Shallcross, L. (2012). A loss like no other. Counselling today, 54(12), 26-31.
Imagine this scenario: You are a counselor, and you have two clients. They are the same age and same gender, and both experienced the death of a partner at roughly the same period in life. So, you can reasonably expect that both will have similar reactions to that parallel loss and both will benefit from similar counseling techniques to deal with the residual grief, right? Not likely.
In fact, says Vincent Viglione, an adjunct professor of counseling at Kean University and Montclair State University in New Jersey, one of the most important things for counsellors to understand about grief and loss is that although the experience of loss is universal, every individual’s grief process is unique. “We as counselors recognize that certain client responses are not necessarily pathological,” says Viglione, who is doing his doctoral dissertation on adult sibling grief and continuing bonds at Montclair State. “As such, we attempt to normalize our client’s feelings. In doing so, however, we must preserve the idea that their circumstance is unique to them. Normalizing, then, is never saying, ‘You’re just like everyone else.’”
Keren Humphrey, a retired professor of counseling at Texas A&M University- Commerce, agrees about the unique nature of each person’s grief experience, not only because of her work with clients but also because of her own experience with grief and loss. “In the last two years, I have experienced a number of significant losses, including breast cancer with a double mastectomy, my husband’s extended illness and death, [and] my mother’s decline from Alzheimer’s and her death only a month after my husband’s death,” says Humphrey, whose book, Counseling Strategies for Loss and Grief, was published by the American Counseling Association in 2009. “These experiences have certainly reiterated my view that each person’s experience of loss and grief is unique. The meanings I attach to my losses and my ways of grieving are specific to me.”
Understanding that notion of uniqueness and applying it in session as a counselor means there is no one “right” approach to grief-related counselling work, Humphrey asserts. Rather, to work effectively with these clients, practitioners must be capable of drawing from a variety of counseling skills and techniques and tailoring a therapeutic approach that is custom fit to the client’s specific personality, situation and needs.
A good starting point for counselors is to take the role of “witness” and realize that the client is the expert, Humphrey says. “It’s a time for you to shut up and facilitate the client in telling [his or her] story. We too often in counseling jump too quickly into reflecting feelings and attending and worrying about the next thing we’re going to say to the client. That interferes with [clients] telling their story. Back off of those automatic responses and just allow clients to tell their story of loss.”
A loss is the absence of something we deem meaningful, Humphrey explains, while grief is our response to that sense of loss. People normally associate loss with the death of a family member or close friend, but it can also be inclusive of the loss of a house, a relationship, a job or any number of other things. Sometimes, says Anne Ober, an assistant professor in the Department of Counseling and Human Development at Walsh University, it can even be the loss of a particular feeling. For instance, Ober points out that after 9/11, even people who weren’t directly affected by the terrorist attacks might have felt a loss of the sense of security they had presumed previously.
Elizabeth Doughty Horn, an assistant professor in the Department of Counseling at Idaho State University, says grief can also stem from the loss of expectations that weren’t met. From the outside, to those observers who aren’t experiencing the loss personally, the loss might not appear particularly significant — for example, a high school student failing to make the cheerleading squad. Many of the losses people experience are disenfranchised, Horn says, meaning they aren’t recognized or appreciated as losses by society. Hallmark doesn’t make cards for disenfranchised losses, she notes.
In some instances, only certain aspects of loss get recognized, while other often more complicated aspects go overlooked. Consider a person recently diagnosed with cancer. “Once someone has been diagnosed with cancer, his or her identity is often linked with the disease,” says Horn, a member of ACA who has researched, published articles, taught classes and presented at conferences on the topic of grief and loss. “The bulk of their day-to-day life is spent focused on cancer — scheduling, getting to and from doctor appointments, reassuring wellwishers, letting people know about their illness, processing their own emotions as well as their family’s. Obviously, people acknowledge grief and loss associated with getting cancer, but they may not view it in terms of the loss of self.”
Many times in cases of disenfranchised loss, clients themselves don’t recognize the issue as one deserving of feelings of grief. They come to a counselor saying, “I shouldn’t be so upset about this,” Horn says. One of the most helpful things counselors can do is to acknowledge the extent of the losses clients have experienced and assist them in connecting the way they are feeling with those losses.
Even in situations in which loss is generally recognized by society at large, counselors say it is common for clients to come into counseling feeling unsure about why they are struggling. “It happens so often,” Horn says. “People come in and recognize there has been a major change, but they’re not seeing it in terms of grief. They might say, ‘I know I lost my job, but I have a new job, so why am I still focused on the job I lost a year ago?’”
Society often emphasizes getting over things and moving on, Horn says, but in many situations of loss, the process of “getting over it” doesn’t happen quickly, if ever. One of the newer trends in grief and loss counseling is the rejection of the idea of “closure” as a completed process, Horn says, especially as it relates to death. But many times, she says, clients either think they should be “over” something already or they don’t even recognize that their pain stems from an issue of grief and loss.
“I believe that once counselors begin to view transitions in terms of grief and loss,” Horn says, “they really won’t have to look for these issues in their clients. Rather, they will see an aspect of them in almost every client issue. I’m not suggesting that everything in life is grief and loss — how depressing — but there can be an element of these in much of day-to-day life in varying extremes.” Viglione, an ACA member who runs a private practice in Denville, N.J., agrees. “For every client that I see, I find an element of loss in what they’re presenting if I look closely enough.”
Stepping Away from The Stages
Counselors say one of the more significant changes in the area of grief and loss counseling in recent years has been the move away from using Elisabeth Kübler-Ross’ stages of grief model. Ober, a member of ACA who has researched, counseled and taught on the topic of grief, points out that Kübler-Ross herself said her stages were misapplied and that she originally designed them to be used with individuals coming to terms with their own death. Although Kübler-Ross’ work was very beneficial and started a larger societal conversation about death and dying, Ober says applying the stages to clients going through grief and loss isn’t very helpful and in some cases can even be harmful.
The problem is that the stages model doesn’t fit everyone’s experience, Horn says, especially in light of how each person’s reaction to loss is unique. Humphrey agrees, saying the model suggests that everyone experiences grief the same way. “That just simply is not true,” Humphrey says. “It does not respect the differences among people in terms of personality, social-cultural influences and that kind of thing. We need models that allow us to focus on uniqueness of people. It also ignores process. Instead, we need to understand that clients are in a process of adapting, renewing and reviewing. They’re in a process, not in a stage.”
Horn says research conducted on how the stages were used in therapy has shown that counselors were doing harm to some clients by trying to shoehorn them into stages. For example, if a client wasn’t having the particular experience the counselor thought he should be having according to the stage model, the client may have tried specifically to have that experience, she explains. “And that’s when people get into trouble — when they’re not following their own natural process, when they try to do something that doesn’t fit into who they are,” Horn says.
The stages also gave the impression that if clients went all the way through each of the stages — denial, anger, bargaining, depression and acceptance — they would encounter an end point to their grief, Horn says. “But grief is an ongoing process of adaptation,” she says. “The idea of closure is no longer seen as being possible for most people. Rather, it’s ‘How do I adapt or integrate this loss into who I am and into everyday life?’”
Humphrey again emphasizes that the trend in grief and loss counselling in the past decade or two has been toward realizing there is no one-size-fits-all model or therapeutic approach to helping clients. “Instead, the counsellor helps clients focus on useful material and implements therapeutic strategies appropriate to the uniqueness of a given client,” she says. “For example, I would use nondirective methods with a client who is uncomfortable with more directive approaches. I might use narrative therapy strategies to help a client explore cultural influences and later use solution-focused or behavior-based strategies for specific problems or to increase aware-ness of personal strengths for the same client. I might use cinematherapy to highlight multiple issues, but not with people who hate movies. It is important that counseling professionals remember that effective grief counseling is not about the counselor’s specialty. … Rather, it is about selecting and adapting various therapeutic approaches to the particular needs, preferences, personal history, grieving style and multiple contexts of a given client. Using only one approach with every client is ineffective and, worse, very disrespectful.”
Go With What’s Natural
The main goal in working with clients who have experienced a loss is to help them experience and express their grief in the style that is most natural to them, Horn says. That might mean encouraging clients to disregard outside influences or the internal “shoulds,” she says. For instance, a person who has just experienced the death of a loved one might get the message from his church that the death was “meant to be” and that it is time to let the person go. “Maybe that ends up making the client feel they should be happier this has happened or that they shouldn’t be feeling so sad,” Horn says. When clients refer to what family members, their religious community or some other outside influence thinks, Horn suggests counselors raise clients’ awareness of this and ask what they are experiencing.
Helping clients find their natural grieving style starts with listening to them and supporting what they say they’re thinking or feeling. “A client might say, ‘I’m really sad, but I haven’t cried and I feel guilty for not crying. I’m more focused on the logistical details of what led up to the person’s death,’” Horn says. “So we try to help foster that rather than putting pressure on them to cry or telling them that they’re in denial.”
In fact, Horn says, one of the newer models some counselors are using in loss and grief work, the adaptive grieving styles model from Terry Martin and Kenneth Doka, recognizes that certain clients will be more affective in their grieving style, some will be more cognitive and others will find themselves along the continuum in between. Understanding that different grieving styles exist and encouraging clients to grieve in the way that’s most natural to them is key, Horn says. For instance, grief groups are often helpful to affective grievers, who might want to share and cry with others, she says. On the other hand, cognitive grievers might want to focus on problem-solving associated with the loss and could find talking about the loss repeatedly with a group to be overwhelming.
“Counselors use this model to help better conceptualize and work with clients,” Horn says. “They educate clients about the uniqueness of grief and help them to identify their personal style, [which is] usually blended, with one more prominent than the other [affective versus cognitive]. This helps to normalize their natural style and helps to remove some of the perceived pressures to grieve in a particular way. Counselors can then use techniques that complement a client’s predominant style, allowing them to experience and express [their grief] more naturally.”
Horn also mentions Margaret Stroebe and Henk Schut’s dual-process model as potentially beneficial because it focuses on different aspects of the loss. It looks at both loss-oriented stressors, which deal with thoughts and feelings related directly to the loss, and restoration oriented stressors, which refer in part to the life roles that have been changed after the loss. The model suggests that people experiencing a loss will oscillate between the two, Horn says.
Ober’s take on the dual-process model is that people need to move between the emotional impact of the loss and the day-to-day logistical impact of the loss. For example, a recent widower might have an intense emotional response in which he cries and talks about his deceased wife, but he may also have to figure out how to cook because she previously prepared all of their meals. “What this theory suggests is that it’s healthy for the person to move between those two [responses] and have a balance,” Ober says. “People who are able to do both fare better in the long run than people who focus on one or the other research shows.”
Meaning-making, which Robert Neimeyer, Thomas Attig and Michael White have researched, is another potentially helpful concept, Ober says. It provides a way of helping clients determine what the loss means to them in their life and their life story, she says, and has similarities to narrative therapy. However, Ober says, counselors need to let clients guide them before using this technique. Clients need to 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. “That won’t be the case for everyone,” Ober says. “You shouldn’t apply it unless your client is really at that place.”
Ober also points to continuing bonds theory as potentially helpful. The theory is in contrast to Sigmund Freud’s idea that a person needs to cut ties with whomever has died and focus instead on the here and now. The continuing bonds theory suggests that a person who has lost a loved one can still have a nonphysical relationship and some sort of communication with the deceased person. Letter writing, putting up photos at home, returning to a special place that was important to the deceased person and celebrating the deceased person’s birthday or death anniversary are a few examples of ways to continue the bond, Ober says.
Viglione recommends William Worden’s tasks of grief approach as another potential tool for helping grieving clients. The tasks take clients through accepting the reality of the loss, working through the pain of the grief, adjusting to the new environment and reinvesting in life.
A Life Story That Continues
Humphrey says helping clients to explore and tell their story of loss is important, as is helping them create a new story of who they are today. “Sometimes people can be stuck with their old story, looking at the past as if time stops,” Humphrey says. “They’re living physically in the present and the world is moving on, but they’re stuck. That brings them into counseling. What you’re trying to do as a counselor is help them create a narrative that builds onto their old story by taking into account their losses.”
“Creating a post-loss story of one’s life involves making sense of the losses; dealing with disrupted beliefs, assumptions and expectations; and developing revised but enduring bonds with the loss object,” she continues. “Many clients respond positively to simply introducing the notion of building or creating a post-loss story, so it becomes an ongoing theme in treatment. Thematic genograms, therapeutic writing, objections of connection, loss timelines, decisional balance, client-generated metaphors and wisdom letters are particularly useful strategies here.”
The difference between primary and secondary losses is an important distinction for counselors to make, Humphrey says, and one that can help guide the course of treatment.
For example, in a scenario in which a client’s spouse has died, the primary loss is the spouse. The secondary losses might include companionship, a sexual partner and expectation of a future together. “The secondary losses are really the guts of the loss, and that’s where the focus of counseling should always be,” Humphrey says. “When you focus on the secondary losses, it helps you understand what the client sees as meaningful and what should be addressed in counseling.”
“Counseling professionals focus on secondary losses because this reveals the unique meanings, influences, individualized adaptive processes, client strengths and potential problematic issues that constitute client grieving,” Humphrey continues. “I ask a lot of open-ended questions that invite exploration and that recognize the client as the expert on their grief. ‘What does that mean to you? Tell me what works and doesn’t work for you. What feelings/ thoughts/behaviors go with this or that? What should I know about you that will help us understand your experience? Tell me the story.’ Their responses provide clues to potential issues and direction for therapy.”
Jane Newman, an ACA member who runs a private practice in Portland, Ore., says one of the first steps she takes with grieving clients is to validate their loss and express empathy for the difficulties they are experiencing. Counselors have to be sure never to minimize or diminish a client’s loss in any way, she cautions.
After validating their loss and pain, Newman says she asks clients, “Now what?” In her current caseload, Newman has a male client recently diagnosed with terminal cancer. He is a respected scientist who has been forced to sideline his career because of the cancer. “He’s mad and unhappy because within weeks, his whole identity changed,” says Newman, who previously worked as a hospice counsellor and in a cancer center as a bereavement counselor. “As a scientist, he doesn’t operate much on a feeling level. He’s mad because he’s not productive right now. I need to honor that and talk to him about how that must feel and not try to take any of those feelings away. And then the [conversation] is, ‘So, now this is part of your life too. This is a new phase of your life. Let’s talk about what you think you might want from this part of your life.’ I want to help him identify those things so that he can get closer to making this part of his life productive, even if that means having some wonderful conversations with his family. I wouldn’t say, ‘How do you make the most of it?’ I would say, ‘Let’s talk about what you might want from this part of your life.’”
Newman says part of a counselor’s role in working with clients who are experiencing loss and grief is to illuminate the strengths and support systems they might be over-looking. Ask how they have coped with stressors in the past and what has helped them get through hard times before, she says.
When Grief and Loss Hit Close to Home
Of course, counselors aren’t immune to experiencing loss and grief in their own lives. Dealing with that reality goes hand-in-hand with all types of counsellor self-care, Horn says. “We need to be acknowledging our own grief and loss and allow ourselves to have that unique experience and expression,” she says. “We tend to feel that we’re above it all or should be immune to losses. We also tend to believe that as counselors, we’re supposed to be so together and that with all of our coping skills, we’re not supposed to hurt.” These misguided beliefs can lead counselors to discount their own grief and loss, Horn says, even as they carefully guide clients to do otherwise.
One of the best things counselors can do is to raise awareness of their own loss histories and their thoughts surrounding grief and loss, Ober says. Ober uses an exercise from Humphrey’s book, Counseling Strategies for Loss and Grief, to help her counseling students become more mindful of their personal experiences of loss and grief, which in turn will lead them to better assist future clients. The exercise involves the counselors-in-training making a timeline of grief and loss through their lives by detailing specific losses. Ober then asks the students to write about what it was like to complete the exercise, including if anything bothered them while exploring past losses or whether they identified something that provided them with encouragement and hope during tough times.
The exercise is one that these counsellors-in-training might choose to repeat with future clients. But the main objective, Ober says, is to get the students to build their personal awareness of grief and loss, which can help them avoid countertransference with future clients and become knowledgeable of their own cultural backgrounds and biases related to grief and loss. For instance, she says, students might learn that their families had specific rules related to grief and loss, such as not talking about the deceased person or not crying about the loss. “We can’t impose those [rules] on clients,” Ober says. Ober suggests that practicing counselors seek supervision or consultation with other professionals so they can talk through what’s going on with their clients and in their own lives. This process can help counselors become aware of how losses might be affecting them and their work, Ober says. Most people deal with loss in an effective way, Humphrey says. However, if counselors are feeling “stuck,” Humphrey says they should consider seeking counseling for themselves, just as they would recom-mend that clients do.
Getting Prepared to Address Grief
Because there are no CACREP standards that deal specifically with grief and loss, Horn says it’s rare that graduate counseling programs require a course on the topic. “It’s really criminal to a certain extent that we do not require students to learn about grief and loss when every client we see will likely present with some element of grief and loss,” she says. “More likely than not, counsellors are graduating without having taken formal training on grief and loss. There is preliminary research showing that having some type of formal education on death and dying or grief and loss does reduce anxiety around working with these issues.” For the very reason that it might not have been part of their training, Horn urges counselors to educate themselves on the topic by going to workshops, reading current literature and taking continuing education classes on the topic.
Counselors need to educate themselves not only on how to work with clients experiencing grief and loss but also how to identify it in the first place, Horn says. “Almost every client we see is going to have an element of grief and loss within their story. [When counselors] don’t have the lenses of being able to identify aspects of their story as being grief and loss, I think we miss a larger picture with that client.”
Humphrey recommends that counsellors who are just starting out stay theoretically grounded so they will be ready and able to integrate any number of theories into grief work depending on the client’s particular needs. Meanwhile, Humphrey urges more experienced counselors to keep current with work in the field because the thinking concerning how best to address grief and loss has changed through the years.
The advice Newman offers to counselors, regardless of experience level, is to remember that work with grief and loss issues remains tied to the fundamentals of counseling. “It’s not about what I have to say to them, it’s about what they have to say to me. It’s really listening, being as present as you can be with that person, not judging, not thinking I’m the expert,” she says. “It’s giving that respect that [clients] have the expertise for what they’re going through.”
In combination with that expertise, it’s trusting that clients also possess the strength and resilience to carry on, Newman says. “Doing this work gave me so much faith in the human spirit,” she says. “I was face-to-face with people who had to find the strength to get themselves through probably the hardest times of their lives, and I don’t think I’ve met the person yet who curled up in a ball and didn’t do that. There’s sadness attached to it, but it’s inspiring the way that people find their way through. It’s about the resilience of the human spirit. People find strength that they didn’t know they had, and that is inspiring. We’re survivors and we are resilient. And at times, when it looks like it’s the worst time ever, it is the worst time ever — but when you feel that pain, then you begin to find your way through it.”
