Getting Grief Working

Bruce, a Silicon Valley engineer, confronts the unimaginable: the loss of his beloved 7-year old son to a cerebral hemorrhage. Mary, a mother of two, struggles with the loss of her 30-year old husband to an aggressive adult leukemia. These are my clients. Is there something different from my everyday approach to psychotherapy that I need to know and do so that I can be optimally helpful to them? My answer is a resounding yes.

Although my everyday approach to psychotherapy has served well for the many loss-related experiences my clients present with, whether a disappointment at work, a midlife crisis, a failed relationship, or the absence of an empathic caregiver during childhood, I have learned that counseling for the loss of a loved one asks more of me both personally and professionally, emotionally and technically. In this brief article I try to capture some of this learning in quick and rather bold advice outlining some core principles—some do’s and don’ts—that guide my personal approach to grief counseling.

My approach to grief counseling is shaped by my basic understanding of grief as a natural condition—the human reaction to loss—that can generally be expected to abate over time and, frequently, to lead to psychological growth. The role of grief counseling, then, is to accelerate or unblock this natural healing process—to get grief working—particularly if this process is moving more slowly than expected or if the reaction to a loss is severe or protracted. Given this central goal for grief counseling, what therapeutic style, understandings, and interventions are most likely to achieve this outcome?

Offer a Supportive Therapeutic Relationship

A deeply empathic, caring, and inviting therapeutic relationship may be the fundamental criterion for effective grief counseling (Larson, 2013). The healing power of the therapeutic relationship, a significant mechanism of change in all psychotherapy, takes on even more significance in work with grieving clients.

Why is this so? First, grieving persons are often dealing with trauma, ruptured attachments, and shattered assumptions about the world being a predictable and orderly place. !e therapeutic relationship provides a secure base or holding environment that enables clients to confront, integrate, and transform trauma and loss as they move forward in their changed lives and worlds.

Second, grieving persons can feel painfully alone in their loss. They often no longer have the very person they would normally turn to for support in times of stress. This sense of aloneness can also result from a widening gap between their inner experience and others’ expectations, e.g., “Isn’t it time to move on?” If we can be fully present as companions to clients when they feel most alone, grief begins to work, and distress over separation and loss lessens.

Finally, grievers’ naturally occurring support systems are often quickly exhausted or lack a nonjudgmental listener unafraid to be present with the intense and often unsettling emotions, thoughts and changes in identity that accompany grief. In-depth discussions of the impact of losing your child are not, as I like to say to my graduate students, Starbucks conversations. It is also well documented that powerful social constraints (Lepore, Silver, Wortman, & Wayment, 1996) make disclosure of loss and trauma in one’s social world both risky and unlikely—another reason a therapeutic relationship can be such an invaluable resource for the bereaved.

Practice balanced empathy

As a grief counselor, you must find a way to achieve a balanced empathic stance toward intense emotional experience. Not doing so leaves you vulnerable to compassion fatigue and burnout. From a Buddhist perspective, this balanced stance can be described as a mindful, nonattached, yet fully engaged witnessing of the client’s experiencing (Gehart & McCollum, 2007). Others term it “exquisite empathy” (Harrison & Westwood, 2009), but I prefer Carl Rogers’s (1957, p. 99) description: "To sense the client's private world as if it were your own, but without ever losing the as-if quality—this is empathy." Losing the “as-if” quality leaves us more vulnerable to vicarious traumatization, countertransferential reactions, and personal distress that derails our therapeutic focus and pulls us into what I call the Helper’s Pit (Larson, 1993). Lacking this balanced stance, repeated confrontations with death and grief can push perhaps our most powerful emotional button —fear of our own mortality—and cause us to distance ourselves from our clients.

Don’t scratch where it doesn’t itch

Our empathy must not only be balanced, it must be accurate. Two common errors in empathy are overresponding and underresponding to our clients’ distress. As recent research tells us (Bonanno & Kaltman, 2001), many bereaved persons do much better earlier on than we might anticipate. If we probe the depths of these persons’ psyches for existential anguish, or aggressively recruit them for our counseling services, we are scratching where it doesn’t itch.

Don’t trivialize distress

Many bereaved persons, however, are doing less well than we might expect. It is not uncommon for friends, family members, coworkers, and even trained psychotherapists, to not recognize this and to instead emphasize the positive side of things, thus trivializing their distress. When encouraged to be “more resilient” or on “grief’s journey” clients may conceal their distress because they see it as a sign of their failure to cope.

Accurate empathy, in contrast, gets grief working: Clients are able to accept and make sense of their loss experience, allow the emotions of grief to guide their adjustment to loss, clarify and integrate new experiences of self, and discover new meanings in the painful events. They begin to convert what is often termed “pathological” grief (grief not working) into normal grief (grief working), and establish continuing bonds with their lost loved ones that are not maintained when they are struggling with the pain of loss. For therapists, accurate empathy leads to an expanded concept of the variability of normal grief, and also prevents taking a one-size-fits-all approach.

Do your homework

Your work with grieving persons will be considerably enhanced and more rewarding if you dedicate time to exposing yourself to recent developments in the field. Become thoroughly acquainted with current grief models, especially Worden’s task model (2009), Stroebe and Schut’s (2010) dual-process model, and Neimeyer’s constructivist approach (Neimeyer, Burke, Mackay, & van Dyke Stringer, 2010). In addition, an extensive and fascinating literature on grief-related constructs and issues deserves your attention, including work on continuing bonds (Klass, Silverman, & Nickman, 1996), disenfranchised grief (Doka, 2008), differing grief trajectories (Bonanno & Kaltman, 2001), complicated grief (Stroebe, Schut, & van den Bout, 2013), posttraumatic growth (Tedeschi & Calhoun, 1995), anticipatory mourning (Rando, 2000), the interaction of trauma and grief (Fleming, 2012), grief across the life span (Walter & McCoyd, 2009), retelling of violent death (Rynearson, 2012), gender and mourning styles (Doka & Martin, 2010), the role of rituals in grief and mourning (Imber-Black, 2004), grief in an online world (Sofka, Cupit, & Gilbert, 2012), and cultural factors (Rosenblatt, 2008).

Use grief-facilitating microskills and interventions

Finding ways to communicate your empathy that get or keep grief working for your clients is a creative challenge because grieving clients take diverse pathways. I find that a more person-centered style is best—fewer questions, less advice, and more (elegant and evocative) reflections of feeling and meaning (Larson, 2013). Use of metaphors can also be helpful (“It’s like being in an earthquake”); however, the test for any intervention is whether it assists your client to discover his or her personal pathway through grief.

Interventions I find helpful include displaying a photo of the deceased during sessions, meeting with family members, referring to local bereavement support groups, and listening for and supporting the establishment of new goals that restore meaning to life. In addition, I typically use the empty chair or imaginal conversation technique, an intervention endorsed by grief therapists of all persuasions.

Be multiculturally attuned

As Paul Rosenblatt says, culture shapes grieving (2008, p. 79). Cultural background makes an important contribution to individual differences in the grieving process. These cultural considerations become even more paramount when theory is translated into practice and we strive to match the type and level of intervention to the needs of a particular client.

Take self-care seriously

Find what works for you and do more of that, whether it is exercise, meditation, a good consultation group, your faith, or your friends. The to-do list here could quite lengthy, but self-care most importantly requires taking the time and making the commitment to doing it. Ongoing exposure to grief, loss, and trauma requires finding a balance between giving to your clients and giving to yourself.

When difficult clinical interactions create self-doubt or personal distress, don’t conceal these experiences and do allow them to become stress-enhancing helper secrets (Larson, 1993). Instead, find a confidant who understands the work and its vicissitudes and can offer you quality social support.

Get grief counseling to all who need it and desire it

In the past decade, a pessimistic view of grief counseling has emerged, with claims that it is ineffective or possibly harmful with normally bereaved clients. Don’t let these claims keep you from providing grief counseling to all those who need and seek it. The claim of harmful effects, based on a single unpublished dissertation, has been shown to be invalid (Larson & Hoyt, 2007), and no other evidence of a pattern for harmful effects has appeared (Stroebe, Hansson, Schut, & Stroebe, 2008, p. 598). Grief counseling, like other therapeutic interventions, tends to be effective for those who seek it out (Hoyt & Larson, 2010; Larson & Hoyt, 2009).

Who should receive grief counseling? Gamino and his colleagues (Gamino, Sewell, Hogan, & Mason, 2009-2010) offer probably the best answer when they conclude that grief counseling is appropriate for all bereaved persons who answer yes to the following two questions: “Are you having trouble dealing with the death?” and “Are you interested in seeing a grief counselor to help with that?”

Conclusion

Describing the qualities of the therapeutic relationship necessary for deeper therapeutic work, Diana Fosha reflects that “the emotional atmosphere should be one in which the patient feels safe and the therapist brave” (2000, p. 213). As a grief therapist, you must find a way to maintain your compassion and emotional involvement while courageously assisting clients to live with hope in a world in which loss is inescapable. This challenge is best met in an authentic and caring helping relationship between a therapist who believes in the client’s healing capacities and a client who is motivated to engage these capacities, get grief working, and move into the future without relinquishing the past.

References

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Doka, K. J. (2008). Disenfranchised grief in historical and cultural perspective. In M. S. Stroebe, R. O. Hansson, H. Schut & W. Stroebe (Eds.), Handbook of bereavement research and practice: Advances in theory and intervention. (pp.223-240). Washington, DC US: American Psychological Association.

Doka, K. J., & Martin, T. L. (2010). Grieving beyond gender: Understanding the ways men and women mourn (rev. ed.). New York, NY US: Routledge/Taylor & Francis Group.

Fleming, S. (2012). Complicated grief and trauma: What to treat first? In R. A. Neimeyer (Ed.), Techniques of grief therapy: Creative practices for counseling the bereaved. (pp. 83-85). New York, NY US: Routledge/Taylor & Francis Group.

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Gamino, L. A., Sewell, K. W., Hogan, N. S., & Mason, S. L. (2009-2010). Who needs grief counseling? A report from the Scott & White grief study. Omega, 60(3), 199-223.

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Imber-Black, E. (2004). Rituals and the Healing Process. In F. Walsh & M. McGoldrick (Eds.), Living beyond loss: Death in the family (2nd ed.). (pp. 340-357). New York, NY US: W W Norton & Co.

Klass, D., Silverman, P. R., & Nickman, S. L. (1996). Continuing bonds: New understandings of grief. Philadelphia, PA US: Taylor & Francis.

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Larson, D. G. (2013). A person-centred approach to grief counselling. In M. Cooper, M. O'Hara, P. F. Schmid & A. C. Bohart (Eds.), The handbook of person-centred psychotherapy and counselling (2nd ed., pp. 313-326). New York, NY: Palgrave-Macmillan.

Larson, D. G., & Hoyt, W. T. (2009). Grief counselling efficacy: What have we learned? Bereavement Care, 28(3), 14-19.

Lepore, S. J., Silver, R. C., Wortman, C. B., & Wayment, H. A. (1996). Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers. Journal of Personality and Social Psychology, 70(2), 271-282. doi: 10.1037/0022-3514.70.2.271

Neimeyer, R. A., Burke, L. A., Mackay, M. M., & van Dyke Stringer, J. G. (2010). Grief therapy and the reconstruction of meaning: From principles to practice. Journal of Contemporary Psychotherapy, 40(2), 73-83. doi: 10.1007/s10879-009-9135-3

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Rosenblatt, P. C. (2008). Grief across cultures: A review and research agenda. In M. S. Stroebe, R. O. Hansson, H. Schut & W. Stroebe (Eds.), Handbook of bereavement research and practice: Advances in theory and intervention. (pp. 207-222). Washington, DC US: American Psychological Association.

Rynearson, E. K. (2012). The narrative dynamics of grief after homicide. Omega: Journal of Death and Dying, 65(3), 239-249. doi: 10.2190/OM.65.3.f

Sofka, C. J., Cupit, I. N., & Gilbert, K. R. (2012). Dying, death, and grief in an online universe: For counselors and educators. New York, NY US: Springer Publishing Co.

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Stroebe, M., Schut, H., & van den Bout, J. (2013). Complicated grief: Scientific foundations for health care professionals. New York, NY US: Routledge/Taylor & Francis Group.

Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage.

Walter, C. A., & McCoyd, J. L. M. (2009). Grief and loss across the lifespan: A biopsychosocial perspective. New York, NY US: Springer Publishing Co.

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Dale G. Larson, Ph.D., is Professor of Counseling Psychology at Santa Clara University where he directs graduate studies in health psychology. A Fulbright Scholar and a Fellow in the American Psychological Association, he is the author of The Helper's Journey: Working with People Facing Grief, Loss, and Life-Threatening Illness.