Grief
Counseling Resource Guide
A Field Manual
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New
York State Office of Mental Health
Sharon Carpinello, RN, Ph.D.
Comissioner
Bureau
of Education and Workforce Development
Deborah Wagoner
Director
Joe LeViness
Project Director
Authors
Susan Wheeler-Roy, Ed.D.
Bernard A. Amyot, M.S., M.A.
Special Thanks To:
Gail Meehan
Ann Cohan
Copyright © 2004 by New York State Office of Mental Health. All rights
reserved.
Table of Contents
Introduction
Section 1 Bereavement Counseling – A Framework
Section 2 Helping Skills for the Outreach Worker
Section 3 Personal Impact of Grief
Section 4 Sudden Death Loss Issues
Section 5 Secondary Loss Issues/Adaptation Strategies
Section 6 Rituals
Section 7 Gender Issues in Bereavement
Section 8 Care for the Caregivers
Bibliography
Introduction
This manual has been developed as a guide for those who encounter
individuals reacting to trauma related grief reactions in the course of
their outreach work. It is hoped that this document will be helpful for
both licensed mental health practitioners with limited experience working
with individuals who are grieving as well as for paraprofessionals and outreach
workers. Whenever a person is encountered who is experiencing severe
reactions or complicating conditions for which the worker feels unqualified
to
address, consultation with an appropriate mental health professional and an
appropriate referral for more formal services should be made.
Section 1 Bereavement Counseling – A Framework
Elizabeth Kubler-Ross has taught us that we must see the bereaved people we
serve
and counsel as our teachers. We need to allow them to teach us what their experience
is, rather than constructing some set of goals and expectations that we expect
them to meet and achieve. In Zen Mind, Beginner’s Mind, Shunryu Suzuki
wrote, “In
the beginner’s mind there are many possibilities. In the expert’s
mind there are few.” We
are not the experts on anyone’s grief. As bereavement workers we must
meet the grieving
without expectations about what should happen or what they should be feeling.
There
are no experts in this work.
John Welshons, in his fine book entitled Awakening from Grief, states:
“So there is no way to apply systems, rules or emotional road maps. Our
job is to be a presence, rather than a savior. A companion, rather than a
leader. A friend, rather than a teacher.” (p 159)
The Companioning Model of Bereavement caregiving developed by Dr. Alan D. Wolfelt
is one in which we as bereavement caregivers help people to integrate life’s
losses by
being present to them and observing them—companioning. He tells us that
observance
comes to us from ritual. It means not only “to watch out for,” but
“to keep and honor, to
bear witness.” Wolfelt elaborates on the companioning idea:
Utilizing this model of bereavement caregiving, the helper:
The heart of grief counseling, according to Dr. Ken Doka, writer and lecturer
in grief and loss, is validation. Grieving individuals need reassurance that what they
are experiencing is normal. Counselors can help people understand and identify the ways they
are reacting. Some people grieve through their expression of feelings. Others grieve
through problem-solving, thinking, and activities. Doka, in a recent presentation (2002),
maintains that there are many different ways in which individuals experience, express
and adapt to loss.
Section 2, Helping Skills for the Outreach Worker
These skills are ways to show people that you are paying close attention, that
you care,
and that you are actively listening. The better the helper listens, the more
the individual
may share. This is a caring relationship and develops through mutual respect.
Eye Contact and Facial Expression:
Body Language:
Vocal Style:
Verbal Following:
Verbal Skills/Interventions:
Open Questions:
Examples:
Paraphrasing:
“How do you feel about the situation?”
“What are some things that trouble you most?”
“Could you tell me how the job is going?”
“Could you give a concrete or specific example?”
Example:
Reflecting Feelings:
“I have been having a terrible time at work. I am so restless and just
can’t seem to concentrate. My supervisor told me that I am not doing a good job and that if
I
don’t improve, she would fire me.”
Example Paraphrase:
“You’re saying that you have difficulty concentrating and that your
supervisor is
displeased with your work and may fire you.”
The helper statement above is a distilled, shortened and clarified statement
which catches the essence of what has been said.
In reflecting feelings, the following steps are most essential:
Examples:
Additional helpful comments/phrasing:
“Sounds like that makes you angry.” “You feel very discouraged right now.”
“I sense some feelings of confusion.” “You are feeling really
sad at the moment.”
Non-Supportive Behaviors
Verbal Behaviors:
Non-Verbal Behaviors:
Section 3, Personal Impact of Grief
The grief experience impacts all aspects of the being of the individual. The
manifestations
listed are more intensified when there has been a sudden, unanticipated
death. With the intensification, the period of time to process the reactions
will often
be longer. It is important to remember there is no timetable for processing.
Grief reconciliation
depends on many other factors confronting the individual in his/her life. People
are not only grieving, they are also participating in life and those stressors
will affect the
journey of adaptation.
An individual may not experience all reactions that are listed. Reactions may
change over
time. What needs to be noted is that the reactions FOLLOW the loss event; it
is then
that a grief reaction is considered.
Physical Reactions:
As part of the individual’s way of handling the stress and anxiety of
his/her loss experience,
the following are possible physical reactions:
Changes in appetite:
Sleep disturbances:
Exaggeration of other physical situations:
Note: All are often triggered by poor eating and sleeping habits, thereby affecting
the
headaches/migraines
immune system and the body’s ability to maintain a healthy balance.
Behavioral Reactions
Because the loss event changes the individual, behaviors, whether while alone
or in
social settings, also reflect the change the individual is experiencing.
Cognitive Reactions
Emotional Reactions
- Self blame and guilt: “I could have..,” “I shouldn’t
have...,” “If only...,”
“ Why didn’t I...”
Fears: of getting through each day; of being alone; of being a
single parent;“What will I do now?”; “Will God punish me too?”; of
the dark; of new places
and of old favorite places; of social settings; of making the right decision(s). - Helplessness/Hopelessness
- Anger: at life’s situation, at God, at unfairness, at the one who died, at others for being happy.
- Yearning/desiring the lost loved one and the world that was.
- Withdrawn; not sharing feelings with others because they don’t understand or “get it,” not able to give emotionally to others—even family members.
- Anxiety: all of the above create an accumulation of general anxiety for many grieving individuals. Trying to handle life in a new fashion means creating a new “normal.” This is all transition and for many that means anxiety until it becomes the “new” acceptable way of life.
- Whatever one’s belief system (part of their assumptive world according to Rando) there may be challenges to that system. What was believed often comes into question and is examined in light of the loss and goes through its own change— strengthened or weakened—but changed. This is part of the process of grief and adaptation to the loss.
- Those with a belief in God may question: why God didn’t intervene, why did God let this happen, where is God in their paining/adjusting experience.
- Various questioning about God and one’s anger towards him, often creates guilt for the individual to work through.
Learning to accept that we do NOT get over a loss, but learn to live with the loss experience, can assist individuals in accepting their grief response as a JOURNEY—as a part of their own life experience—and not see this merely as tasks to be accomplished to “get better.” The loss experience is part of the individual’s life journey in all aspects listed above—physical, behavioral, cognitive, emotional and spiritual.
Section 4, Sudden Death Loss Issues
As described in Section 3, some of the possible reactions involved in the “normal” processing of a death loss are more intensified with a sudden death loss, and tend to take much longer to process due to the overwhelming disbelief that impacts the individual. Some issues that lead to complications in reconciling the loss include the following.
- Inability to comprehend– the disbelief of the event does not allow the individual to grasp what has actually happened. There is a searching for “why” and “how” this happened in the initial period following the death-loss event.
- The ability to cope is diminished due to the shock of the event and the additional stress that has just been imposed on the individual.
- Because the death event is sudden there is a loss of safety and security in the survivor’s world. This affects all aspects of the person’s life and creates much anxiety as the person attempts to confront “who” was lost to his/her world.
- There was no time to say good-bye to the individual and this often adds hurt and emotional pain. There was no time to say or to hear “I love you,” “I’m sorry,” to reminisce or review past events—both good and bad—and for the survivor to plan a future without that individual.
- Major secondary losses, including financial, loss of friends, loss of a job, need to relocate, loss of family-unit stability, loss of faith/belief, may all impact the adjustment of the individual and how he/she reconciles the loss.
- “The assumptive world is violently shattered: Without time to incorporate the change, the mourner’s assumptive world is abruptly destroyed. Control, predictability, and security are lost, and the assumptions, expectations, and beliefs upon which the mourner has based her (his) life are violated.” (Rando 1993).
- Some losses are categorized as “ambiguous.” When a body is not or cannot be recovered, then complications will occur in the mourning process. Shifting their perceptions about absence or presence is difficult in cases such as those experienced by some with the World Trade Center disaster, with planes that have crashed at sea, with those who have a loved one missing in action. Depression, anxiety, and movement from hope to hopelessness all intensify the individual’s response almost to the point of freezing the grief (Boss 1999). Verification and proof of the death are concrete ways of making the loss real. Rituals may need to be developed to assist the mourner to move beyond this uncertainty.
During the mourning period, the grieving individual not only focuses energy toward the deceased, but must adapt the self to changes and continue life incorporating the loss —the good and bad—of the relationship. What is truly lost is examined; what roles, expectations, opportunities and hopes must be given up; and what personal adjustments must be made all comprise the transitional aspects of the grieving process.
The personal experience of grief must be processed through the eyes of the grieving individual as he/she sees his/her loss and its ramifications. Each secondary loss perceived requires its own grief response.
The following is a list of some identified aspects of the loss that may be perceived as part of the unique process.
- Part of the Self: That which was given to the other in love, care, concern, is immediately altered in sudden death. Where does that energy go? to whom? The unique relationship has changed; the energy from one to the other is now severed. The individual does not feel whole. Rediscovering roles and sense of purpose and how he/she is needed by others helps an individual process the change knowing the specialness can never be replaced. Wholeness can be restored over a period of time.
- Loss of Self-Confidence: Because the individual has difficulty seeing him/herself as a whole person he/she experiences feelings of inadequacy, which may lead to much indecision. Those who struggle with a poor sense of self will struggle more in this grief situation. Assisting the individual by reinforcing simple decisionmaking and helping him/her identify areas of success in daily activities helps rebuild personal confidence which can then be extended to the work-world and community/social interactions.
- Family Structure: The family unit undergoes forced change due to the loss of a member. The role(s) lost here must be addressed on a daily basis. Not only do we grieve the personality lost but all the roles and expected behaviors that became so much a part of daily living. Loss of a mom presents certain issues; loss of a dad presents others; loss of a child of any age will affect the dynamic of what is vs. what is desired and expected for the present and the future.
- Desired Lifestyle: Sudden death forces a change in marital status. Many individuals have not chosen to be “single” again; to be a single parent with all the responsibilities and sole decision making. The emotional pain, and day-to-day struggle with the issue needs to be part of the process, respected and not minimized by being “strong.”
- Loss of the Future and Dreams: Survivors and the deceased had seen and planned a particular future. That is now gone and the survivor is often directionless for a time. The future is now uncertain and viewed as an obstacle; dreams are dashed regarding spending time with that individual and/or watching him/her grow and succeed. Again, role plays an important part here—who was the deceased? a spouse? an adult child? a parent? a grandparent? a sibling? a fiancé? a coworker? Loss of hope and anticipation for that lost individual are part of the grieving process.
- Social Changes: Often survivors now relate differently to friends, acquaintances, even family members—including in-laws. Because many individuals are unsure of how to relate to the survivor, they step back and often avoid the individual. They do not know the survivor in this changed situation; the survivor may be less confident, more emotional, not as cheery or uplifting, more temperamental, indecisive, more withdrawn. In-laws may be reminded too emotionally of who was lost and struggle with confronting that issue when the survivor is seen. Friends may have been connections through a work setting or school or religious place of worship. Some individuals are forced to relocate creating another loss of support and forcing more change. Financial situations may force a change in school for children, creating a loss of friends and teachers who knew them before and who try to journey with them through the loss.
- Recall humorous events
- List qualities of the deceased person that impacted them
- Review the time/events important to both
- Review the struggles in the relationship
- Identify change in self due to that other individual in their life...how did I change for the good.
- Identify how the deceased changed because I was part of their life.
- List favorite foods, scents, events, teams, holidays of the deceased,
so you never
forget, and to share the history of that person with others (possibly children
and/or grandchildren).
Section 6, Rituals
Rituals provide us with acts to engage in for the purpose of meaning-making (Neimeyer). Dr. Kenneth Doka discusses ritual as giving extraordinary meaning to the commonplace. Ritual provides symbolic connection to the lost persons. For example, on Thanksgiving a woman makes her deceased mother’s recipe for cranberry relish. Only a few people in the family enjoy this dish but she continues to prepare it because during the preparation she feels connected to her mother and feels her mother is within her and thus, present at the holiday.
Dr. Kenneth Doka has identified four functions of ritual that may help in a variety of situations:
- Rituals of Continuity – This type of ritual implies that the person is still part of my life and there exists a continuing bond. The Thanksgiving ritual described above is an example of this.
- Rituals of Transition – This marks that a change has taken place in the grief response. For example, parents who have lost a child marked a transition in their mourning by cleaning out their deceased child’s room after a period of time acceptable to them.
- Rituals of Affirmation – This is a ritual act whereby one writes a letter or poem to the deceased thanking the person for the caring, love, help and support. This is especially useful for those who never said “thank you.”
- Rituals of Intensification – This type of ritual intensifies connection among group members and reinforces their common identity. For example, the AIDS Quilt, the Vietnam War Memorial, the Oklahoma City Memorial Park.
Rituals must fit the story. They must be planned ahead and thoroughly processed
after
completion.
Certain dates are particularly troubling and anxiety producing for the bereaved.
These
include birthdays, anniversaries, holidays, religious celebrations, Valentines
Day, anniversary
of the death and other specific family markers.
The goal is to plan ahead a remembrance ritual in order to acknowledge the day
both
cognitively and symbolically. Utilizing any of the above mentioned rituals will
help
acknowledge in some personal way the relationship and life that was shared.
The day is best
confronted and dealt with through ritual rather than avoided. Following is a
list of rituals.
Rituals To Commemorate
Rituals are effective and meaningful when they have significance to the deceased
and to
the survivor. The following are merely suggestions and might be altered and
enhanced to
appropriately accommodate the relationship involved.
- Prepare a favorite meal of the loved one and enjoy it as he/she did.
- Prepare a favorite dessert – share with family or friends.
- Watch a movie(s) enjoyed by your loved one.
- Plant flowers, a tree or a flowering bush in memory of your loved one.
- Enjoy a toast to your loved one on a birthday, anniversary or holiday.
- Light a candle and recall the comfort or guiding light he/she was for you.
- Read book(s) or article(s) on a favorite topic(s) he/she enjoyed.
- Play music appreciated by your loved one and see if you can enjoy it now.
- Attend a concert/performance that would be pleasurable to you both.
- Look through photo albums and focus on shared times and memories.
- Wear a piece of jewelry that was a favorite of the person.
- Wear cologne or perfume he/she liked on you.
- Wear an item of clothing given to you by him/her.
- Buy something for yourself he/she would like you to have.
- Enjoy lunch or dinner at a favorite cafe/restaurant.
- Visit the burial place – bring a balloon or symbolic item to leave.
- Journal some favorite stories.
- Travel to a place he/she enjoyed or always desired to visit.
- Review how your life is better because he/she was a part of it.
- Focus on the gift he/she was to you.
- Purchase flowers on the anniversary. Bring for display at church or home gathering. When people leave, have them take a flower.
- Send flowers to a close family member on the anniversary.
- Read a favorite poem(s) or book enjoyed by your loved one.
- Watch home videos and remember.
- Volunteer for an organization in memory of your loved one.
- Become an activist in the cause of death issue – by participating in a walk-a-thon, phone-a-thon, etc.
- If you kept greeting cards given to you by your loved one, take time to read them again.
- Enjoy a leisurely walk taking time to recall shared events in life together.
There is literature on the market focusing on gender differences in processing a loss event. These may be helpful, but often give a stereotyped view of gender in the grief process. We must recognize the uniqueness of each individual and therefore his/her personal style may be a blend of often stated gender patterns. Some of the items listed may be more “feminine” in style; others may seem more “masculine” in style. There is no right or wrong way to grieve. There is the individual’s way; whatever works for him or her is what is important. Helping individuals find successful methods can be part of the companioning model previously explained.
Beliefs:
- Women talk about feelings with little effort. Men are more stoic and appear to lack feelings.
- Women tell and retell their story and the events to make sense of it. Men know the story is etched in their mind—no need to be reminded.
- Women seem to FEEL their way through grief—EMOTIONS are the pilot. Men tend to THINK their way through grief—INTELLECT is the guide.
- Feminine language is often described as intuitive, earthy, fluid or elusive. Masculine language is thought to be orderly, concise, controlled and goal-oriented.
- Women largely focus on CONNECTIONS and interdependence; they explore emotions. Men’s language focuses on independence, self-reliance with the external world as a priority for maintaining control.
- Women are encouraged to focus on affiliation, connectedness, and intimacy. Men are taught to be less self-disclosing, less expressive, less interdependent.
- Women seek companionship to support feelings and meet intimacy needs. They find help in groups. Men grieve on the inside and their work is more cognitive. They appreciate time alone to think it through.
Intuitive Griever:
- FEELINGS are intensely experienced.
- Expressions such as crying and lamenting mirror the inner experience.
- Successful adaptive strategies facilitate the experience and expression of feelings.
- There are prolonged periods of confusion, inability to concentrate, disorganization, and disorientation.
- Physical exhaustion and/or anxiety may result.
- THINKING is predominant to feeling as an experience; feelings are less intense.
- There is a general reluctance to talk specifically about feelings.
- Mastery of oneself and the environment are most important.
- Problem-solving as a strategy enables mastery of feelings and control of the environment in creating the new normal.
- Brief periods of cognitive dysfunction are common—confusion, forgetfulness, obsessiveness.
- Energy levels are enhanced, but symptoms of general arousal caused by the loss go unnoticed.
Gender may contribute to a particular style due to socialization rather than gender itself. One needs to carefully consider the style of the individual and support it. Accordingly, know there is not a right or wrong way—just the way this individual must process this particular loss. Some individuals have never dealt with a sudden death, so the way to grieve and adapt to the loss is unfamiliar to them. Patience is important; support and encouragement for where the individual is at any particular time after the loss is important
Personality and style are important—some people are less verbal than others; others think things through before reacting. Some go right into a task and take control of a situation, while others react emotionally first then gather themselves for action. Both genders may represent the “blended” pattern.
Section 8, Care for the Caregivers
Burnout occurs in any helping situation when there is too much work and too little support for the caregivers. If burnout is to be avoided, support must be available to the helpers through regular supervision and through sharing their work with other helpers. Group support is nurturing and can renew commitment to loss and bereavement work. Keeping a personal journal of the helper’s work and feelings and reactions can help. Stories of grieving individuals’ resiliency serve as powerful reminders that healing does occur.
Each worker must find what works best to help him or her keep in touch with self. Walks, family and free time, prayer, meditation, exercise, cooking, gardening, and yoga can serve as opportunities for a breathing spell from work.
Daily rituals and routines can help to ground helpers for the work ahead each day. Lighting a candle daily before beginning work, meditating, or reading a particularly meaningful passage can help center us. Keeping fresh flowers nearby and caring for one’s workspace in a way that makes for an atmosphere of comfort and security can help. Even when one does not have choice or control over workspace, personalizing the space in some small way can create a caring and safe atmosphere for oneself and one’s clients. Perhaps bringing a few pillows or lighting a small candle can be enough to support a sense of solidness and centeredness.
Following are a few suggestions for preventing burnout of caregivers (Corey 2001):
- Find other interests besides work.
- Learn to monitor the impact of stress at work and at home.
- Develop a few friendships that are characterized by mutuality of giving and receiving.
- Learn how to work for self confirmation and self reward as opposed to looking externally for validation.
- Avoid assuming burdens that are properly the responsibility of others.
- Take classes and workshops, attend conferences, and read to gain new perspectives on old issues.
- Form a support group with colleagues to share feelings of frustration and to find better ways of approaching the reality of difficult work.
- Make time for your spiritual growth.
Attig, Thomas. The Heart of Grief: Death and the Search for Lasting Love. Oxford
University Press. NY. 2000.
Boss, Pauline. Ambiguous Loss: Learning to Live with Unresolved Grief. Harvard
University Press. MA. 1999.
Collins, Bonnie. “Expect Miracles,” Psychotherapy Networker. V.26, No. 5, Sept/Oct
2001, pp. 23–24.
Corey, Gerald. Theory and Practice of Counseling and Psychotherapy, 6th Edition,
Belmont CA: Wadsworth, 2001, pp.39–40.
Doka, Kenneth, ed. Disenfranchised Grief: New Directions, Challenges, and Strategies for
Practice. Research Press. II 2002.
Doka, Kenneth. Second Annual Bereavement Conference, The Sage Colleges, Albany,
NY. Oct 4, 2002.
Dyer, Wayne. There’s a Spiritual Solution to Every Problem. Harper Collins. NY. 2001.
Figley, C., Bride, B., and Mazza, N. eds. The Traumatology of Grieving. Taylor and
Francis. Washington DC. 1997.
Golden, Thomas. The Gift of the Masculine Side of Healing. Golden Healing
Publications. MD. 1996.
Ivey, A., et al. Basic Attending Skills, 3rd Edition, Microtraining Associates, Amherst, MA.
1992.
Kauffman, J. ed. Loss of the Assumptive World: A Theory of Traumatic Loss. Brunner-
Routledse. NY. 2002.
Klass, D., Silverman, P. and Nickman, S. eds. Continuing Bonds: A New Understanding
of Grief. Taylor and Francis. Washington, DC. 1996.
Kubler-Ross, E. and Kessler, D. Life Lessons. Scribner. NY. 2000.
Martin, T. and Doka, K. Men Don’t Cry... Women Do: Transcending Gender Stereotypes
of Grief. Brunner and Mazel PA. 2000.
Neimeyer, R. Lessons of Loss. Center for the Study of Loss and Transition, Memphis,
TN. 2000.
Pread, A. D. Transcending Loss: Understanding the Lifelong Impact of Grief and How to
Make it Meaningful. Berkley Books. NY. 1997.
Rando, Therese. How To Go On Living When Someone You Love Dies. Bantam Books.
NY. 1988.
Rando, Therese. Treatment of Complicated Mourning. Research Press. Chicago, IL 1993.
Rich, Phil. The Healing Journey Through Grief: Your Journal for Reflection and Recovery.
John Wiley & Sons. NY. 1998.
Suzuki, S. Zen Mind, Beginner’s Mind. Weatherhill. NY. 1999.
Welshons, J. Awakening from Grief. Open Heart Publications. NJ. 2002.
Wolfelt, Alan D. “Companioning vs. Treating: Beyond the Medical Model of
Bereavement Caregiving– Part 1.” The Forum Newsletter. Association of Death Education
and Counseling. July/Aug1998.
Wolfelt, Alan D. “Companioning vs. Treating: Beyond the Medical Model of
Bereavement Caregiving– Part 2.” The Forum Newsletter. Association of Death Education
and Counseling. Sept/Oct 1998.
Wolfelt, Alan D. “Companioning vs. Treating: Beyond the Medical Model of
Bereavement Caregiving– Part 3.” The Forum Newsletter. Association of Death Education
and Counseling. Nov/Dec 1998.
OMH Bureau of Education
and Workforce Development
518-474-2578
Deborah Wagoner
Director