Section 3: Grief and Loss Support

People may attend counselling for many different issues and at different points in their journeys. People who have experienced a loss may seek reassurance from a counsellor that what they are going through is ‘normal’ and that they are not ‘going mad’. Sometimes, people may not get the support they need – either because this is unavailable through family, friends or the community or because they don’t feel comfortable expressing or sharing the intense, often distressing emotions that can result from a significant loss. Support may be sought in situations of disenfranchised or unacknowledged grief, where a loss is not recognised by others. And often, loss issues arise in counselling settings when the counselling is focussed on something else.

As Machin explains, counsellors may work with people experiencing various forms of loss at different points in clients’ journeys and focussing on different aspects of the experience:

^{Figure 1.1 Practitioner involvement at various points in the loss journey}

A. Practitioner engagement in anticipation of a loss: supporting people making choices about placing a child for adoption, preparing for an abortion, pre-bereavement support, etc.

B. Breaking bad news or discussing emerging life-changing events/circumstances: imparting a medical diagnosis where the prognosis is poor, emergency services informing people of serious accidents and deaths, etc.

C. Giving support during the process of loss: support for people with a chronic disability who are physically/mentally deteriorating, providing palliative care for the dying, etc.

D. Retrospective support: as a result of abuse, following the break-up of a relationship, following a bereavement, etc.

^{(Machin, 2014, p.4)}

All counsellors must have a solid understanding of loss, grief, and ways to support people who have experienced loss. The aim of this module is to help you better recognise and respond to grief responses, which is essential as most clients attending counselling would have experienced some kind of loss. Whilst this module equips you with fundamental skills and knowledge about supporting clients who have experienced loss, it is important to remember that grief counselling is a specialised area that requires in-depth knowledge and specific skills. So, where clients require significant grief-specific counselling, referral to other specialists in grief and loss, such as grief or bereavement counsellors, is called for. We will explore referral options later in this section of the module.

Also, remember that while we often talk in generalities, every experience of loss and grief is unique:

Clients who have experienced losses may be very vulnerable, whether due to the nature of the loss, their grief responses, or other circumstances (Harris & Winokuer, 2016). It is, therefore, critical that counsellors engage empathetically with clients to facilitate a confidential and safe space where clients can feel safe expressing intense and often distressing emotions.

Unlike many other issues that clients bring to counselling, grief is not an ‘issue’ or ‘problem’ that needs to be solved but a natural, adaptive process. While a counsellor may aim to support a client in resolving or changing a particular issue by applying specific problem-solving or distress-alleviating strategies, supporting people who have experienced losses primarily revolves around providing a safe space where the loss and its effects are recognised and validated. As Pomeroy and Garcia (2009) put it, the job involves ‘holding space’ for the client. It may also involve helping clients by providing information about grief and normalising grief responses; assisting clients in developing and using healthy coping strategies; recognising and helping clients develop continuing bonds or ways of meaning-making; and helping clients access and build on their strengths and resources (Harris & Winokuer, 2016).

Core Counselling Conditions and Skills

A person-centred approach is often appropriate when engaging with and supporting grieving clients. The counsellor should acknowledge the client as the expert in their own grief and should focus on the core conditions, including empathy, congruence, and unconditional positive regard:

• Empathy. The ability to be empathic with clients – recognising and understanding their loss and grief responses – lies at the heart of grief and loss support. However, there is a line between empathy and over-identification with the client. Self-awareness is the key to maintaining a professional distance from your client’s pain and suffering (that is, maintaining appropriate boundaries) while experiencing genuine care for the client and being interested in their experience. A counsellor might express their understanding and genuine care for a client by using attending and active listening skills while the client discusses a loss and responds with something like, “I’m sorry, that’s such as significant loss. Would you like to tell me more about it?”
• Congruence. Genuine conversation avoids clichés and easy answers. Telling grieving clients that they will ‘get over it’, ‘better days will come’ or ‘the darkest hours are just before dawn’ is demeaning. More appropriate responses demonstrate a genuine interest in the client’s experience: Genuineness can be enhanced by using honest, matter-of-fact terms related to the experience of grief and loss.
• Unconditional positive regard and non-judgemental acceptance. As discussed previously, losses can be disenfranchised, unrecognised, and socially unacceptable. Sharing any aspects of the loss and grief experience without fear of judgement, and receiving understanding in response, can be very powerful.

Various counselling and communication skills can also enhance your connection with the client and their sense of safety and support. Some of these skills include:

• Presence and immediacy. Counsellors working with people who have experienced losses often talk about the ‘companionship’ aspect and often emphasise how much of their role involves ‘being with’ clients and bearing witness to their pain.
• Communication skills. As with most forms of counselling, attending to the story and emotional needs of the grieving person is crucial. Use the verbal  (questioning, verbal encouragers, reflection of feeling and content) and non-verbal techniques (appropriate body language, non-verbal encouragers and mirroring) you have learned throughout your diploma. Using these skills will help you to ‘tune in’ to the aspects of a client’s grief experience that are unique to that person (including social and cultural context) and will help you understand how these shape their grieving process and current needs (Winokuer & Harris, 2012).
• Silence. Counsellors working with loss and grief issues must develop the ability to allow a client space to grieve by maintaining a respectful silence. The willingness to sit with clients when there are no words that can convey what they are experiencing is an important skill.
• Open-ended questions help the client explore their experiences while acknowledging that the client is the ‘expert’ in his or her own grief.

Along with these communication and counselling skills, there are general behaviours and values that you should demonstrate when interacting with and supporting clients, particularly clients who have experienced losses. These include the following:

• Professionalism. This does not mean that you should be detached, clinical, or neutral in your interactions, but that you carefully manage your responses and emotions during sessions; are reliable (for example, being on time for sessions, following up on the agreements made with clients); maintain healthy professional boundaries; and use support systems such as debriefing and supervision to process the emotions that will inevitably come up for you. Remember that you may be an ‘anchor’ for some clients and that those who have experienced losses are particularly vulnerable. Therefore, it is crucial that you are reliable and professional in your behaviour and communication.
• Courtesy. This involves being polite and respectful, including responding to the client’s experiences and belief systems, which may differ significantly from your own. It also involves acknowledging the client’s role as ‘expert’ in their own experience.
• Sensitivity. Clients may present in a highly distressed state and relay personal or distressing information about their loss. Whilst it is important to gather information and carry out assessments, particularly where there is a potential risk, do this in respectful, responsive ways that acknowledge the upsetting nature of the client’s experience. Providing an emotionally safe space may involve slowing down story-telling, focusing on other things, and taking more time in assessment, for example.

Grief Counselling - Let Your Client Talk About Their Loved One

In this video, you will see a demonstration and description of how rapport building during a grief counselling session can help to let your client talk about their loved one, with Mark Tyrrell  and an actor.

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A Note of Caution About Story-Telling And Focussing On Loss Experiences

Providing space to talk about their experience and express emotions, including painful ones, is an important part of supporting people who have experienced loss. It can be a validating experience and provide space for clients to express and discuss things that help them integrate the loss. It can also help clients recognise and come to accept the reality of the loss (Worden, 2009). However, not all clients want or need to talk at length about a loss to adapt healthily to it. As always, it is important to respond to the client's wants and needs. So, if the client does not want to discuss a loss, do not pressure them. And remember that, in some circumstances, telling and retelling a loss story can be harmful, even if the client wants to.

However, exploring the loss story should not be the focus if a client presents in a highly distressed or agitated state, particularly if the loss is recent, sudden, or traumatic. In these situations, the counsellor should focus on helping clients reduce their immediate sense of overwhelmedness. Grounding techniques help clients reconnect with their present experience and ‘contain’ distress. You can use these techniques in sessions with clients and teach them how to use such strategies outside of sessions. Be particularly careful and aware when using such a technique that you are not inadvertently trying to avoid the client’s useful expression of emotions due to your own discomfort or approaching the situation in such a way that the client feels that their emotions or experience are being invalidated.

Grounding strategies are many and varied. A few that can be useful in and out of session include mental and physical strategies:

Helping with Grief & Loss

Grief after a loss is a common and natural reaction, yet can take on different forms in each individual

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Given that no two people grieve precisely the same way, you will see different grief responses across your clients and changes in grief responses within individual clients. Recognising grief responses in clients will help you normalise their reactions and better respond to their needs for further support.

Consider the domains of functioning and potential impacts of loss discussed in the first section of this module. (It may be useful to review the ‘Effects of loss and grief’ in section one before continuing with this section of the module.) When working with clients who have experienced loss, gather information about the potential effects from assessment and in the stories they tell while keeping in mind that what seems to be grief responses may be something else and that the client may not recognise grief responses as what they are. For example, a client may complain about having trouble concentrating and making decisions; if you know that the client has experienced a significant loss, you might hypothesise that these cognitive features could be related to the loss. Of course, we cannot assume such a relationship, but you can then explore such a possibility with the client if appropriate. You can also provide information about common grief responses to normalise and help clients understand the range of potential responses to loss.

Case Study

Daphne was a care worker who had been working with a woman with Down Syndrome called Alice for a long time. Alice had a longstanding heart complaint that was supposed to be minor, but then at 35, it proved to be more serious, and she eventually died from complications relating to it. Throughout several counselling sessions, Daphne described a feeling of panic that would suddenly wash over her and how sometimes she would realise she had been standing for some time just staring vacantly into space. She was on leave from work but could not get motivated – she watched a lot of daytime TV and rarely changed out of her pyjamas until well into the afternoon. When she began to try and express how she felt, she said she mostly felt ‘empty’.

Exploring Cultural and Spiritual Belief Systems

As you have learned in the previous section, it is important to understand grief responses in the context of that person’s social (including family and other relationships), cultural, and spiritual context. Questions as simple as “What do you think your family’s expectations are of you at this time?” or “How are losses understood within your community?” can help a client explore what may be hidden influences on the grief experience. It can also help establish the availability of social support and the client’s perception of it.

It is helpful to ask specifically about any cultural and spiritual beliefs that might relate to how the client feels. For example:

• Tell me about your religion/spiritual beliefs/cultural beliefs/traditions.
• How do these influence your funeral and memorial rituals? To what extent do you/your family observe these rituals?
• Is there a particular resource you’d recommend that I could look at to learn more about your traditions to facilitate our work together?

It is also useful to invite clients to “talk about their religious and spiritual involvement and how they can draw on these areas in coping with their loss” (McLeod & McLeod, 2011, p. 291). For example:

• What are your beliefs about death?
• How does this affect how you maintain a relationship with your loved one?
• Do you have a spiritual or religious community that supports or could support you?

Counsellors don’t need to know everything about a client’s culture, social set-up, or spirituality to help them. But they need to listen and be interested, open, and non-judgemental. This is important when the client’s culture or beliefs differ from the counsellor’s, but it remains crucial regardless of familiarity with any group. You must listen carefully even when you share a client’s religion, spiritual perspective, or cultural background. Acknowledge the reality that there will be differences between your experiences and beliefs and those of the client, and possibly pay even more attention to the assumptions and ideas you hold about the shared perspective or culture. In addition, counsellors who have strong beliefs need to be particularly careful not to impose their own belief systems or assumptions onto their clients. Remember that clients are the greatest source of knowledge about their own social and cultural context, and counsellors must collaborate with clients to develop their understanding of the client’s circumstances and respond to their unique needs.

Some clients may express a strong preference for a particular spiritual or cultural perspective in their counselling, in which case counsellors should respectfully explore the client’s expectations for the counselling process and their intended goals or outcomes. Taking a not-knowing stance and being open and genuinely interested in clients’ spiritual perspectives is also helpful. Where necessary, counsellors may consider educating themselves about a client’s spiritual and cultural background to facilitate understanding of the client’s context and thus respond more appropriately to the client’s needs.

In some cases, clients may be supported to seek resources and professionals in the community for particular issues relating to their spirituality or culture while they continue using the counselling process for issues for which counselling is relevant. However, if a client has a strong preference for using a service that shares their culture or belief system or if the client’s intended outcome falls out of the counsellor’s work role (for example, to obtain support to mourn using a particular religious or cultural practice), the counsellor can still support the client in identifying appropriate services or professionals and referring the client in accordance with their professional responsibilities and workplace guidelines.

Due to the variety of ways that grief is expressed among different cultures, the distinction between expected and complex grief responses can only be made when considered within the individual's cultural context. However, it is important to recognise indicators of complex grief, partly because it is a clear sign that referral to a mental health professional – preferably one with significant grief counselling experience – is required. So, what is complex grief, and how does it differ from ‘uncomplicated’ grief?

Identifying Complex Grief

Most people who experience a loss will adapt, integrate their loss, and be able to carry on with their lives, with or without the support of a counsellor. There is a lack of evidence that grief counselling is helpful in cases of uncomplicated grief (Harris & Winokuer, 2016). However, a small proportion of people get ‘stuck’ in the grieving process or experience overwhelming reactions that can indicate additional support needs. These problems in the grieving process are called complex grief (or complicated grief).

As Harris and Winokuer define it, complex grief includes “persistent feelings of intense yearning or preoccupation with the deceased; shock, disbelief, and anger about 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” (2016, p. 144). They go on to identify some particular indicators of complex grief, which also indicate the need for referral for more specialised support:

There is currently controversy around the identification of complex grief within the broad spectrum of ‘normal’ grieving, making it challenging to identify when a bereaved individual may benefit from more specialised care (Winokuer & Harris, 2012). Grief in the early weeks, in particular, is often very intense, making it difficult to judge based solely on grief responses. Wilson suggests using the following checklist of risk factors for severe, prolonged, or otherwise complex grief reactions that indicate a likely need for specialist referral:

Complex grief is associated with higher risks of physical health problems, mental disorders, and suicide (Hall, 2011; Harris & Winokuer, 2016). Thus, it is crucial to identify cases where people exhibit symptoms of or are at risk of developing difficulties related to complex grief.

Am I Experiencing Complicated Grief?

Grief is tricky... and when it stays stuck in an Acute Phase it is called Complicated Grief. This video describes complicated grief.

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Identifying Trauma

Trauma is often experienced after a sudden, violent death, particularly if the individual witnessed this. However, it may also be experienced in relation to other losses, including non-death losses, and traumatising events often bring losses with them. As such, it is important that anyone working with people who have experienced loss understand trauma and can identify indications of trauma responses.

Uncovering Hidden Trauma PTSD

In this video, Mark Tyrell will walk you through five cases from his own records where trauma was found to be the unexpected root cause of the clients' problems.

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Trauma responses include physical, cognitive, behavioural and emotional symptoms, including:

^{(Adapted from Australian Psychological Society, n.d.)}

These can be perfectly normal reactions to distressing or traumatic events and are not necessarily cause for concern, provided they are not overwhelming and fade quickly (Kitchener, Jorm, & Kelly, 2017). However, particularly distressing or ongoing symptoms can prevent an individual from adjusting to a loss and lead to other problems, including serious mental disorders. Trauma symptoms like these indicate referral for more specialised mental health assessment and intervention. And, of course, if someone has experienced something traumatic and wants to access post-trauma support, regardless of whether or not they show such symptoms, they should be helped through referral to a mental health specialist (such as a clinical psychologist).

The following excerpt involves a client whose wife died in a drive-by shooting.

Given the violent nature of the death of this client’s wife, the counsellor should be aware of the potential for trauma reactions. Indeed, the client clearly describes intrusive thoughts, disturbed sleep, numbness, hypervigilance, poor concentration, and irritability. Unless the counsellor happens to have clinical mental health and specialist trauma training, they should refer the client for specialised support. This is the appropriate course of action if, at any point during your work, you become aware that a client is experiencing complex grief, trauma, or other indications of serious mental health issues. As you may remember from previous modules, it is part of a counsellor’s ethical responsibility to recognise their limitations in terms of training and expertise and to follow professional and organisation guidelines for referral and additional support options for clients who require specialised support.

check your understanding of the content so far!

Why There’s No Need to Relive the Trauma All Over Again

A long-established approach to helping people through traumatic experiences is to get the victims to 'relive' their trauma by 'talking it through', or even by hypnotically reliving it as it happened. Getting people to 'relive' their trauma is NOT therapy, and if this approach could heal PTSD then the first real flashback would do the trick. In this video Mark Tyrell explains what's wrong with this, the approaches to treating post traumatic stress disorder that can make the trauma worse, and what approach to take instead.

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By this point in your studies, you are already aware of the legal and ethical considerations involved in providing counselling. However, given the complexities involved in working with clients who have experienced loss, we must revisit a few legal and ethical considerations that are particularly important in the context of loss and grief. These include:

• Duty of care. As you know, counsellors are responsible for protecting the well-being of themselves, their clients, and relevant others in the counselling process. This includes providing competent and safe services and assessing and responding to relevant additional issues. Appropriately referring clients experiencing complex grief, trauma, and other mental health issues is part of discharging this duty of care. Counsellors must also assess whether clients pose risks to themselves or others and respond accordingly. In limited cases, duty of care requires sharing information with relevant authorities, even without the client's consent.
• Privacy, confidentiality, and disclosure. As you know, clients who have experienced a loss can be particularly vulnerable. It is your responsibility to provide a safe and private space for your clients to explore their loss experiences and to protect all information you have about clients. However, in cases with a risk of harm to self or others identified, you may be required to disclose client information to another agency or authority. When doing so, you must follow your organisational guidelines and the guidance of your supervisor or manager. On the other hand, if you need to disclose client information for referral purposes, discuss referral options with your clients and obtain their consent for all of the information you provide about them.
• Work role boundaries. Whilst grief and loss issues are not uncommon in general counselling work, specific grief or bereavement counselling is an area that requires specialist knowledge and skills. As a counsellor, you must be mindful of the responsibilities relevant to your work role and your limitations in supporting clients with complex grief and loss issues (for example, trauma, complex grief, mental health problems, suicide risk, or other significant co-occurring issues). You are not expected to work outside your role, nor is it ethical. Where necessary, support clients to connect with more appropriate professionals or services (for example, trauma specialists, mental health clinicians and bereavement counsellors).

Within organisations, such legal and ethical considerations are usually incorporated into the organisational policies and procedures. It is the responsibility of all workers to be familiar with and follow these guidelines. Counsellors in private practice must also set and meet appropriate professional standards, monitor their practice, consult with more experienced supervisors, and take responsibility for providing a competent and compliant service.

Client Risk to Self

The grieving process can be an overwhelming and challenging experience, evoking strong feelings of frustration, helplessness, and despair. As such, a grieving person may engage in high-risk behaviours, including substance and alcohol misuse, self-neglect, risk-taking and suicidal ideation (Wilson, 2014). It is not unusual for newly bereaved clients to express that they ‘want to join the deceased’ or to ‘fall asleep and not wake up’. Some will even consider ending their lives. As always in counselling, it is crucial to be aware of the potential for suicide and other risks to the client and to assess such risks appropriately. This includes asking clients clearly and directly about suicidal thoughts and other risk indicators, carrying out an appropriate risk assessment, and referring any client at risk of suicide (or other significant risks to self) to appropriate services.

Organisations that work with clients must have appropriate protocols and processes for managing suicide risk, which workers must follow. It is also important that all counsellors know what is involved in a comprehensive suicide risk assessment and can use this knowledge in identifying and responding to suicide risk. Suicide risk assessments include the following elements (adapted from SuicideLine Victoria, n.d.):

Contrary to what some believe, asking someone about suicide does not ‘give the idea’ to the person. Rather, asking about clients' thoughts or plans in a calm, matter-of-fact, non-judgemental way is a crucial part of increasing the likelihood that those at risk of suicide will be identified. It can even help people feel understood and supported. You might ask:

• “Sometimes people who have lost someone close to them think about suicide as a way to escape the pain. Have you had any thoughts of suicide?”
• “Are you feeling hopeless?”
• “Have things been so bad lately that you have thoughts that you would rather not be here?”
• “Have you had any thoughts of joining [the deceased person]?”
• “Have you had thoughts about taking your life?”

If the client indicates that they have had thoughts of suicide, this needs to be followed up with specific questions about when the thoughts were happening (including whether they are still happening) and what they involve, such as:

• “When have you had these sorts of thoughts?”
• “Do you have a plan to take your life?” or “Have you thought about a plan to end your life?” and, if they have or have considered a plan, “Would you tell me about the plan?”

It is critical that you ask about suicidal thinking and other risk factors directly, clearly, and sensitively, avoiding any language that could be misconstrued. For instance, it is not appropriate to use a leading or judgmental question such as “You’re not thinking of doing anything stupid, are you?” (Mental Health First Aid Australia, 2016, p.2). Terms involving ‘harm’, ‘risk’, or ‘hurt’ do not directly enquire about suicide; they are ambiguous and could mean anything from drinking alcohol to scratching one’s skin to suicide. As such, using these terms when assessing suicide risk (for example, asking, “Do you think you might hurt yourself?”) can lead to misunderstanding and generate inaccurate (and, therefore, dangerous) responses.

Keep in mind, too, that some language relating to suicide that is commonly in use can be problematic (Beaton, Forster, & Maple, 2013). In particular, when discussing suicide, we should avoid using terms such as ‘committed’, ‘successful’, ‘unsuccessful’, and ‘completed’. ‘Committed’ links suicide with crime and sin, so while it has been in regular use for decades, it is now increasingly recognised as stigmatising and, therefore, is to be avoided. ‘Successful’, ‘unsuccessful’ (for a suicide attempt), and ‘completed’ risk bringing positive connotations to death by suicide (Beaton et al.). Instead, use terms such as ‘suicide’, ‘died by suicide/death by suicide’, ‘took their own life’, and ‘suicide attempt/attempted suicide’. It can be challenging at first to change the terminology that we are used to using. Still, it is well worthwhile to make an effort to identify problematic terms and build your familiarity and comfort with appropriate terminology.

In addition to assessing risk, responses to suicide risk should also consider identifying and fostering protective factors (which help reduce risks). According to SuicideLine Victoria (n.d.), protective factors include:

Actions to address the client’s risk to self should be guided by organisational guidelines and protocols and will typically vary according to the level of risk involved. Responses to low-risk situations may include monitoring the situation. Still, suicide risk always indicates that consultation with your manager or supervisor is required and that referral to a specialist service should be considered. Moderate-risk situations necessitate the development of a safety plan with the client, organising a referral to an appropriate mental health service or general practitioner, and potentially engaging with the client’s other supports (family, friends or other services). High-risk situations will typically require you to assist the client in contacting acute mental health services or to alert the police or ambulance and stay with the client until further support has arrived. In all cases, you must consult your manager or supervisor immediately and document all concerns, assessments, and actions taken.

Risk to Others

Just like in any other area of counselling, counsellors must stay vigilant for potential risks to themselves while working with clients. Counsellors can reduce these risks by ensuring a safe work environment (not working late at night alone and ensuring access to panic alarms). You should always follow the Work, Health and Safety (WHS) protocol set out by your organisation.

Similarly, counsellors must be on the lookout for any indicators of possible risks to others as part of their duty of care. Crises can develop between the impacts of primary and secondary losses, sometimes placing the client and others at risk. Sometimes, a client poses a risk to someone else. For example, clients may indicate they intend to harm an ex-partner after a relationship breakdown. In other situations, risks and losses are interrelated, such as when a client and their children are subjected to domestic and family violence (DFV), which causes both losses and risks to the client and children.

Where there are serious concerns about risks to others, particularly when the risks are to children or where the client themselves poses a risk to someone else, it is important that you respond appropriately following your organisational protocols and professional responsibilities. This will always involve consulting with your supervisor or manager and may involve informing relevant authorities (police, the child welfare authority in your state or territory, etc.) and taking other appropriate actions.

Although much of the counsellor’s role in supporting grieving clients involves empathetically listening and ‘holding the space’ as the client works through what is happening for them, there are both informal and formal strategies that you can implement to help clients adjust to the losses they have experienced.

Acknowledge, Validate, and Normalise

As you have learned, grief may be expressed in many ways and evoke uncomfortable and distressing feelings. One of the most helpful things a counsellor can do is validate the client's feelings. Clients may present in counselling with grief experiences that have been viewed as ‘wrong’ or ‘pathological’, or which they themselves are concerned are wrong or indicate that they are abnormal. Some will have experienced losses that are not well recognised, and the loss experience is potentially disenfranchised grief. Listen carefully, acknowledge the client’s experience of grief, and help them understand that a wide range of reactions can be part of responding to loss.

Given grief's significant and wide-ranging effects, it is not surprising that clients may express worries about ‘going crazy’ or ‘losing my mind’. Counsellors need to normalise grief reactions by providing information about the range of responses and experiences that can flow from loss. This can be done informally throughout discussions with the client (as shown in the following counselling excerpt) or more formally with printed materials about grief (provided that these are from appropriate sources). Understanding grief in general and identifying particular responses relevant to clients can help them (and their support people) anticipate and cope with the changes and fluctuations in emotions and behaviours that often accompany grief.

Fluctuations in mood, and the absence and recurrence of particular responses, can be likened to a ‘wave’, as described in the following excerpt. Explaining these fluctuations in mood can help clients understand and anticipate them and alleviate concerns about ‘sliding backwards’ or ‘getting worse’.

Working with Emotions

Emotions play a pivotal role in the grieving process, and, as we discussed in the beginning section of this module, it is common for clients to experience a range of emotions, including less-expected emotions such as anger, guilt, or relief. It is important to remember that emotions serve an important function and that the counsellor’s role is not to try to talk the grieving person out of any particular feelings or to try to make them feel better, but to normalise and validate these emotions, allowing the client a safe, non-judgemental space to express them (Winokuer & Harris, 2012). Winokuer and Harris describe the following strategies for helping clients identify and work with their emotions, with examples of how a counsellor might start the conversation:

It is not unusual for grieving clients to associate intense emotions with negative thoughts or worries (for example, a client might say, “I think I’m going nuts”) so it is an important part of the counsellor’s role to help clients recognise the validity and normalcy of their emotions. In some situations, emotional challenges can also be reframed as strengths.

It is also important to consider individual client differences such as personality, grieving styles, and social or cultural preferences when working with emotions. Consider the following:

John, a 48-year-old man whose 19-year-old son died, demonstrated little visible emotion around his son’s death. During counselling, John often spoke in detail about his son’s death and he philosophically reflected on the ways the death altered his life.. He was stoic when discussing his feelings and rarely cried during these sessions. Although the counsellor talked to John about the usefulness of emotional catharsis, she was careful not to belabour this point and imply judgement of him for not being more emotionally demonstrative.

Unexpectedly, but to his pleasure, John found himself doing more and more volunteer work with his local Boy Scout troop—the same troop, his son, had been a member of in his youth. As John and his counsellor explored this together, he concluded that this was one way that he was expressing his grief—by being in contact with young boys who looked to him as a father and who allowed him to easily recall memories with his son. John seemed visibly relieved to realize that this was appropriate, healthy, and productive to his grieving process. John’s grieving style was more instrumental in nature. Understanding this helped him identify more actions that he could take to help him express his pain over the loss and feel connected to the memory of his son. For example, on the anniversary of his son’s death, he spearheaded a tree planting at the local park in honour of his son.

Kathy, John’s wife, had difficulty understanding her husband’s grieving style because it was very different from her own. Kathy cried often and felt a need to talk at length about her son and her feelings about his death. Kathy attended individual counselling sessions and looked forward to these times when she could freely emote with a safe, supportive, and understanding person. Counselling sessions for Kathy helped her to discover the benefit of journaling about her feelings. In addition, she learned healthy ways to express her anger and how to identify “safe” people in her social support system with whom she could talk about her grief. Kathy’s grieving style was clearly more intuitive. Through counselling, the couple learned to appreciate and support the opposite, though equally valid, grieving style of the other. Together, Kathy and John made a quilt out of their son’s shirts. While doing this they talked about their experiences with their grief and shared memories of their son. This activity proved useful by allowing for the expression of both the intuitive and instrumental grieving styles.

^{(Pomeroy & Garcia, 2009, pp. 59-60)}

While some approaches to counselling demand emotional expression, this can be unhelpful and even harmful. It is important not to force clients to emote and always remind them that they have a choice in how they want to manage their emotions (Winokuer & Harris, 2012). Allow the client to guide what is discussed and when, and help them learn to use grounding strategies or other ways of self-soothing and regulating emotions.

Remembering

There is often a lot of pressure on bereaved individuals to ‘get over’ a loss and move on with their lives. Counselling offers an opportunity for clients to tell their story of loss by remembering – who the loved person was before the loss, the relationship with the person, the nature of the loss and its meaning, and what life has been like since the loss occurred (Winokuer & Harris, 2012).

Continuing Bonds

As you may remember from the previous section, contemporary approaches to grief and loss include a focus on helping clients ‘relocate’ the deceased loved one rather than attempting to sever the bonds. The initiation of rituals associated with the loss or establishing legacies to commemorate a loss may be helpful in both attaching meaning to what has occurred and establishing continuing bonds with a loved one. Although there are few prescribed mourning rituals in current Western society, clients may find their own personal rituals that give meaning to their experiences or bring them comfort (Winokuer & Harris, 2012).

Just a few examples of ways to continue the bond after a person has died include:

• Letter writing, such as writing letters to or about the person who has been lost.
• Putting up photos or creating collages of pictures of or relating to the person who has died.
• Visiting places important to the deceased or significant in the relationship between the grieving person and the person who has died.
• Celebrating or otherwise recognising the deceased person’s birthday or death anniversary.
• Personal rituals such as reflecting on objects that relate to the person, lighting a candle, singing or playing music that is connected to the deceased person or which expresses the grieving person’s grief, and so on.

Meaning Making

Supporting clients in determining what the loss means in the context of their own life and life story may also be helpful.

It is important to let clients guide counsellors before using this approach. Clients should indicate on their own in some way that they are trying to make sense of why the loss happened and what it means to them, and they must be in the ‘driver’s seat’ when choosing ways to try making meaning in the context of loss.

3 Ways To Spot Trauma In Your Clients

In this video, Mark Tyrell shares three tips on how to spot when a memory needs to be deconditioned using examples from a client who he found had not been traumatized, by what sounded like a traumatic experience. He explains the route he took to reach that conclusion, and why this happens.

watch

Cognitive Behavioural Strategies

As well as focusing on loss-orientated processes such as grief responses, counsellors can also help facilitate the management of restoration-orientation activities. Cognitive behavioural techniques can be particularly useful in this area:

TIPS From a Hospice Bereavement Counselor

Tips from a Grief Counselor and Bereavement Coordinator for over 10 years.

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check your understanding of the content so far!

Part of a counsellor’s role is to help clients who have experienced losses to access relevant information and support from other sources. This may involve identifying materials and resources (for example, books, brochures, websites) that might be helpful and facilitating access to support available in the community or specialist services. For example, GriefLine offers telephone and online counselling as well as information resources. Following is a page from their website:

Before directing a client to any resources or service information, it is important to ensure that the information is current and suitable. For instance, some support organisations have religious affiliations, and some clients are uncomfortable with this. Other resources, such as books and websites, may provide inaccurate or even harmful information or services, so it is crucial that you critically evaluate any resource before suggesting or providing it to a client. Information also needs to be provided in an understandable way to the client. For example, the resources and the way you discuss them needs to be developmentally appropriate and responsive to any language, intellectual, or comprehension needs the client has.

Additionally, when sharing information or suggesting resources or services, you should:

• Be aware that grief may impact the client’s mental functioning; explain things clearly and slowly.
• Check-in with the client frequently to see whether they have understood the information and/or options presented and whether this is useful to them and to provide clients with the opportunity to give feedback. For example, you could say:
  • “Is this the sort of thing you had in mind?”
  • “Do you think that could be helpful?”
  • “No one option suits everyone. Should we consider a few other options?”
  • “Do you have any questions or concerns?”
  • “Should we go over that again?”
• Take care not to overload clients with much information at once.
• Ensure resources are culturally and developmentally appropriate.
• Access translated material in the language of your client where appropriate.

As well as helping clients access community resources and supports, it may also be useful to help clients use and build upon their natural support network (family, friends, neighbours, and groups they belong to). Some people are reluctant to ask for help or cannot identify what specific assistance would be helpful. Counsellors can facilitate this process by exploring support options, discussing needs and who could help with them, and role-playing approaches with the client.

Remember, if you become aware that your client could be experiencing complex grief, trauma reactions, or other mental health issues, it is important that you refer them to specialist services such as a clinical psychologist or specialist grief or trauma counsellor. We turn our attention to a few relevant referral options now.

Grief Counselling and Other Specialist Support

Grief counselling is a specific type of counselling that focuses on supporting people concerning significant grief and loss issues: “A counsellor who understands the basic tenets of good counselling practice and who also has expertise in the grieving process can provide a highly specialised form of support to an individual who is struggling with a significant loss” (Harris & Winokuer, 2016, p.8). Such specialist support is particularly important when a client’s focus for counselling is a significant loss or when they are experiencing complex grief.

Generally, a grief and loss counsellor recognises grief as a normal response to loss and focuses on helping the client to acknowledge and integrate their experience. Some of the goals of grief and loss counselling are:

The grief counsellor should also have specialised training in helping clients with intense emotions, contemporary approaches such as meaning-making, and responding to complex grief and other significant issues that arise in grief counselling. Grief counsellors may have high-level university qualifications in counselling, social work, or psychology and significant experience counselling clients experiencing a wide range of grief responses. They also need to thoroughly understand mental health and risk issues, including assessment and intervention processes. Where mental health issues are a concern, referral to a clinical psychologist or psychiatrist or working with the client’s general practitioner (GP) to arrange this is important.

Support Groups

In addition to specialised counselling support, clients can benefit from interacting with others who have experienced similar losses. Support groups offer many potential benefits to those who have experienced a loss. Grief can be a lonely and isolating experience, and many people find it helpful to talk to others who truly understand what they are going through. Groups offer the opportunity to share support, information, and mutual concerns (Pomeroy & Garcia, 2009). They also offer clients the opportunity to learn healthy behaviours and strategies from others.

In considering which groups may best support client needs, you consider developmental needs and the circumstances of the loss. For example, an adolescent may be supported best by organisations such as Headspace, where counsellors have specific expertise in supporting young people, and some people will benefit from participating in groups where people have suffered similar losses, such as stillbirth or suicide bereavement groups. As community resources such as specific services and groups will vary between areas and over time, it is important to research and develop a current list of resources and keep this updated.

Case Study

Rachel suffered complications during the birth of her baby, and her daughter was stillborn. Her counsellor, Petra, shows her some brochures from a bereavement organisation, SANDS, which cover various topics relevant to loss and grief. Petra asks her which one she would like to look at, and Rachel chooses a booklet on creating memories of her daughter.

They slowly look through the booklet, talking through each suggested strategy for creating memories. Rachel decides to talk to her partner about which strategies they would like to try, and Petra lets Rachel know that they can return to the topic in their future counselling sessions if Rachel would like. Petra also tells Rachel about support options in the community and asks her whether there are any Rachel thinks could be helpful to her or her family. The options they discuss include the following:

• the SANDS National Support Line
• a specialist bereavement counsellor
• a community organisation that services parents after losing a pregnancy or child
• a local support group for women who have experienced pregnancy loss and stillbirth
• a free online grief counselling service.

Petra notices that Rachel is struggling to decide, so she slows the discussion down and reassures Rachel that there is no pressure to decide now. She encourages Rachel to take her time considering the options and to raise any questions, assuring Rachel that Petra will provide additional information later if that would be helpful.

At the next session, Rachel asks for more information about the SANDS National Support Line. They discuss these options further, and Petra gives Rachel a SANDS brochure with contact details and information about the support line. Petra checks throughout the session that Rachel has understood the information and options that have been presented. Rachel also wants to connect with the local support group but feels anxious about making the call herself, so they also use some of their session time to call the contact for the local support group, using speakerphone so that Petra can start the call and introduce Rachel, and Rachel can be supported throughout the process.

Other Relevant Services

Other than grief-specific services, clients may also benefit from referrals to other specialist services and support. This often aims to facilitate adjustments to both primary and secondary losses and the various impacts of grief that clients experience (for example, relationship difficulties, addictions, and health issues). If you become aware that clients may benefit from additional support for needs outside of your expertise, you should always refer clients to services that are more appropriate to meet their particular needs. All counsellors are responsible for maintaining up-to-date knowledge of available services to provide effective information and referral services whenever there are indications that clients may benefit from support options in addition to or as an alternative to counselling.

We have already discussed the role of specialist grief and bereavement counsellors and clinical mental health professionals. Some other services you may commonly refer clients to include:

• Health and medical services. Loss and grief can significantly impact a person’s physical and emotional well-being, so it is not uncommon for clients to experience physical symptoms or life-depleting behaviours (for example, lack of appetite and not sleeping properly). However, it is important not to assume that physical symptoms are necessarily caused by grief or will reduce with time. So it’s worthwhile to encourage clients to talk with their GP, refer them to a supportive GP if they do not already have one, or refer them to other relevant medical and health care services.
• Relationship or family counselling. Significant losses experienced in a relationship or a family can strain the clients’ relationships with significant others and often cause difficulties more broadly within families than simply impacting one individual. Where appropriate, clients can be referred to family or relationship counselling or other family-orientated services for additional support.
• Legal and related services. Some clients need legal advice or support concerning their circumstances after losses. For instance, clients who have experienced a relationship breakdown may be referred to mediation, family dispute resolution services, or family lawyers for support in parenting arrangements and financial settlement; a client who has lost their job and believes they were unfairly dismissed can be referred to Fair Work Commission; Legal Aid Commissions offer legal support to financially disadvantaged individuals; and various services can help with other legal and financial issues.
• Substance abuse and other addiction services. As mentioned before, grieving individuals may react to losses by engaging in life-depleting behaviours, including excessive or dangerous use of alcohol or other drugs or other addictive behaviours. Clients should be referred to appropriate specialist services or practitioners where there are concerns.
• Financial counselling and emergency relief. Clients facing financial difficulties (for example, struggling with debts or bills or dealing with significantly reduced income) may benefit from a referral to a financial counsellor who can assist with budgeting, debt management, and dealing with debt collection agencies. Many community services also offer assistance in dealing with financial difficulties, including providing financial relief (such as food assistance and vouchers).

Remember that people who are experiencing grief are particularly vulnerable. When referring clients, ensure that you follow all ethical principles and guidelines set out by your organisation and the counselling profession, including those relating to privacy, confidentiality, getting informed consent for disclosure of client information, and responding appropriately to risks.

Working with clients who have experienced significant losses can be challenging and confronting, particularly regarding empathy and the ability to sit with intense emotions (both the clients’ and the counsellor’s own). Counsellors need to be able to recognise and respect individual differences in grieving responses and processes while at the same time remaining alert to possible risks and complications that can arise. Counsellors and other helping professionals can support clients impacted by loss by adopting a person-centred, empathetic, and professional approach; acknowledging and respecting emotions; paying close attention to the client’s particular circumstances, responses, and needs; and helping clients learn about, normalise, and develop healthy ways to respond to loss and grief reactions. Before we wrap up this module, reflect on the following case study, and try to identify some of the aspects of loss and grief support we have discussed in this module as they are applied in the case study.

Case Study

Kim Jones is a 56-year-old woman who lost her mother after an extended and debilitating illness. She came to counselling shortly after the 3-month anniversary of her mother’s death. Kim is married and has one son in college. She currently works at a home-based business as a Certified Public Accountant.

Session 1: Kim spoke in general terms about her mother’s illness and death. At times she became tearful and apologized for doing so. She complained of difficulty sleeping, irritability, trouble concentrating, and lack of motivation. I normalized these responses to the grief and did some teaching about the grief process. I also discussed with Kim the role that healthy expression of emotion often plays in the healing process of grief.

Session 2: At the beginning of the session, Kim expressed frustration that her grief related symptoms have not abated. She indicated feeling hopeless about ever feeling “right” again. I validated the pain and destabilization that comes with losing one’s mother and normalized these symptoms. Kim and I discussed how she might respond to her own son’s loss of his grandmother and I encouraged her to be kind to herself as she would her son. I also discussed how grief comes in waves and assured her that she will move through this process. At the end of the session, Kim appeared more relaxed and hopeful.

Session 3: Kim reported feeling overwhelmed by work, housekeeping, family needs, thank you notes, and other life demands. We discussed ways of coping successfully with these demands. This included engaging assistance from her husband, hiring outside help, and reducing her expectations of herself. Kim stated that she realized she had unintentionally isolated herself from many of her friends. We discussed the role that her grief plays in this behaviour, how it enabled her to heal initially, and how it may currently be thwarting her progress. She agreed that she would benefit from having some outside support.

Session 4: Kim appeared more refreshed and energetic today. She smiled for the first time since beginning counselling. She shared memories about her mother and stated that she had lunch with a long-time friend who had known her mother. She mentioned that she was able to realistically talk about her mother’s foibles. Kim laughed and told me, “You know, my mother wasn’t perfect.” Kim and I discussed her ability to begin to see both the positive and negative aspects of her mother’s personality. Kim stated that it was a relief to acknowledge that her mother “wasn’t a saint.”

Session 5: Kim expressed appreciation for these sessions and described how they have helped her by normalizing her experience and preventing her from “getting stuck.” She said, “It still hurts a lot, but I now feel more confident that I’ll get through it.” I applauded her decision to make a scrapbook of pictures of her mother. She said that looking at pictures prompted her to contemplate the ways that she was both similar and different from her mother. She asked for information about the grief support group that I conduct on a weekly basis, indicating that a group of others who had also lost their mothers might be helpful. I praised Kim on her willingness to engage in the grief process and on her accomplishments in counselling. I also explained to Kim that grief is an ongoing process and that she may benefit from additional sessions in the future.

^{(Pomeroy & Garcia, 2009, p. 59)}

Given the confronting nature of grief and loss work, it is particularly important for counsellors to engage in self-care, supervision, debriefing, and practice reflection. We focus on these next.

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Kitchener, B. A., Jorm, A. F., & Kelly, C. M. (2017). Mental health first aid manual (4th ed.) Parkville, Australia: Mental Health First Aid.

Morris, S. (2011). The psychology of grief: Applying cognitive and behavioural therapy principles. InPsych, 33(6). Retrieved from https://www.psychology.org.au/for-members/publications/inpsych/2011/dec/The-psychology-of-grief-%E2%80%93-applying-cognitive-and-b

Najavits, L. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guildford Press.

Pomeroy, E., & Garcia, R. (2008). The grief assessment and intervention workbook: A strengths perspective. Belmont, CA: Brooks/Cole Cengage Learning.

SuicideLine Victoria (n.d.) Completing a risk assessment. Retrieved from https://www.suicideline.org.au/resource/completing-a-risk-assessment/

Wilson, J. (2014). Supporting people through loss and grief. An introduction for counsellors and other caring practitioners. London, UK: Jessica Kingsley Publishers.

Winokuer, H. R. & Harris, D. L. (2012). Principles and practice of grief counseling. New York. NY: Springer.

Worden, J. W. (2009). Grief counseling and grief therapy. A handbook for the mental health practitioner. New York, NY: Springer Publication Company.