in the world (Practice Example 14.3). The uses of email and texting have also changed how we practice our profession. Many of our clients no longer call our offices to inquire about our services or to set up their appointments, preferring instead to send emails or texts for this purpose. It is not uncommon for a new client to come for a first appointment after email contact only, with our first actual conversation occurring when they are in our office. This change has both positive and negative aspects to it. On the one hand, it is convenient to be able to answer emails and texts when you are available to do so and to not have the interruption of the phone and the frequent

P R A C T I C E EXAM PLE 1 4 . 3 THE ROLE OF SOCIAL MEDIA IN THE GRIEVING PROCESS

Ken was 62 years old when he died suddenly of a heart attack. He had been a beloved husband, father, and friend to many people. News of his death hit his local community very hard, as he was so well-known through his philanthropy, involvement in civic clubs, and his work as a professor at the local university. Ken had a Facebook account, where he regularly posted funny things and pictures of his adventures (like skydiving) and his family (he was especially proud when his oldest daughter graduated from medical school the year before). Ken’s wife had the passwords for all of his accounts, including his Facebook account. She was about to take down his Facebook page when she saw how many people had posted their condolences and memories of Ken onto his site. Reading these posts was heartwarming to her, reminding her of many of his special qualities and seeing how many people whose lives he touched in various ways. She decided to keep the Facebook page as it was, using it to post memories herself, and to continue to share special things with his friends. She was especially touched when many of his friends posted tributes to him at the one-year anniversary of his death. She regularly went to his page and felt comforted by looking through the pictures and posts. She wasn’t sure how long she would keep the page active, but she knew that right now, Ken would feel pleased that his friends were supporting her in this way.

276

III.  Current Issues and Trends

occurrence of phone tag, leaving messages back and forth to try to reach someone who has called. On the other hand, the counselor can find electronic communication can be intrusive, as emails and texts from clients can be received 24 hours a day/7 days a week because there is no filter for the times when you are not in your office, and it takes diligence to set your boundaries in place so that your personal time is protected. There is also the issue of professional responsibility. For example, how would you handle an urgent text from a suicidal client on a Saturday evening? Some clients will also use email to process their feelings in between sessions, which can become lengthy and time consuming for the counselor to read, and most counselors do not bill for electronic communication with clients. Some regulatory bodies require counselors to treat electronic communication as part of the client record; if that is the case with your practice, you need to advise clients that any emails or texts they send to you will be printed out and will become part of their file. In addition, the counselor is at a disadvantage in using email to respond to clients during these times because much of the work of counseling involves the interactional component between the client and counselor, and many intuitive and more nuanced aspects of the communication can be lost in electronic communication. We thus will often advise clients that any electronic communication of substance sent to us between sessions will be reviewed with the client in the session times, unless there is an emergency or urgent issue that requires immediate attention. It also might be expeditious to indicate to clients that you can’t guarantee your availability outside of office hours, and to provide them with after-hours resources should they need urgent attention. Another new area in counseling is Internet counseling, using an application such as Skype or Facetime. This type of counseling can be advantageous to clients who otherwise would not be able to go to a counselor because of location, disability, difficulties with transportation, or unavailability of a grief counselor in their locale (Gamino, 2012). Training programs and workshops in how to offer counseling online are now very common, with many of these educational opportunities being provided by professional organizations whose members are involved in online counseling. Caution must be used with online counseling because of issues related to confidentiality and concerns that others may be able to “hack into” an unsecured wireless connection, and there must be consideration of where the client and counselor are both located at the time the online session occurs to ensure that their conversation is private. The Internet connection must be stable and allow for clear and accurate exchanges between the client and counselor. There is also concern for counselors who are located at a great distance from a client who is in acute distress, and whether the counselor has the ability to assist the client to get appropriate urgent help if necessary. Offering online counseling is also dependent on the ability of the counselor to feel comfortable in being able to engage with clients satisfactorily online in order to attend to the client in a similar way that he or she might in a regular face-to-face session. Obviously, Internet counseling is not going to appeal to everyone, but you will no doubt be asked about your ability to offer this type of support at some point in your practice. For more information about the use of online resources in grief counseling, we suggest the book Dying, Death and Grief in an Online Universe (Sofka, Cupit, & Gilbert, 2012).



14.  Current Issues and Trends for Grief Counselors

277

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

GLOSSARY “Broken-heart phenomenon”  The view that when the death of a bereaved individual occurs after the loss of a significant loved one, the individual “dies of a broken heart.” It is related to studies that demonstrate higher rates of morbidity and mortality in some bereaved individuals after the death of a loved one. Congruence  An individual’s ability to experience and express his or her grief in a way that feels consistent with his or her personality, beliefs, culture, and experiences. Resilience  The ability to recover quickly from illness, change, or misfortune; buoyancy. Not seen as a trait or characteristic in individuals, but an observation of their response to adversity. Social media Tools or applications that can be accessed through digital devices (smartphones, computers, tablets) that allow people to create, share, or exchange information, ideas, and pictures/ videos in virtual communities and networks. Stage theories of grief  The notion that a natural psychological response to loss involves an orderly progression through distinct stages of bereavement.

QUESTIONS FOR REFLECTION 1. You are a grief counselor. List sources of information on practice and research in

the field that you would regularly consult to stay current in the field. What might be the barriers to your being able to regularly access this information? What are possible ways that you could network and exchange information with other professionals in the field?

2. What do you think should be the minimum level of education, training, and expe-

rience for individuals who assist bereaved individuals?

3. One of the current controversies in grief counseling is the argument that the focus

on professional intervention for grief implies that normal grief needs professional intervention, despite the fact that most people do not require the assistance of a professional to successfully navigate through their grief. When do you think people might need the assistance of a grief counselor? When might grief counseling be unnecessary, or even harmful?

278

III.  Current Issues and Trends

4. Complete a search of online resources for grieving individuals. Which ones might

you find helpful in your work with clients? Which ones might be helpful for your clients?

5. Discuss the pros and cons of offering online grief counseling to bereaved

individuals.

REFERENCES Altmaier, E. M. (2011). Best practices in counseling grief and loss: Finding benefit from trauma. Journal of Mental Health Counseling, 33(1), 33–45. doi:10.17744/mehc.33.1.tu9wx5w3t2145122 Beckett, C., & Dykeman, C. (2017). A metatheory of grief: Implications for counselors. VISTAS Online (American Counseling Association). Retrieved from https://www.counseling.org/docs/defaultsource/vistas/Metatheory_of_Grief.pdf?sfvrsn=6 Bonanno, G. A., Westphal, M., & Mancini, A. D. (2011). Resilience to loss and potential trauma. Annual Review of Clinical Psychology, 7, 511–535. doi:10.1146/annurev-clinpsy-032210-104526 Breen, L. J. (2010–2011). Professionals’ experience of grief counseling: Implications for bridging the gap between research and practice. Omega, 62(3), 285–303. doi:10.2190/OM.62.3.e Bruera, E. (2018). Parenteral opioid shortage—treating pain during the opioid-overdose epidemic. New England Journal of Medicine, 379(7), 601–603. doi:10.1056/NEJMp1807117 Bruinsma, S. M., Tiemeier, H. W., Heemst, J. V. V., van der Heide, A., & Rietjens, J. A. (2015). Risk factors for complicated grief in older adults. Journal of Palliative Medicine, 18(5), 438–446. doi:10.1089/ jpm.2014.0366 Butler, P. M., Barash, J. A., Casaletto, K. B, Cotter, D. L., La Joie, R., Geschwind, M. D., . . . Miller, B. L. (2019). An opioid-related amnestic syndrome with persistent effects on hippocampal structure and function. The Journal of Neuropsychiatry and Clinical Neurosciences, Appi-Neuropsych. 31(2), 1–5. doi:10.1176/appi.neuropsych.19010017 Center for Disease Control and Prevention. (2019). Drug and Opioid-Involved Overdose Deaths– United States, 2013–2017. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1 .htm?s_cid=mm675152e1_w Corrigan, F. M., Fisher, J. J., & Nutt, D. J. (2011). Autonomic dysregulation and the window of tolerance model of the effects of complex emotional trauma. Journal of Psychopharmacology, 25(1), 17–25. doi:10.1177/0269881109354930 Doka, K. J., & Martin, T. L. (2011). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Brunner Routledge. Folgheraiter, F., & Raineri, M. L. (2017). The principles and key ideas of relational social work. Relational Social Work, 1(1), 12–18. Freed, P. J., Yanagihara, T. K., Hirsch, J., & Mann, J. J. (2009). Neural mechanisms of grief regulation. Biological Psychiatry, 66(1), 33–40. doi:10.1016/j.biopsych.2009.01.019 Gamino, L. (2012). Ethical considerations when conducting grief counseling. In C. Sofka, I. Cupit, & K. Gilbert (Eds.), Dying, death, and grief in an online universe: For counselors and educators (pp. 235– 246). New York, NY: Springer Publishing Company. Gamino, L. A., Sewell, K. W., Hogan, N. S., & Mason, S. L. (2010). Who needs grief counseling? A report from the Scott and White grief study. Omega: Journal of Death and Dying, 60(3), 199–223. doi:10.2190/OM.60.3.a Gamondi, C., Pott, M., Forbes, K., & Payne, S. (2015). Exploring the experiences of bereaved families involved in assisted suicide in southern Switzerland: A qualitative study. BMJ Supportive & Palliative Care, 5(2), 146–152. doi:10.1136/bmjspcare-2013-000483 Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15(3), 199–208. Golden, T. R. (2001). Swallowed by a snake: The gift of the masculine side of healing (2nd ed.). Kensington, MD: Golden Healing. Granek, L. (2016). Medicalizing grief. In D. Harris & T. Bordere (Eds.), Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion (pp. 111–124). New York, NY: Routledge.



14.  Current Issues and Trends for Grief Counselors

279

Hieftje, K. (2012). The role of social networking sites in memorialization of college students. In C. Sofka, I. Cupit, & K. Gilbert (Eds.), Death, Dying, and Grief in an online universe: For counselors and educators (pp. 31–46). New York, NY: Springer Publishing Company. Kersting, A., Ohrmann, P., Pedersen, A., Kroker, K., Samberg, D., Bauer, J., . . . Arolt, V. (2009). Neural activation underlying acute grief in women after the loss of an unborn child. American Journal of Psychiatry, 166(12), 1402–1410. doi:10.1176/appi.ajp.2009.08121875 Konigsberg, R. D. (2011). The truth about grief: The myth of its five stages and the new science of loss. New York, NY: Simon & Schuster. Larson, D. G., & Hoyt, W. T. (2009). Grief counselling efficacy: What have we learned? Bereavement Care, 28(3), 14–19. doi:10.1080/02682620903355424 Lund, D. A. (2001). Men coping with grief. Amityville, NY: Baywood. Miller, G. E., Chen, E., Sze, J., Marin, T., Arevalo, J. M. G., Doll, R., . . . Cole, S. W. (2008). A functional genomic fingerprint of chronic stress in humans: Blunted glucocorticoid and increased NF-kappaB signaling. Biological Psychiatry, 64(4), 266–272. doi:10.1016/j.biopsych.2008.03.017 Morrow, R. L., Bassett, K., Maclure, M., & Dormuth, C. R. (2019). Outcomes associated with hospital admissions for accidental opioid overdose in British Columbia: A retrospective cohort study. BMJ Open, 9(5), 1–20; e025567. doi:10.1136/bmjopen-2018-025567 Mughal, S., & Siddiqui, W. J. (2018). Grief reaction. In StatPearls [Internet]. StatPearls Publishing. Retrieved from https://europepmc.org/abstract/med/29939609 Neimeyer, R. A. (2014). The new grief for the new therapist: A contemporary orientation to bereavement counseling. New Therapist, 90, 6–13. Neimeyer, R. A., & Currier, J. M. (2009). Grief therapy evidence of efficacy and emerging directions. Current Directions in Psychological Science, 18(6), 352–356. doi:10.1111/j.1467-8721.2009.01666.x Norcross, J., Beutler, L., & Levant, R. (2005). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association. Ober, A. M., Granello, D. H., & Wheaton, J. E. (2012). Grief counseling: An investigation of counselors’ training, experience, and competencies. Journal of Counseling & Development, 90(2), 150–159. doi:10.1111/j.1556-6676.2012.00020.x O’Connor, M. F. (2012). Immunological and neuroimaging biomarkers of complicated grief. Dialogues in Clinical Neuroscience, 14(2), 141. O’Connor, M. F. (2013). Physiological mechanisms and the neurobiology of complicated grief. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 204–218). New York, NY: Routledge. O’Connor, M. F., Irwin, M. R., & Wellisch, D. K. (2009). When grief heats up: Pro-inflammatory cytokines predict regional brain activation. Neuroimage, 47(3), 891–896. doi:10.1016/j.neuroimage .2009.05.049 O’Connor, M. F., Wellisch, D. K., Stanton, A. L., Eisenberger, N. I., Irwin, M. R., & Lieberman, M. D. (2008). Craving love? Enduring grief activates brain’s reward center. Neuroimage, 42(2), 969–972. doi:10.1016/j.neuroimage.2008.04.256 O’Connor, M. F., Wellisch, D. K., Stanton, A. L., Olmstead, R., & Irwin, M. R. (2012). Diurnal cortisol in complicated and non-complicated grief: Slope differences across the day. Psychoneuroendocrinology, 37(5), 725–728. doi:10.1016/j.psyneuen.2011.08.009 Phillips, D. A., & Shonkoff, J. P. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academies Press. Rocker, G., Bourbeau, J., & Downar, J. (2018). The new “opioid crisis”: Scientific bias, media attention, and potential harms for patients with refractory dyspnea. Journal of Palliative Medicine, 21(2), 120– 122. doi:10.1089/jpm.2017.0619 Roest, B., Trappenburg, M., & Leget, C. (2019). The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: A systematic mixed studies review. BMC Medical Ethics, 20(1), 1–21. doi:10.1186/s12910-019-0361-2 Siegel, D. J. (1999). The developing mind. New York, NY: Guilford Press. Siegel, D. J. (2010). The mindful therapist: A clinician’s guide to mindsight and neural integration. New York, NY: Norton. Simon, N. M. (2013). Treating complicated grief. Journal of the American Medical Association, 310(4), 416–423. doi:10.1001/jama.2013.8614

280

III.  Current Issues and Trends

Sofka, C., Cupit, I., & Gilbert, K. (2012). Death, dying, and grief in an online universe: For counselors and educators. New York, NY: Springer Publishing Company. Srinivasan, E. (2018). Grief and medical assistance in dying: Lessons learned from Oregon. Journal of Pain and Symptom Management, 56(6), e30–e31. doi:10.1016/j.jpainsymman.2018.10.028 Stroebe, M., & Schut, H. (2010). The dual process model of coping with bereavement: A decade on. Omega: Journal of Death and Dying, 61(4), 273–289. doi:10.2190/OM.61.4.b Stroebe, W., Schut, H., & Stroebe, M. S. (2005). Grief work, disclosure, and counseling: Do they help the bereaved? Clinical Psychology Review, 25, 395–414. doi:10.1016/j.cpr.2005.01.004 Stroebe, M. S., Stroebe, W., Schut, H., & Boerner, K. (2017). Grief is not a disease but bereavement merits medical awareness. The Lancet, 389, 347–349. doi:10.1016/S0140-6736(17)30189-7 Templeton, L., Valentine, C., McKell, J., Ford, A., Velleman, R., Walter, T., . . . Hollywood, J. (2017). Bereavement following a fatal overdose: The experiences of adults in England and Scotland. Drugs: Education, Prevention and Policy, 24(1), 58–66. doi:10.3109/09687637.2015.1127328 Versalle, A., & McDowell, E. E. (2005). The attitudes of men and women concerning gender differences in grief. OMEGA-Journal of Death and Dying, 50(1), 53–67. doi:10.2190/R2TJ-6M4F-RHGD-C2MD Wagner, B., Muller, J., & Maercker, A. (2012). Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide. European Psychiatry, 27(7), 542–546. doi:10.1016/j.eurpsy.2010.12.003 Worden, J. W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (5th ed.). New York, NY: Springer Publishing Company.

CHAPTER 

15

C A SE S T UDI E S I N G R I E F C O UNS E L I N G

INTRODUCTION We have included this section with sample case studies for you to consider in light of what you have now learned and can hopefully apply in real-life situations with grieving individuals. Please note that the sample case studies described here are fictitious and are not actual client stories . In each of the following case studies, imagine that you are the counselor who is working with these individuals/families. In your role as the grief counselor, identify the following: 1. What is/are the main loss(es) that are described in this situation (both death and

non-death)? Next, identify the aspects of the individuals’ assumptive world that could possibly have been affected by what has happened.

2. Can you identify any potential factors that might predispose one of these indi-

viduals toward the development of complicated grief? Next, are there any signs of complicated grief in any of the individuals described here?

3. Consider the social context of the people involved in the case study. How might

social views and norms have an impact on this scenario and those involved? Are there aspects of disenfranchised grief in the scenarios?

4. Are there any indications of special precautions or interventions that you might

draw upon as you work with this case? Remember, your goal is not to “fix” things, but to provide the best supportive and compassionate presence that will allow your client to honor his or her grief in the best possible way.

282

III.  Current Issues and Trends

CASE STUDY 1: ALICE Alice was 46 years old and sought counseling for what she described as depression and anxiety. In the last 3 years, she had experienced the death of both parents for whom she had been a caregiver, and also her wife of 10 years. Her father died of a sudden heart attack and her mother died after living with cancer for many months. Her wife, Mary, died due to surgical complications after a mastectomy. Alice was able to express her feelings of sadness and loss at times, yet her central narrative was that she should “deal with it” and “get over it” and she often felt like a burden to those around her. Mary had 3 adult children from a previous marriage and while they shared a good relationship with Alice, they had recently become more distant after Mary’s death. As a result, Alice felt she should act more “in control” in order to support her stepchildren’s grief. Additionally, Alice’s parents’ estate was recently settled. Due to Alice and Mary’s relationship, her father had expressly stated that she was not to receive any of his vast estate. All four of Alice’s siblings were given a sizeable inheritance, thus creating significant strain in their relationships. Alice felt excluded, invalidated, and angered by the discrimination within her family. Specifically, she felt distressed by her father’s homophobia and her sibling’s inability to recognize her as family when the estate was being settled. While Alice described feelings of depression, she also explained that she did not sleep well, had lost weight, was experiencing difficulty regulating her emotions, and she often did not want to leave the safety of her home. She had maintained her job as a paralegal, yet felt she was underperforming and often did not want to go to work. Alice also disclosed that she often thought about killing herself, as the pain, loss, and loneliness were overwhelming to her.

CASE STUDY 2: JEREMY Jeremy was a 24-year-old law student who had been seeking supportive counseling for several months while completing his studies and working part time. He was living away from his family and had developed a few close friendships with his classmates. Jeremy was highly driven and focused, and he wanted to be a prosecuting attorney. He had been encouraged to go into law by his grandfather, who was a prominent lawyer. Jeremy felt very supported by his grandfather throughout most of his life, as both of Jeremy’s parents struggled with alcohol addiction and his grandfather had often assumed a parenting role. Much of Jeremy’s counseling had focused on maintaining wellness during his schooling, yet he did acknowledge the strain with his parents and the worry about their ongoing struggles with alcohol use. Jeremy found it helpful to be living away from them so that he could focus on establishing his own life apart from them. One day, he attended counseling and was very distraught. He had heard that a man who used to live in his neighborhood had died. This neighbor, Andrew, had been a close friend of his parents and had also been Jeremy’s soccer coach. Andrew often attended the many parties that Jeremy’s parents hosted at their home. Jeremy explained that 2 years ago, Andrew got very drunk and sexually assaulted him, yet Jeremy never disclosed this to anyone. Upon learning of Andrew’s death, Jeremy felt both sadness and anger. He was struggling to make sense of why he was crying over someone who hurt him so deeply.



15.  Case Studies in Grief Counseling

283

CASE STUDY 3: BETH Beth’s husband David died after a workplace accident. At the hospital, he was misdiagnosed as having non-life-threatening injuries and released. At home, he became quite ill and collapsed in front of Beth and their four children. They all witnessed him being taken away by ambulance and the family followed behind in the car. In the emergency department, medical staff realized he had serious internal bleeding and required immediate surgery. Due to the chaos of this medical emergency, Beth witnessed all of this. The last time she saw her husband was when he was being whisked away on a gurney into the operating room. David died while on the operating table. Beth was unspeakably devastated. She described her marriage as strong and loving, and they shared an enjoyable family life together raising their four kids. David enjoyed his job, coached various sports teams that his kids were on, and they had a large, loving extended family. In addition, Beth worked as a nurse. She knew David was misdiagnosed but could not get medical staff to take her seriously. They dismissed her as being an overprotective, doting/ grieving wife.

CASE STUDY 4: SYLVIA Sylvia was a 37-year-old woman whose mother died under suspicious circumstances. It is unclear whether she died of an intentional or accidental overdose. Sylvia lived one hour away and tried to visit with her mother at least once a month. Sylvia was the first to find her mother after coming home for a visit. She initially thought her mother was sleeping, since her mother was struggling with depression and was often on the couch. After watching television for a brief period, she wondered why her mother did not wake up and she did not respond when Sylvia tried to wake her. Sylvia then realized that her mother might be dead, and she called 911, then the neighbors. She recalls how chaotic it was, and how she felt so helpless. While Sylvia tried to support her mother prior to her death, they had a difficult relationship, as her mother struggled with depression and substance abuse throughout Sylvia’s childhood and into adulthood.

CASE STUDY 5: MICHAEL Michael was a 22-year-old who had been best friends with Jordan since they were 4 years old. Over a long weekend, Jordan was killed in a motor vehicle accident and Michael was in complete shock. He remembers many details of finding out about Jordan’s death and the funeral, but describes feeling numb, like it was all a really bad nightmare. Three months after Jordan’s death, Michael made an appointment with a grief counselor. He reported feeling sad most of the day, with a sense of hopelessness, thinking that the world was cruel for killing his friend when there are awful people who do horrible things who are still alive. This deep sense of unfairness was the focus of the first few counseling sessions. Michael also described their friendship and his feeling that they had been more like brothers, lived three houses from each other their whole lives, played on the same sports teams, and had planned to travel around the world together in the next year. Michael feels he is not

284

III.  Current Issues and Trends

sure how he can move forward. He reports disrupted sleep patterns, low appetite, weight loss, low energy, and has difficulty concentrating.

CASE STUDY 6: AYESHA Ayesha came for counseling to talk about her “family situation.” She and her husband had two daughters, one who was in her first year of university, and the other who was still in high school. A year ago, the younger daughter was involved in a bad car accident, which led to several broken bones and a traumatic brain injury. Ayesha was a surgeon at the hospital where her daughter had been admitted after the accident. She took several weeks off from work to be at her daughter’s bedside and to assist with her rehab and physical therapy. As a result of the brain injury, her daughter’s personality was different. She became angry easily and often lashed out at her family members and the care team. She was often frustrated because she couldn’t concentrate or focus, and she had been a straight-A student beforehand. When she was finally able to return to school, her daughter could not keep up with the reading and assignments. She failed several tests because she couldn’t remember the information she needed for her exams. She began to hang out with kids in the school who were known to have “troubles.” When Ayesha expressed concern about these friends, her daughter said, “They understand me, and they don’t give me a hard time about things.” Several months later, Ayesha discovered street drugs in the pocket of her daughter’s jacket. When she confronted her daughter about this, her daughter stormed out of the house and didn’t return that night. Ayesha was sick with worry and frightened for her daughter. Over the next few months, her daughter’s behavior escalated, and Ayesha knew that she was using drugs and often skipping her classes. She also discovered that her daughter had been stealing cash from her purse and had sold some of her personal items to make money to buy drugs. When she came to counseling to discuss all that had happened, Ayesha said, “I feel like I have lost my daughter. The young girl that I knew no longer exists, and I don’t know what to do with the girl that has replaced her.”

CASE STUDY 7: STEPHEN Stephen was a corporate executive whose career took off two years ago, when he was named as one of the vice presidents of his company. While he was incredibly happy about his career trajectory, there was friction between he and his wife at home because he was often late getting home due to meetings, and he was continually available by phone/text on all evenings and weekends. He only saw their two young children briefly at night before they went to bed if he was lucky, and they often went with their mother to do things on the weekends because he had a hard time getting away. Finally, his wife gave him an ultimatum and told him that she had not married a husband who would be absent to her and their children, and she went to her parents’ place for the weekend. Stephen loved his family very much, and he decided to plan a weekend getaway for the family at a cottage on a lake where the cell phone coverage was spotty so that he would be pretty much unreachable during that time. When they were driving to the cottage for their weekend getaway, Stephen’s phone went off. He sheepishly



15.  Case Studies in Grief Counseling

285

reached for it on the dashboard, but in the few seconds that he reached over, he misjudged a corner on the road and they collided into an oncoming car. His youngest child was killed, and they were all hospitalized with injuries for several weeks. Months after the accident, Stephen sought counseling. He described feeling completely responsible for his son’s death, and he didn’t know how he could continue living with the knowledge that his distraction had caused the loss of his son and his family as he had known it. He and his wife could not talk about what happened, and he assumed that she blamed him for what happened as well. There was an “icy coldness” between them that he didn’t feel he could do anything about. In one session, he said “I think it would be better if I just wasn’t around anymore.” Spending time with his daughter was incredibly difficult because it made him feel worse about losing his son. His daughter had suffered a broken arm and leg in the crash, and she had needed therapy to walk again. He described the pain of his grief as “just unbearable.” To complicate matters, he was being pressured by his workplace to resume his duties as a key person in the organization. Stephen felt that he had lost all that was important to him just months prior.

CASE STUDY 8: SAMUEL Samuel was a 25-year-old Indigenous man who had experienced the death of his father at age 2, and then his mother when he was 24. His father was killed in a car accident and his mother died of cancer. He had been one of her caregivers, alongside many family members and friends. He and his family had lived on the reserve throughout his entire life and he could not imagine living anywhere else. He felt a sense of community and connection with his family and peers. Samuel acknowledged that he typically did not see the need for counseling and questioned if his culture would be respected throughout the process. As he shared his grief, he commented that he often felt conflicted between traditional Indigenous practices and beliefs in contrast with Christian values. Several elders he knew had attended residential school and no longer spoke their language or attended ceremonies. Other family members attended a nearby Christian church and strongly encouraged him to abandon the Indigenous rituals, beliefs, and ceremonies. Meanwhile, some of his friends attended pow wows, participated in Longhouse ceremonies, and spoke their language openly. As he grieved his mother’s death and revisited the loss of his father, he wanted to find a way to make sense of these contrasting beliefs. He felt that traditional ceremonies and practices were essential to his sense of well-being; however, he felt pressured by some of his family members to abandon these cultural customs. Being at this crossroads made him feel like he was dealing with more losses than of his parents alone.

CASE STUDY 9: COLIN Colin had been married for 16 years to his wife Catherine. They had three children under the age of 12. They met in medical school and both worked as physicians; Colin was a cardiac surgeon and Catherine had been an oncologist. With two full-time jobs and three kids, their lives were full and busy each day, yet they enjoyed their lives, both personally and

286

III.  Current Issues and Trends

professionally. They had extended family members nearby who helped with the kids and they had several friends with whom they enjoyed socializing. Over a 6-month period, Colin noticed that Catherine was not quite herself. She was restless, did not sleep very much, and she had lost 10 pounds from her slight frame. She seemed unfocused at times and started socializing less. When he approached her about it, she said that work and home life were just tiring sometimes, and she wanted to have more time to stay home. Colin could not shake the sense that something was wrong but couldn’t articulate what it was. One morning, he took the children to the park and when they came home, he discovered that Catherine had taken an overdose of medication and had died. When he presented for counseling 6 months after her death, he described the routine he had established for himself and the kids and how he had modeled an open approach to discussing their shared grief; however, he explained that he felt overwhelmed and tremendously guilty for not intervening prior to her death.

CASE STUDY 10: RICHARD Richard was a 73-year-old man who sought counseling after the death of his wife 4 months prior. When he came for his first session, he shared that “I am no stranger to grief.” He then described how his first wife had died of cancer when they were in their late 30s. Richard parented their four children alone for several years until he met his second wife. His described his second marriage as “phenomenal.” He felt very fortunate to have married two “wonderful women.” When his second wife was diagnosed with cancer, Richard froze. She had surgery and was given a clean bill of health after undergoing chemotherapy that was meant to “catch any cancer cells that might have been left.” Six years after her treatment, the cancer returned and had already spread through her body. Once again, Richard was the caregiver to his dying life partner, an oddly familiar role to him. After she died, he described feeling that his life was “gray and lifeless.” His children were all grown and lived in different cities. He would receive frequent phone calls from them, and he felt their worry for him was “just sad that they have to spend time fretting about me.” He traveled to visit friends and family who lived out of town to distract himself, always dreading returning home to his empty house. He regularly drove by the cemetery where his second wife was buried, describing his grief as a “deep ache” inside his chest. At one point, he shared that he felt “lost” and “tired,” and wasn’t sure he wanted to continue to live and experience more pain that would inevitably be part of his life.

AFTERW OR D

NEXT STEPS Donna was a 40-year-old woman who asked for an appointment to talk about her concerns about her father. Her mother had died 6 months prior, and she felt that her 68-year-old dad was in denial about the death of her mother. Less than a month after her mother died from a 5-year bout with cancer, Donna’s dad began going out with a woman who lived in his condominium complex. When Donna ran into them at a restaurant one night, she was flabbergasted to see them together, obviously enjoying each other’s company. Donna felt a sense of betrayal for her deceased mother, wondering how her dad could so readily forget about their lifelong marriage. In the session where Donna shared her feelings of shock and betrayal about her dad’s dating so soon after her mother died, she and the counselor talked about how her dad might be feeling. Donna recognized that her mother really had not been much of a partner to her dad for several years, as she had become dependent upon him for care and monitoring of her medications for a long time. She also considered that the woman that her dad was dating knew her mother, and they were friends. Perhaps her dad felt comfortable with her because they could easily talk about her mother in ways that he might not have been able to with anyone else. The counselor also talked about the statistics that indicated that what her dad was doing was both common and probably helpful for a man of his age whose wife had died. Donna left that session feeling sad that she had been so judgmental of her dad, who had always been a devoted father to her and husband to her mother. She went to his home later in the week and told him that she was sorry for her harsh words about his choices and that she loved him dearly. He then told her that he missed her mom very much, especially the way she was before she became so ill. He knew that nobody could ever replace her in his life, but he

288

Afterword

was also lonely and felt sad at home alone. The woman he was dating would often share her own memories of his wife with him, which he found comforting. Donna was honest about needing some time to adjust to his new relationship, but she also expressed her love for her dad and told him that above all, she wanted him to be happy. She also thought that her mom would want him to be happy as well. Thinking back about what we have shared in this book, could you think about ways that you might have handled Donna’s feelings? How about her concerns for her father? How would you have known what was most important to focus on in her sessions? We hope that after reading the content of this book, you would feel more confident in your support of a client like Donna and that you would be able to assist her to honor her own grief even as her father grieved in his own way. In this book, we have discussed many aspects of grief counseling. We have delineated how grief counseling is unique from other forms of counseling because the normal grieving process is not something that needs to be treated, but rather allowed to unfold in its own healthy and adaptive way. Whether you are a clinician with many years of experience or a novice to this field, hopefully you have gleaned a good, solid understanding of the grieving process and an appreciation for the importance of learning how to be fully present to the experiences of bereaved individuals, both as a professional and as a fellow traveler on life’s path. We also hope that you will more readily recognize that experiences of significant loss and change can be akin to the grief that occurs after the death of a loved one. There is no need for there to be a “body” per se in order to realize that a death of something intangible or symbolic (but nonetheless significant) has occurred. Grief counseling is really about honoring losses that occur as part of normal lived human experience. The grief response is often socially stigmatized because it reveals our vulnerability in the midst of a society that places such a high value on productivity, efficiency, and rugged individualism. Human beings are social creatures, meant to form strong attachments to others as part of their existence and survival; however, the focus on highly individualistic and materialistic goals makes this relational side of our being seem like a detriment instead of a gift. What we have often found in counseling individuals whose worlds have been shattered by loss is that the time we feel broken and vulnerable can also be a time of great potential. In the painful process of having to rebuild your assumptions about the world after a significant loss, you might also begin to question priorities and goals that were previously taken for granted, or to see life in a way that you may never have seen it before. After a period of time, it is common for our clients to begin to realize that they are much stronger and more resilient than they ever thought was possible. With this recognition, they find possibilities that they may never have been considered before. When you journey alongside bereaved clients for a while and begin to see this type of pattern emerging from the despair, you begin to trust the process more, and you can find the work fostering a sense of hope and meaning rather than being depressing and morbid. Halifax (2004) refers to this type of journey as the “fruitful darkness,” indicating that we often become more open to receiving and learning some of the most valuable lessons and insights about ourselves, others, and the world after we go through some of the darkest times in our lives.



Afterword

289

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

REFERENCE Halifax, J. (2004). The fruitful darkness: A journey through Buddhist practice and tribal wisdom. New York, NY: Grove Press.

INDEX

accommodation, 37 accurate empathy, 9 ADEC. See Association for Death Education and Counseling adult grief, 110–113 advanced empathy, 88, 89 advocacy and complicated grief, 181–182 ambiguous loss, 127–129 ambivalent attachment style, 33 American Psychiatric Association (APA), 158 anger, 151–152 APA. See American Psychiatric Association assimilation, 37 Association for Death Education and Counseling (ADEC), 263 assumptive world and grief, 16–19 and loss, 122–124 atomistic focus, 46–47 attachment and grief response, 29–31 attachment behaviors, 29 attachment bonds, 29 attachment relationships, 29 attachment style and grief experience, 33 attachment theory, 16–17, 30 attending skills attentive body language, 81–82 eye contact, 80

SOLER model, 82 verbal tracking, 81 vocal qualities, 81 attentive body language, 81–82 auditory style, 84 avoidant attachment style, 33 behaviorally experienced grief, 103–104 being with presence, 67–68 bereavement by homicide, 173–176 bereavement efficacy studies, 22 bereavement theory, 20–21 body scan technique, 201 boundaries, therapeutic relationship, 220–224 broken-heart phenomenon, 267 burnout, 243–244 Canadian Association of Social Workers (CASW), 228–229 Canadian Counselling and Psychotherapy Association (CCPA), 228–229 CASW. See Canadian Association of Social Workers CBT. See cognitive behavioral therapy CCPA. See Canadian Counselling and Psychotherapy Association CFT. See compassion-focused therapy CG. See complicated grief

292

Index

CGT. See complicated grief therapy change and loss, 19–20 childhood attachment, 30–31 children and youth, developmental grief, 107–110 chronic sorrow clinical depression vs., 127 definition of, 126 nonfinite loss and, 124–127 posttraumatic stress disorder vs., 127 clinical depression vs. chronic sorrow, 127 closed questions, 84 clustering, 193–194 cognitive behavioral therapy (CBT), 178–179 cognitively experienced grief, 101 compassion cultivation, 72–74 definition of, 72 compassionate awareness cultivation, 59–60 compassion fatigue, 244 compassion-focused therapy (CFT), 202–204 competence ethical issues, 262 grief counseling, 228–230 professional currency and, 261–265 complicated grief (CG) advocacy, 181–182 assessment for, 117 clinical implications for, 176–177 cognitive behavioral therapy, 178–179 complicated grief therapy, 178 description of, 161–162 empowerment, 181–182 meaning reconstruction therapy, 179–180 multiple risk factors, 163 Shear’s clinical features of, 162 social support and stigma in, 181 traumatic grief therapy, 178 use of medication in, 180–181 complicated grief therapy (CGT), 178 confidentiality, therapeutic relationship, 224–226 conflicted relationships, 192–193 congruence, 9, 273 contemplative practices, 71–72, 247–248 continuing bonds theory, 32–35 coping resources, 242 counseling. See also grief counseling

conditions, 9 couple, 10 definition of, 4 family, 11 goals of, 4, 11–12 individual, 10 marriage, 10 counseling misconceptions counselor as expert, 5–6 emotionally unstable people, 6–7 focusing on problems, 7–8 good friends, 7 only weak individuals seek counseling, 5 counseling practice appropriate use of questions, 84–87 attending skills, 80–82 empathy, 87–89 encouraging skills, 89 first session, 95–96 immediacy, 90–91 observation skills, 82–84 overview of, 79–80 paraphrasing skills, 89–90 resistance, 93–95 self-disclosure, 92–93 setting groundwork, 80 summarizing skills, 90 tracking skills, 82–84 counseling psychology, 4 counselor ethical issues self-awareness, 220, 221 shadow side of counseling, 218–220 counselor’s feelings, 153–154 couple counseling, 10 critical feelings, 140–141 culturally conscientious practice, 57 demographics and grief, 110–113 depression and grief, 167–168 developmental grief adult grief, 110–113 changing demographics, 110–113 children and youth, 107–110 Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 158 disenfranchised grief, 52 disordered grief, 48–49 disorganized attachment style, 33

dissociation, 166 diversity in grief, 105–107 diversity within grief, 273 DSM-5. See Diagnostic and Statistical Manual of Mental Disorders dual process model bereavement, 31–32 of grief, 31–32 dual relationships, 226–228 economically experienced grief, 103 EEs. See extraordinary experiences EFT. See emotional freedom technique electronic communication, 192 EMDR. See eye movement desensitization and reprocessing emotion(s). See also feelings counselor self-awareness, 148 feelings vs., 140 intense, 143 learning to work, 147 suggestions, 149–153 working with, 148–149 emotions in grief, 100–101 emotional freedom technique (EFT), 198 emotional intelligence, 142–147 empathy, 87–89 accurate, 9 advanced, 88, 89 empowerment and complicated grief, 181–182 empowerment model work, 58 encouraging skills, 89 energy-based therapies emotional freedom technique, 198 eye movement desensitization and reprocessing, 197 overview of, 196–197 thought field therapy, 198 ethical issues competence, 262 counselor ethical issues, 218–220 overview of, 217–218 therapeutic relationship, 220–228 experience of grief behavioral, 103–104 cognitive, 101 economical, 103

Index

293

emotional, 100–101 physical, 101 social, 102–103 spiritual, 101–102 experiencing presence, 71 external stresses, 241–242 extraordinary experiences (EEs), 104–105 eye contact, 80 eye movement desensitization and reprocessing (EMDR), 197 family counseling, 11 fear, 149–151 feelings counselor’s, 153–154 critical, 140–141 emotions. See emotion(s) functional, 142 vocabulary list, 145–146 felt sense, 142 “fight–flight” response, 142 first session counseling practice, 95–96 friendship relationship, 222 functional feelings, 142 fundamental illusion, 20 GRACE model, 73–74 grief acknowledging, 53 after medical assistance in dying, 269–270 assumptive world and, 16–19 attachment and, 29–31 attachment style and, 33 continuing bonds theory, 32–35 cultural perspectives, 54–56 definition of, 28 depression and, 167–168 disenfranchised, 52 diversity within, 273 dual process model of, 31–32 hardiness, 40 individual. See individual grief meaning reconstruction and growth, 37–39 neurobiology of, 265–268 normal, 47–51 phase-based model of, 36 posttraumatic growth, 40–41 resilience, 40–41

294

Index

grief (cont.) social expectations vs. individual experience of, 274 social rules and norms, 51–54 stage-based model of, 36 stage theories, 263 task-based model of, 36–37 traumatic, 164–166, 177 two-track model, 32–35 validating, 39 grief counseling. See also counseling benefits from, 22–23 bereavement efficacy studies, 22 bereavement theory, 20–21 case studies in, 281–286 change and loss, 19–20 definition of, 9–10 recognition of, 273 technology and, 274–276 unexpected benefits of, 6 grief counselors compassionate awareness cultivation, 59–60 diagnostic criteria applications, 57–58 empowerment model work, 58 language monitoring, 58–59 overview of, 56–57 self-awareness cultivation, 58 subjective experiences, validating and supporting, 59 grief surges, 105 grief triggers, 105 grief work hypothesis, 21, 35 grieving process, social media, 275 grieving styles, recognizing, 11 group work, 208–210 hardiness, 40 helper-therapy principle, 261 homicide bereavement, 173–176 ICD-11. See International Classification of Diseases immediacy, 90–91 individual counseling, 10 individual grief atomistic focus, 46–47 micro practice, 46 individualistic disordered grief, 48–49

innate resilience, 260–261 instrumental grievers, 106 Integration of Stressful Life Events Scale (ISLES), 122–123 intelligence, emotional, 142–147 intense emotions, 143 Internal Family Systems (IFS) model of therapy, 204–205 internal resources, 242 internal stressors, 238–241 International Classification of Diseases (ICD-11), 160 intimate relationship, 222 intuitive grievers, 106 ISLES. See Integration of Stressful Life Events Scale journals, 192 kinesthetic style, 84 language monitoring, grief counselors, 58–59 suicide bereavement, 171 tracking skills, 83 letters, 192 letter writing, 195–196 life as book, 195 linking objects, 115 rituals and. See rituals and linking objects use of, 190 living bereavement, 272 living loss, 129–130 living loss implications fostering realistic expectations, 132 identifying resources, 134 naming and validating loss, 132 normalizing ambivalence, 133–134 overview of, 130–132 reconstructing identity, 133 loss ambiguous, 127–129 assumptive world and, 122–124 definition of, 28 living, 129–130 nonfinite, 124–127 traumatic, 164, 174, 177, 179 loss line exercise, 74

macro practice, 46 MADD. See Mothers Against Drunk Driving marriage counseling, 10 master narrative, 38–39 MBTI. See Myers-Briggs Type Indicator meaning finding, 39 meaning making definition of, 39 social constructivist view of, 38–39 meaning reconstruction, 37–39 meaning reconstruction therapy, 179–180 mediators of mourning, 107 metaphors, 195 mezzo practice, 46 micro practice, 46 mindfulness-based interventions body scan technique, 201 breath, 201–202 overview of, 200–201 Mothers Against Drunk Driving (MADD), 38 movement synchrony, 82 Myers-Briggs Type Indicator (MBTI), 199–200 narcissistic snares, 239 neurobiology of grief, 265–268 nonfinite loss, 124–127 normal grief, 47–51 observation skills, 82–84 occupational stress burnout, 243–244 coping and internal resources, 242 external stresses, 241–242 internal stressors, 238–241 manifestations of, 243–245 secondary traumatization, 244–245 ongoing disparity, 126 open-ended questions, 84–86 opioid crisis effects, 270–272 paraphrasing skills, 89–90 parent-child relationship, 222–223 PCBD. See persistent complex bereavement disorder PDMPs. See prescription drug monitoring programs perinatal loss mementos, 191–192

Index

295

persistent complex bereavement disorder (PCBD) diagnosis of, 160 DSM-5 criteria for, 159–160 personality inventory, 198–200 PGD. See prolonged grief disorder phase-based model of grief, 36 photo narrative definition of, 208 in grief therapy, 209 physically experienced grief, 101 posttraumatic growth, 40–41 posttraumatic stress disorder vs. chronic sorrow, 127 power therapies. See energy-based therapies preparation for presence, 71 prescription drug monitoring programs (PDMPs), 271 presence being with, 67–68 overview of, 65–67 recognizing patient’s needs, 68 therapeutic, 66, 68 presence cultivation compassion, 72–74 reflection, 70–72 safety inside/safety outside, 69–70 self-awareness, 70–72 presence exercise, 75–76 presence practice loss line exercise, 74 simple presence practice, 76 process of presence, 71 professional peer support groups, 246 Professional Quality of Life Scale (ProQOL), 254–258 prolonged grief disorder (PGD) diagnosis of, 160 ICD-11 criteria for, 161 ProQOL. See Professional Quality of Life Scale questions appropriate use of, 84–87 closed, 84 guidelines, 86–87 open-ended, 84–86 reflection, 70–72 reproductive loss mementos, 191–192

296

Index

resilience, 40–41 innate, 260–261 resistance, counseling practice, 93–95 resurgences, 105 rituals, 116–117 rituals and linking objects conflicted relationships, 192–193 letters, journals, and electronic communication, 192 overview of, 188–189 perinatal/reproductive loss mementos, 191–192 symbolic objects and personal belongings, 189–191

suggestions for grief do less and be more, 114 knowing yourself, 114 legacies, 116–117 referring help, 117 re-membering, 114–115 rituals, 116–117 tuning in, 116 suicide bereavement, 168–169 complexities around, 169 impact of, 170–173 language around, 171 summarizing skills, 90 symbolic objects, 189–191

sadness, 152–153 safety inside presence, 69–70 safety outside presence, 69–70 sandtray therapy definition of, 205 hands in sand, 206 tray as metaphor, 206–208 secondary traumatic stress, 244 secondary traumatization, 244–245 secure attachment style, 33 self-awareness, 70–72, 114 self-awareness cultivation, 58 self-care, 245–249 self-compassion, 245–250 self-disclosure, 92–93 sense of relief, 172 separation distress, 29, 122 shattered assumptive world, 17 simple presence practice, 76 SMILES. See Social Meaning in Life Events Scale socially constructed views of disordered grief, 48–49 socially experienced grief, 102–103 Social Meaning in Life Events Scale (SMILES), 123 social media, grieving process, 275 social rules and norms, 51–54 SOLER model, 82 spiritually experienced grief, 101–102 stage-based model of grief, 36 sudden temporary upsurges of grief (STUG) reactions, 105

task-based model of grief, 36–37 teacher-student relationship, 223 technology and grief counseling, 274–276 temperament inventory, 198–200 TFT. See thought field therapy TGT. See traumatic grief therapy therapeutic alliance, 8–9, 188 therapeutic presence, 66, 68 therapeutic relationship, 8–9 boundaries, 220–224 confidentiality, 224–226 dual relationships, 226–228 thought field therapy (TFT), 198 tracking skills, 82–84 transformed faith consciousness, 102 traumatic countertransference, 239 traumatic grief, 164–166, 177. See also complicated grief (CG) traumatic grief therapy (TGT), 178 traumatic loss, 164, 174, 177, 179 traumatization, secondary, 244–245 trauma, vicarious, 244 two-track model grief, 32–35 unconditional positive regard, 9 validating grief, 39 verbal tracking, 81, 83 vicarious trauma, 244 virtual dream exercise, 196 visual style, 83 vocal qualities, 81 vulnerability, 53

WHO. See World Health Organization window of tolerance, 268 World Health Organization (WHO), 160, 270 writing and narrative as therapy

Index

clustering, 193–194 letter writing, 195–196 life as book, 195 metaphors, 195

297