Monthly Archives: October 2016

Walking with clients through their final days

By Laurie Meyers October 31, 2016

During the time that Kerin Groves spent by her dying client’s hospital bed, she could tell that he felt conflicted. “I sensed he kept hanging on because his adult children were unable to cope with him dying,” she recalls. “The son kept urging him to fight and get better, even though the patient was in his 90s and ready to go.”

When the man’s children left his room for the day, he visibly relaxed. Groves, a licensed professional counselor (LPC), gently pointed out the difference in his tension level.

“[I] let him know it was OK to go whenever he was ready, and I assured him that I would be there to help his son get through it,” Groves says. “He looked right at me, held my gaze for a time and then closed his eyes for the last time. Given permission and support, he was able to go in peace.”

Groves, an American Counseling Association member who has worked with older adults in retirement communities, assisted living, nursing homes and home care settings, is among a select number of counselors who routinely help individuals and their families cope with the process of dying.

Acceptance and denial

Receiving a terminal diagnosis, or having a loved one receive it, is almost too much to comprehend initially, says Mary Jones, an LPC who spent 20 years counseling patients and their families in an oncology center. “People go into shock, and there is an inability to wrap their minds around what they are hearing,” she says.

Loved ones who are in the room when the terminal diagnosis is given often go through a secondary trauma — shock at what they are hearing and concern for their loved one’s feelings, Jones says. In fact, she adds, these loved ones may initially experience more anxiety than the person receiving the diagnosis.

branding-images_final-daysJones counseled patients with varying prognoses, including those who would go on to live long lives after treatment, but in her role, she often saw people at the very end, when they had been told they had only months or weeks to live. “Once they know that treatment isn’t working and there are no more options, it seems like people hit a fork in the road emotionally,” she says.

One path certain patients chose was accepting their impending deaths but also determining to answer a weighty question: What do I do next? In her role as a counselor, Jones would talk to these clients about their legacies — what they wanted to say to or leave behind for their loved ones.

One of her clients was a father with a young son. He made a video that talked about the things he wanted his son to know but wouldn’t be there in person to tell him. The video included subjects such as what the son should know about middle school, about girls and about sex.

The other fork in the path that Jones commonly witnessed was complete denial of the terminal diagnosis. She heard patients make statements such as “This isn’t happening” or “I’m not going to die.”

As a counselor, her role was to try to guide these patients toward acceptance. She acknowledges that the task was difficult. “It so goes against our belief and training and experience [as counselors] to have to say to someone, ‘But your end is near,’” she says.

Jones would sit with these patients and encourage them to talk about their feelings regardless of what they were: fear, anger, sadness, disbelief, etc. After validating what they were feeling, she would circle back around to acceptance and the importance of deciding what they wanted to do or say before they died.

Groves, currently a private practitioner in Denton, Texas, often used existential and person-centered therapy when working with individuals in denial about their impending death. “Person-centered therapy gives the patient the lead in directing the conversation in the way they feel it needs to go, at their own pace,” she says. “We talk about denial openly and how it helps or serves a purpose, as well as how it might work against them. Helping a client make a cost-benefit analysis regarding denial is empowering and respectful of [his or her] needs.”

Of course, it isn’t uncommon for family members to be dealing with denial too. Jones, who would also provide family therapy in her role, says this can create tension between family members and the person who is dying, just when that person needs more support than ever.

Seeking support

Emotional support from family members is important, but the principal source of support for many clients is their husband, wife or partner. If discord is already present in the couple’s relationship, these problems will only be exacerbated by the stress of serious or terminal illness, says ACA member Nicole Stargell, who has used emotionally focused therapy (EFT) with couples facing breast cancer diagnoses. EFT operates on the premise that to feel “attached” (safe and secure) in a relationship, couples must be able to manage and share their emotions, she explains.

When certain people experience conflict or distress, they withdraw — sometimes physically — and don’t want to talk about the problem or issue, Stargell says. Other people are “pursuers,” she continues, and their desire is to talk about what is wrong. Pursuers will actively seek responses from their partners.

Anytime that either partner displays withdrawing or pursuing behaviors, implicit assumptions are being made, says Stargell, an assistant professor of counseling and the field placement and testing coordinator at the University of North Carolina at Pembroke. For instance, partners who withdraw often do so because they perceive themselves not to be strong enough to cope or view themselves as being deficient in some other way. When pursuers try to talk to withdrawers about what is wrong, this just reinforces the withdrawers’ feelings of deficiency, Stargell explains. Meanwhile, pursuers are thinking that withdrawers don’t regard them as being important enough to try to talk things through with them. As a result, both partners end up feeling alone and unsupported, which isn’t good for either individual’s mental or physical health, she says.

Using EFT, Stargell would identify the cycle of misunderstanding that plays out repeatedly between the couple but make it clear that neither partner is to blame. Next she would help the couple start to reframe their interactions by asking them to talk about a conflict and actually say out loud what they were thinking in response to their partner’s behavior.

Stargell would then help the couple see that their reactions had more to do with self-blame than with the other person’s actions. In other words, there was no implicit message attached. She would also have the couple role-play, taking turns presenting a problem and practicing reacting differently to what the other person said or did.

Stargell also works with couples to identify triggers or recurring situations that tend to set off the negative cycles. For instance, in the week following chemotherapy, the partner who is a withdrawer and is undergoing treatment might retreat emotionally, in part because he or she is sick and feels like a failure for not being able to perform his or her normal role, such as being the one who washes the dishes. Because the withdrawing partner is sick, the pursuer doesn’t want to push for interaction. However, Stargell says, it’s not uncommon for the pursuer to feel some anger or resentment about the things the partner with cancer — or the couple together — can no longer do. The withdrawer can typically sense the underlying tension, which makes him or her withdraw even more. Together, Stargell and the couple would talk about what the couple could do differently the next time the withdrawing partner has chemotherapy.

Approaching the end 

There are many ways that counselors can support and assist clients who know that they are dying. “I have helped clients find meaning in their personal [histories] and accept suffering during the dying process by engaging in life review and reminiscence, with both laughter and tears, allowing them to say what they haven’t been allowed to, reconciling unfinished business from the past [and] helping them connect with and share their true feelings with their loved ones,” Groves says. But sometimes, the most significant role is “just sitting with them in silence as a companion,” she adds.

Groves has also helped clients facing death to work through their fears and concerns. These have included issues such as feeling guilt about being ready to die when family members beg them to keep fighting; fear of more pain or agony; weariness from long medical treatments; spiritual doubts or fears; and anger over family conflicts erupting or being exacerbated during the medical crisis.

Jones would sometimes take on a sort of facilitator role with these patients, making sure they received what they wanted or needed in their final weeks or days of life. But counselors can also advocate for patients in other ways, Jones says. Especially toward the end, patients with terminal illnesses can experience a significant amount of pain but may not want to take yet another medication. She recommends that counselors working with this population educate themselves about alternative methods of pain relief and relaxation techniques.

As the end approaches, some individuals find it easier to accept that they are going to die, whereas loved ones often have the opposite reaction, Groves notes. “Curiously, people who are near death may be more calm … because they have accepted their prognosis, while their loved ones struggle with denial and avoidance because they are not ready to let them go,” she says. “When a person dies, the opportunity to make peace with them is over, so at least when the person is still hanging on, the belief or hope that it can be reconciled is still there. They may fear letting that person die with unfinished business still between them but struggle to vocalize those unsaid things because they don’t feel it’s appropriate or acceptable.”

Groves says counselors can also play an important role in preparing family members for what to expect in the dying process. “If hospice is involved, their nursing staff may make an extra effort to help counselors explain to the family what is happening biologically, the signs of impending death and other medical information,” she says. “A counselor can also be of help with active listening, reflecting feelings, normalizing emotional responses, addressing spiritual and existential concerns, and [exuding] warmth. Many people do not know what to do or say, so they do or say nothing at all, leaving the family members stranded in their grief. Counselors are equipped to sit with people in pain and be present with them.”

Groves also believes that being present when a loved one dies can be very healing for family members. “It’s very hard to witness a death and, frankly, most people fear and avoid that experience,” she says. “They are typically afraid they will be overwhelmed with their feelings and be unable to cope. But if one is willing and able to tolerate the discomfort, with the support of the counselor, being with a dying person in their final moments allows one to genuinely embrace the natural process of death and confront its reality, which is important for healthy grieving.”




Related reading: See Counseling Today‘s November cover story, “Grief: Going beyond death and stages




Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.



Vote against anxiety: Managing 2016 election stress

By Bethany Bray October 27, 2016

If this fall’s presidential debates have left you feeling angry or dejected and the thought of finding out election results state by state on the evening of Nov. 8 makes you break out in a cold sweat, you are not alone.

More than half of U.S. adults who took a recent survey from the American Psychological Association reported that the 2016 election is either a “very significant” or “somewhat significant” source of stress. In addition, 38 percent of respondents said that political and cultural discussions on social media cause them stress.

Donkey and elephant symbols of political parties in America. USAEvery presidential election cycle brings its fair share of contention and mudslinging, but the 2016 race to succeed Barack Obama as president has been especially divisive. Many Americans can’t help but be affected, whether they’re interested in politics or not. For individuals who struggle with anxiety or have experienced trauma, grief or loss, the stress of election night – and the tumultuous weeks that lead up to it – can be especially hard.

“This election cycle has been so contentious, and there seems to be so much unhappiness on both sides of the ticket. A number of my clients have described feeling uncertain and unsafe about what the future will hold,” says Samantha Klassen, a licensed professional counselor (LPC) in Corpus Christi, Texas.

Don’t get overwhelmed, however. Election-induced stress can be avoided or lessened with a little intentionality. Here are some helpful reminders and tips from professional counselors for those experiencing election-induced stress:



Reoccurring negative thoughts can impede your ability to function throughout the day. For those who are feeling anxious this election season, Klassen suggests trying to refocus their thoughts on something positive, such as thankfulness.

“Take time to practice gratitude for the things that are going well, both in your life and in the lives of others around you. When you are able to remember and appreciate the small, everyday moments, you build up a reservoir of positive emotions which can help mitigate some distress,” says Klassen, an American Counseling Association member and doctoral candidate in counselor education at Texas A&M University Corpus Christi. “Learn to recognize what is within your scope of influence and try to engage in activities which give you a sense of power. Remember that you are in control of how you spend your time, what you pay attention to and how much mental energy you expend on the election.”


Don’t go it alone

Keep in contact with supportive friends, family members, neighbors or co-workers through the next several weeks. If you decide to watch election night news coverage, try to watch with a friend or family member. “Having a circle of support can help mitigate some of the powerful emotions that arise,” says Klassen, a child, adolescent and family therapist and graduate assistant for the Supporting Pediatric Adjustment and Resilience through Counseling program at Texas A&M Corpus Christi.


Unplug or limit your news and social media usage

If election coverage – and the partisan banter that accompanies it on TV and social media – is making you stressed or angry, limit your consumption. Read just enough to stay informed, or set a time limit for yourself. Also, turn off your TV, smartphone and computer at least 30 minutes before going to bed, says Beth Patterson, an LPC and American Counseling Association member in Denver.

“I advise clients to limit their expose to television and their devices, and to turn them off when they are getting triggered [and anxiety flares],” says Patterson, a grief counselor who specializes in working with clients through loss and life transitions, trauma, depression and anxiety. “Doing so is even more important in this emotional election season. Although social media can be a beneficial tool for bringing like-minded friends together and sharing ideas, we all need to be vigilant about using Facebook and other sites in small doses only.”


Take time for yourself

When anxious feelings start to swell, be intentional about doing things that you enjoy. Counselors call this “self-care.” Perhaps it’s a favorite hobby, such as knitting or listening to a (nonpolitical) podcast, going for a run or having a cup of tea.

“When you feel particularly tense or overwhelmed, take a walk, meditate, call a friend or read or watch something funny or inspirational,” Klassen says. “Focus on something totally unrelated to the election. … Rumination can lead to more tension and impact your physical health as well.”

When you are consistently anxious, “hearing more distressing stories [such as news coverage] can keep you stuck much like a hamster who keeps going around in a wheel,” agrees Maggie Kerrigan, an LPC and American Counseling Association member in Westminster, Colorado. “Instead, consider engaging with people or activities that you find uplifting. Perhaps you find beauty in watching leaves fall to the ground or noticing how light strikes a building. Maybe you can seek out friends with whom you feel safe and who value kindness and generosity. Let yourself be drawn to something that represents the opposite of what causes your anxiety.”


Visualize something better

Feeling anxious or threatened – such as dread about the future if your preferred candidate doesn’t win – can trigger the human brain’s “fight, flight or freeze” response, Kerrigan says. When this happens, do not blame yourself, she encourages.

Instead, “use your imagination to guide you as to what you would really like to do with the distressful situation. … Perhaps you can see yourself escaping to someplace that represents paradise, with just the right people, politics and environment,” says Kerrigan, a therapist who specializes in working with adults and teens who have experienced trauma, childhood abuse or neglect. “When you think of what you don’t like about what is happening, only think of a small portion of what is wrong, rather than going into a long litany of all that distresses you. … Remind yourself that having these [fight-or-flight] feelings does not make you a bad person. It is what your brain is designed to do when it perceives a threat.”


Realize that past trauma can resurface

This fall, news coverage and political debates have included the topic of unwanted sexual advances. This can dredge up painful memories for people who have experienced similar trauma personally.

“You may not be consciously aware of an earlier trauma, but your body is acting in ways now that could suggest that something happened to you [in the past],” Kerrigan says. “It may be unusually tense, you may be holding your breath, digestion may be difficult or you are less interested in sex. It’s not uncommon to go years without knowing about the harmful things that were done to you as a child. If you suspect that this might be the case, consider finding a therapist to help you make sense of how your body is reacting.”


Stay in the moment

The concept of mindfulness – keeping your train of thought on the here and now – can be helpful when anxiety flares. Focus on where you are and what you are seeing, smelling and feeling. For example, when driving, think about the sound of the engine and how the steering wheel feels in your hands, Patterson says.

Notice your thoughts and let them go, she explains. “It is so important to keep coming back to the present moment, feel what you are feeling and breathe,” Patterson says. “If a client is having difficulty turning off their thoughts, I advise them to sit and feel both feet on the ground and take full, deep breaths with long exhalations. Imagine the breath going down their entire body, through the bottoms of their feet and into the ground. This releases the energy of the thoughts in our heads. Taking a walk while concentrating both on your breathing and each step is also immensely helpful.”


If your candidate loses

Regardless of who wins the election, you can make a difference locally by getting involved in your community.

“Remember that there are ways for you to take action, politically and otherwise, to feel like you’re making a difference in the issues that really matter to you,” Klassen says. “Also, recognize that there are checks and balances in our political system intended to limit the power of the executive branch – and that state and local elections also matter.”

“As a grief counselor,” adds Patterson, “I believe we are all experiencing a sense of loss this election season: loss of idealism, loss of a belief in the high standard to which we hold our leaders and, for many of us, the impending loss of the current president as our leader. It is important to validate feelings of loss that clients may feel if their candidates do not win. I always emphasize that clients should find meaningful and healthy ways to cope with loss, such as volunteering, journaling, making sure to get plenty of sleep and having healthy eating habits. Calling on those you know can be of support. Also, it is so important to take breaks from feelings of grief or anxiety by watching a funny movie, doing yoga, getting together for a fun evening with friends, playing with pets or getting out in nature.”





If you do find yourself overwhelmed by anxiety, negative feelings or election-induced stress, reach out to a counselor.

If you find yourself in crisis, contact the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA)’s 24-hour helpline at 1-800-662-HELP. Help is available in both English and Spanish.



More information:


The American Counseling Association’s 2016 election counselor resource page:


From the American Counseling Association’s government affairs team: “Your Voice. Your Vote. Your responsibility.”


Data and tips on election-induced stress from the American Psychological Association:




Bethany Bray is a staff writer for Counseling Today. Contact her at


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at



Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Grief: Going beyond death and stages

By Laurie Meyers

For many years, mental health practitioners labored under the assumption that grief was a relatively short-lived process that people navigated in an orderly and predictable fashion until they reached “closure” — the point at which the bereaved would move on and put the person they had been grieving in the past. Despite the continued prominence of Elisabeth Kübler-Ross’ “five stages” in the public lexicon, experts now know that grief does not move smoothly and predictably through a series of predetermined stages. In reality, it is a process that follows a different course for each individual.

Furthermore, the experiencing of grief isn’t exclusive to the loss of a loved one through death. As American Counseling Association member Kenneth Doka explains, grief is a reaction to the branding-images_griefloss of anyone or anything an individual is attached to deeply. Although society expects people to grieve the death of a family member, people also mourn events such as the passing of a pet, a divorce or the loss of a job, Doka says.

Licensed mental health counselor Beverly Mustaine, a private practitioner and an associate professor of counseling at Argosy University in Sarasota, Florida, has taught graduate-level courses in loss and grief for 20 years. She notes that she has helped clients cope with grief connected to experiences as varied as moving, losing contact with a friend, retiring and aging.

“Counselors are going to be working with grief and loss really in some regard with every client they see,” asserts Elizabeth Horn, an assistant professor of counseling at Idaho State University’s Meridian Health Science Center.

Doka, Mustaine and Horn agree that counselors who do not work regularly with issues of loss may need to rethink their concepts of grief.

“There’s so much outdated information about how we conceptualize grief and loss,” Horn says. “We’ve gone beyond the idea of ‘stages.’ We really see grief as a unique process for each individual.”

Regardless of the nature of the loss, Horn says she approaches grief work with the same goal in mind: to help clients experience and express their grief in a way that is natural for them.

It’s personal

“People react to loss in all kinds of ways,” says Doka, who has written numerous books on grief and loss, including his latest, Grief Is a Journey: Finding Your Path Through Loss, published earlier this year. Clients grieving a loss may feel sadness, yearning, guilt, anger or loneliness, but some may also feel a certain sense of relief or emancipation, particularly if they had a problematic relationship with the deceased, he explains. Whatever clients are experiencing, it is important for counselors to provide a safe place and to validate their losses, Doka says.

“We [counselors] have to communicate that we’re safe — that other people may not want to hear about this [loss] anymore, but we do,” says Mustaine, a member of ACA.

She likes to use Rogerian methods when helping clients process their grief. “I’m reflecting feelings, repeating, setting up a ‘holding’ environment where it’s OK to say the unsayable or mention the unmentionable, like ‘I hated my father, I’m glad he’s dead,’” she says. In addition to talk therapy, Mustaine often uses nonverbal tools such as sand trays or music to help clients evoke and express their emotions.

Horn, whose research focuses on grief and loss, says it is important for counselors to recognize that people have different coping styles when it comes to processing losses. Some people process loss affectively, which means they tend to express their grief verbally; others are more likely to process the loss cognitively, which means they rely more on thinking than feelings to work through their grief and tend to give expression to their grief through physical activity. In general, men are more likely to use cognitive coping styles and women affective coping styles, Horn says, but she cautions that this is not always the case.

Horn also warns that counselors shouldn’t label either coping style as the “right” way or the “wrong” way to process loss. “Within our field, we frequently have an affective or an emotional bias,” she says. “We are trained to elicit emotion and focus on emotion, and that’s great for people who grieve that way. But sometimes if we have someone who grieves in a more cognitive way, we might say that they are in denial … but that’s how they’re dealing.” She also notes that most people aren’t exclusively affective or cognitive while experiencing grief; instead, they use a mix of both coping styles.

That is one of the reasons that Horn is a proponent of helping clients design rituals, whether they involve holding a memorial ceremony or simply lighting candles in a counselor’s office, that will be meaningful and beneficial to them in processing their grief. Rituals can offer opportunities for both cognitive and affective grieving, she explains. For example, someone who copes cognitively might take charge of making all the practical arrangements, whereas someone with a more affective style might arrange for speakers or even speak himself or herself at the ceremony, Horn says.

The importance of rituals

“The ritual aspect is really important,” Horn explains further, “because frequently we have funerals, and for some folks that’s great for providing an outlet for mourning a loved one. On the other hand, it often happens so soon after [a person’s] death that there’s not a chance to really make it meaningful.”

Rituals can provide a very personal and ongoing way for family and friends to remember the deceased in a meaningful way. Horn shares a ritual that she describes as her favorite.

The son of one of Horn’s friends had died from an overdose. Although his family and friends remembered him with fondness, they felt it was important to also honor his ornery personality, so they developed a ritual based on an actual incident. At one point, the son had been asked to get his younger siblings some food from McDonald’s, but he didn’t want to. The task left him so agitated that when he returned home, he threw a cheeseburger at the wall in a fit of pique. So every year, a group of his family members and friends pick a date to get together, buy cheeseburgers from McDonald’s and throw them against the wall.

Doka tells the story of a good friend who died from amyotrophic lateral sclerosis (ALS). Before the ALS rendered him incapable of physical activity, Doka’s friend — who described himself as “an engineer by vocation but a bluegrass musician by avocation” — played with a band at various outdoors venues, which made the performances dependent on the weather. As a nod to this reality, the band always opened its sets with a song titled “Singing in the Sunshine.” When Doka’s friend was diagnosed with ALS, the band started opening instead with “Singing in the Rain” and telling the audience about their missing band mate. When he died, the band played the song at his memorial service.

Doka believes that when a child or teenager dies, it is important to get his or her friends and classmates involved in the memorial service. For instance, Doka, a Lutheran minister, presided over the funeral of a 13-year-old girl, and her family asked her friends and classmates to help design the service. The friends suggested having her school choir sing at her service. “It let the kids feel involved and was also very powerful for the family,” Doka says.

Children’s friends and classmates are the people who really know them best, says Judy Green, whose work as a private practitioner and school counselor in the Jacksonville, North Carolina, area has focused on grief and loss. She encourages children and adolescents to reach out to the families of friends or classmates who have died to share their memories. In her experience, Green says, families often find this helpful in mourning their child’s death. Both Green and Doka say it can also help the child’s friends and classmates better deal with the death.

Horn says it is important for counselors to talk to their clients about their cultural backgrounds and discuss any rituals that they might find helpful in grieving the loss of a loved one. Some rituals can even affect how clients verbalize their grief, she says. For instance, in certain Native American cultures, a person who has died is believed to be on the “spirit road,” which is an essential journey. Speaking a person’s name after death will take the deceased off the road, Horn notes.

Horn emphasizes that whatever a client’s background, grief is still very individual, so rituals should take whatever form is comfortable for the client. “We are all so very unique in the way that we interact with our culture, ethnicity and personal traditions,” she concludes.

Adjusting to the new normal

Rituals can also help grieving clients move on to what counselors call the “new normal,” a world in which the person, relationship or other object of loss is no longer with them, yet they continue to make a place in their lives for that connection. Counselors can assist clients in coming up with rituals that recognize the progression but also honor the relationship to the loss, Doka says.

As Doka explains, these might include a ritual of continuity, such as lighting a candle on the person’s birthday; a ritual of transition, such as a ceremony for a widow removing her wedding ring; a ritual of reconciliation, in which the client says, “I’m sorry” or “I forgive you”; or a ritual of affirmation, in which the bereaved says, “Thank you.”

“Creating a memory box with mementos from the loved one or creating a figure out of molding clay can be helpful to capture the grief and shift the sadness,” says Barbara Sheehan-Zeidler, a licensed professional counselor in Littleton, Colorado, whose practice specializes in grief and loss. “Sometimes clients write letters, poetry, songs, or draw pictures to their loved ones that they either save or we burn or shred together. Sometimes clients write letters to their future selves as an attempt of encouragement that the future will be different and they will be all right. I have also helped create a ritual, usually around the anniversary of the death, using candles, burning items, shredding old papers or burying artifacts like a time capsule.”

Sheehan-Zeidler encourages clients who desire a longer-lasting remembrance to volunteer or join a group that is connected to their loved one or to create an annual event in honor of the person.

Says Green, “When people realize that their relationship with the deceased did not end when the death occurred, but that the relationship will always be part of them, they will be well on their way to healing from the loss.” At the same time, Green urges counselors to let their clients know that grief isn’t linear. Months or even years after the loss originally happened, they might wake up and hear a song on the radio that reminds them of their loved one. And that experience might trigger a brief wave of grief, she says.

Green says many people do most of their active grieving within the first six to eight months of the loss. But she adds that grief cannot fully be processed until the client has lived at least a year without the loved one and gone through events such as birthdays, anniversaries and any holidays that were significant in their relationship.

Complicated grief

Complicated grief occurs when people become so debilitated by grief that they are unable to return to their daily activities, even after an extended period of time. The symptoms are similar to those of “uncomplicated” grief, but more intense and debilitating, and longer lasting, Green says.

“There is no specific time frame for grief to end,” she adds. “Everyone is different, so our reactions to loss will be unique to every individual. As a general rule, however, people usually work through their grief and can get back to their life tasks within six months of the loss.”

A variety of factors can contribute to the presence of complicated grief, Green says. These include the death of a child, the perception that the death was avoidable, an unhealthy or dependent attachment to the deceased, death following a prolonged illness, a client’s prior history of loss and a lack of social support.

Clients who are experiencing mental health issues at the time of the loss — or have experienced them in the past — are also at greater risk of being confronted with complicated grief, Doka says.

“Each of these factors can result in interrupting [the ability] or prolonging the grieving person’s inability to cope with the death,” Green says.

“Complicated grief can be likened to a wound that will not heal,” she continues. “In addition to emotional problems, a person who is experiencing complicated grief becomes at risk for health-related issues such as lack of adequate sleep, severe depression, suicidal ideation or behavior, substance abuse, suppressed immune system and stress that can lead to heart attacks or strokes.”

As for treating complicated grief in clients? “I have found that group counseling is one of the most healing methods for people suffering from complicated grief,” Green says. “Being able to share with others who have suffered a similar loss lets people know that they are not alone. By sharing a similar loss, people come to realize that there is hope for them even though they might be experiencing deep despair. By sharing experiences with others who have suffered similar losses, people learn that in allowing themselves to experience the pain of their loss, eventually the pain lessens as they learn to adjust to life without the deceased and begin to invest in their future without the loved one present.”

“This does not mean that they lose the connection with their deceased loved one,” Green explains. “Rather, they learn that their emotional connection with the deceased will go on forever; they learn how to embrace that and move on.”

An important consideration is that these groups be made up of people who have experienced the same kinds of losses, Green emphasizes. For example, a group for those who have lost a child, a group for those struggling with the aftermath of a loved one’s completed suicide and a group for those who have lost someone to a sudden and unexpected death.

Green finds group counseling so helpful for these clients that she often recommends they stay or rejoin another group once they have processed, or are well on their way to processing, their grief. “Their experiences can help others and they continue to heal further [themselves],” she says. “In fact, I have had many people ask to rejoin a new group or take training to lead the groups because they have found how therapeutic this modality is.”

She acknowledges that these groups aren’t offered as widely as they need to be. “However, my suggestion is that counselors build a network wherever they are so they know where grieving people might attend such groups,” she says. “First, I [would] begin with hospitals. Many run groups for the families of cancer victims, cancer patients themselves and parents who have lost babies through miscarriage or stillbirth, for example. Another great resource is local funeral homes. Many have a social worker or trained person on the staff who runs such groups, [which are] usually open to anyone, not just those who have used the services of that particular funeral home.”

In addition, cognitive behavior therapy (CBT) can be very beneficial for those who are struggling with complicated grief, Green says. It helps them “think about their situations from different points of view, thus altering how they feel and behave when thinking about the deceased,” she explains. “The structure provided using CBT techniques can help grieving individuals deal with their loss and provide a means to measure how much progress is being made each week.”

Green assigns her clients homework, such as journaling about feelings and memories connected to their loved one or developing lists (e.g., five things the client misses about the deceased). “These activities help clients focus on their relationship with the deceased rather than on the loss itself,” she says. “For example, having them make a list of things they enjoyed sharing with the deceased or writing a goodbye letter to the deceased, which is then shared with the counselor, is both cathartic and healing. This also helps clients begin the process of experiencing the pain of the loss that might otherwise remain unattended to. Stuffing down one’s thoughts and feelings is detrimental, so these activities help gently to bring the thoughts and feelings to the surface where they can be dealt with.”

Counselors should also help grieving clients work through any unfinished business, Green says, such as not having been able to say goodbye to the deceased or feeling guilty about something related to the deceased.

Doka has clients write letters to the deceased or engage in role-play to have conversations with the deceased. He gives the example of a boy who had carried guilt over the death of his father. When the boy and his family visited his father as he lay dying in the hospital, the father would always ask the boy for a hug before he left. The final time that the family visited, the boy didn’t want to give his father a goodbye hug before leaving because he had already hugged him earlier in the visit.

During a counseling session, Doka had the boy role-play with him and apologize to his father. He then asked the boy to move to the “father’s chair” to better imagine what his father might say to him. Doka says that as soon as the boy inhabited his father’s chair, he could imagine his father saying, “That’s what you’ve been worried about, sport?”

The boy realized his father would have been surprised that the incident was such a source of guilt to his son. What happened would not have stood out as a source of hurt for the father or been something that he held against his son.

Sheehan-Zeidler uses a similar method, asking clients to imagine what they would say or want to hear if they could talk to their deceased loved ones. But certain types of death, such as suicides, horrific accidents, murders or even sudden and unexpected losses, can be traumatizing to clients. In such cases, Sheehan-Zeidler has found that the use of eye movement desensitization and reprocessing can be helpful.

All losses can be complicated

A loved one’s death is not the only type of loss that can result in complicated grief. Mustaine once counseled a woman who had been divorced for five years yet still fully expected her ex-husband to return, even though he had remarried and had children with his second wife.

In cases such as these, clients may not even have begun to grieve because they have not identified (or cannot identify) the loss and associated feelings that it engenders. Mustaine doesn’t dive into grief work right away with clients who are experiencing complicated grief. Instead, she focuses on establishing the therapeutic bond and giving the client time to accept the counseling office as a safe space. Later, she asks these clients — such as the woman who couldn’t accept her divorce — how they feel about their loss and starts to tease out any underlying feelings. For instance, “I hear you saying that you have not experienced any anger over your divorce, but a lot of people would feel angry.”

Mustaine waits to see if the client takes her statement as a cue to express anger. If the client doesn’t, Mustaine will circle back and say something such as, “You really don’t feel anger?”

In these instances, it is not uncommon for clients to respond that they don’t feel anything because they are numb, Mustaine says. So she sometimes asks them to imagine what they might feel if they weren’t numb. She then explores the reasons behind their inability to truly express their emotions. “What were you taught about having feelings?” Mustaine asks. “Maybe that it’s not OK to express your feelings?”

“You give them permission to have their defenses,” Mustaine continues, “but broach the idea of emotion: ‘What’s so scary about thinking about even having a feeling?’”

Some clients grew up in environments in which it wasn’t safe to express emotions, Mustaine says, such as having a father who would say, “You don’t have anything to cry about. I’ll give you something to cry about!” In such cases, Mustaine says there might be a need to switch from grief work to traditional psychotherapy.



All of the sources Counseling Today spoke to for this article cautioned that in order for counselors to avoid their own complications, they should engage in their own grief work before working with clients on grief and loss issues.




Additional resources

To learn more about the topics addressed in this article, take advantage of the following resources offered by the American Counseling Association:

Books, etc. (

Podcasts (

  • “When Grief Becomes Complicated” with Antonietta Corvasce
  • “Remembering Lives: Conversations With the Dying and Bereaved” with John Winslade and Lorraine Hedtke

VISTAS Online articles (

  • “A Shift in the Conceptual Understanding of Grief: Using Meaning-Oriented Therapies With Bereaved Clients” by Jodi M. Flesner
  • “Current Trends in Grief Counseling” by Elizabeth A. Doughty, Adriana Wissel and Cyndia Glorfield
  • “Frequency and Importance of Grief Counselor Activities” by Darlene Daneker
  • “The Anniversary of the Death of a Loved One” by Rebecca M. Dedmond, Annie K. Smith and Sania Frei-Harper
  • “Understanding Grief and Loss in Children” by Jody J. Fiorini and Jodi A. Mullen

Practice Briefs (

  • “Death and Dying Issues” by Kathryn Layman & Jessica Swenson




Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Nonprofit News: Building a community on social media

By “Doc Warren” Corson III October 24, 2016

As a guy who doesn’t even use a cellphone, I’m not exactly what many would consider a technology wizard. Still, I make sure to maintain an updated and functioning website and a viable and active social media presence for the charity that I direct. This has helped us not only when it comes to receiving referrals, but also in building a community feel for our programming and growing our volunteer base.

Here are a few guidelines that may help you establish a solid social media presence for your counseling nonprofit.


Make your name matter: This is a time to keep things simple and clear. Try to avoid acronyms unless you have a widely known one. Many folks may be familiar with HRC (Human Rights Campaign), WWF (World Wildlife Fund) and NPR (National Public Radio), but chances are good Social Media Logotype Backgroundthat your program isn’t a household name. Our main program is a therapeutic farm that many call the “WIP” for short, but on social media we spell out the name (Pillwillop Therapeutic Farm) so that folks can find it easily.

Having a social media page name that is known and understood only by an inside few is not going to help things grow. Having a clear and concise name can help you pick up random followers and those who are legitimately looking for you without having to possess any inside knowledge of nicknames or the like.

You can also choose to name a specific program that your nonprofit runs as opposed to featuring the main company. We elected not to have much social media coverage of our parent company because it seemed much more limited than our community-based therapeutic farm. We do, however, make it clear that the farm is one of our programs.

Moderate your page and membership: A small percentage of people may want to get into your social media page for all the wrong reasons. Some may want to sell things such as cheap sunglasses, whereas others may want to use it as a platform to go on a political, religious or hate-filled rant. This can kill or greatly reduce your program’s reach and reputation.

Thankfully, it is typically rather simple to keep most of this stuff out by moderating your page. First, set up your page to require permission to join, and then screen these members to make sure they are real. Take a minute to go over their personal pages to ensure they are not spammers. Look for pictures of the person and the types of posts they generally make to help you determine a spammer. In addition, have moderators for your social media page who help ensure that people are staying within established bounds. If things do go beyond what is allowable, be sure to react swiftly and politely.

Establish clear and simple rules: No one wants to belong to a page with a ton of boilerplate rules that need to be read, signed off on and followed to the letter. Instead, pick a few clear and simple rules that help establish group norms. For our program we have three main rules:

  • No religion
  • No politics
  • No negativity or personal attacks

“No religion” does not mean that churches or other spiritually based programs are forbidden from posting. It simply means that no one is allowed to belittle beliefs that differ from their own. In fact, we actively have people on our site who offer to pray for someone going through tough issues, and folks do indeed post events that are being held at local churches, synagogues, etc.

Our “no politics” rule is set up much the same way. Folks can encourage others to vote or register to vote, but they cannot promote a given candidate or party because that is beyond our scope. The “no negativity or personal attacks” rule can be a bit more confusing for some folks because they are allowed to speak about things that are troubling them. However, they are not allowed to personally attack someone or be overly rude when discussing something that is troubling them.

Lead by example: Moderators help set the tone and pace of a page. Ask folks to serve as moderators who are active, positive and have an ability to get and keep people interested. Moderators should make posts consistently without giving page members the sense they are being flooded. For instance, moderators might consider holding back a few of their planned posts if the page has been particularly active.

Encourage communication among members: Encourage your members to post openly and often. Maintain a safe posting environment that leads people to feel that their voice is important and valuable. You will be surprised at the great ideas often posted by the general membership. Your social media page shouldn’t be meant as a place where only a select few people post.

Provide a solid description: A solid description can help folks get a better understanding of your program and the goals of the group. Be clear and help people get to know the program better by offering a few short paragraphs. If your program name is hard for some to pronounce, offer a pronunciation key. Also include the types of services you offer, a word about the setting and whatever else you feel sets your program apart from others. Here is an example:

“Pillwillop (pronounced: pill will up) Therapeutic Farm is a program of Community Counseling Centers of Central CT Inc. (; We provide high-quality, affordable holistic mental health services to the greater central Connecticut area.

“Nature supports healing of all kinds. Within this picturesque setting we offer outpatient therapy, art therapy, therapeutic gardening, hiking, passive recreation and other programs to support mental health and wellness. Nurture in Nature.

“We are a working community in which all members contribute in their own unique ways to the best of their abilities. By taking an active role in the work and the life of a community, people can gain or recapture a sense of self-esteem, self-identity and a sense of purpose that can often become lost in today’s fast-paced, electronic age. By connecting with each other in a natural setting, each member learns more about themselves and the ways they interconnect with the world.”

To advertise or not, that is the question: Some folks set up social media pages and let them grow organically through word-of-mouth, whereas others aim for fast growth through paid advertising. There really is no right or wrong way. However, paid advertising can create somecoffee with foam in like form issues with quality control and monitoring. This is where moderators can really come in handy.

If you do advertise, be realistic in the scope, cost and reach of the advertising plan. If you are a local program with limited reach, a national ad campaign will likely be a waste. Some social media sites offer targeted advertising that can reach particular towns or even certain sections of towns. Think and choose wisely.

Be aware of HIPAA and confidentiality issues: It’s important to remember that while you may be doing your best to build an online community, HIPAA (the Health Insurance Portability and Accountability Act) and other confidentiality issues are still in play. Be careful not to ever put any information on the site that is protected or that will identify anyone as a client. Do not ever identify page members as clients, even if they identify themselves as such. You owe it to your clients to maintain their privacy.

Pictures can be posted, but it is best to focus on the program itself and not the people unless 1) the pictures are of a public event that you held, 2) the pictures do not identify anyone as a client AND 3) you have full permission to post the pictures.

Social media can be an effective and free way to help promote your nonprofit program. If you are not currently using it, you really should give it a second thought.




Dr. Warren Corson III

Dr. Warren Corson III

“Doc Warren” Corson III is a counselor, educator, writer and the founder, developer, and clinical and executive director of Community Counseling Centers of Central CT Inc. ( and Pillwillop Therapeutic Farm ( Contact him at


Fraudster targets counselor’s innate empathy

By Bethany Bray October 20, 2016

Picture this scenario: You’re a counselor in private practice and a potential client contacts you via the email address listed on your practice website. The emailer expresses interest in attending marriage counseling with his wife, then goes into detail about the specifics of his situation and the struggles he and his wife are facing.

He requests to set up a series of appointments over four weeks while he and his wife are in town visiting relatives. After a series of emails back and forth, you discuss pricing and schedule depositphotos_5439676_m-2015appointments for the couple at your practice.

No cause for concern or reason to put up your guard, right? Not so, asserts a licensed professional counselor (LPC) and American Counseling Association member in Colorado who says she fell victim to a scam that followed that exact series of events, resulting in her losing several thousand dollars.

She agreed to share her story publicly with CT Online (on the condition that her name be withheld) because she wants to make other counselors aware of a scheme that preys particularly on their desire to help others.

“Even though we [counselors] are helpers, we are not immune to fraud,” the LPC says. “It wasn’t even on my radar to be thinking someone might try this. … I would want other counselors to know that people could be wanting to scam us at any given point in time.”

The fraud occurred when the emailer sent the counselor a cashier’s check in advance to pay for his couples counseling sessions. He contacted her soon after and explained – in multiple convincing, well-written emails – that there had been a mix-up and that the cashier’s check had mistakenly been made out for more than he owed her. He asked the counselor to send back the extra funds, and she agreed. After she wired the extra money back to the “client,” her bank returned the cashier’s check as uncollectable.

Unbeknownst to the counselor, banks often will make funds available before they are fully clear, which can sometimes take months.

“I didn’t want to hold on to money that wasn’t rightfully mine. I was trying to be the professional and do the right thing for these people,” she says. “When I found out I had been scammed, I went into the worst panic attack I have ever had. I couldn’t even hold my phone. I couldn’t talk. I was shaking. I thought to myself, ‘How did I get scammed?’ It didn’t make any sense.”

The counselor, who has been in private practice in Colorado for six years, has contacted her bank and filed a police report, but says she has been told there is not much else she can do to recover her money.

The counselor says that throughout the process, she never suspected any fraudulent activity on the part of the “client.” Potential clients have often contacted her via email, she says, and clients have also prepaid for a series of sessions.

In addition, the fake client’s emails didn’t resemble the “Nigerian Prince” scams that have proliferated over email. The counselor says the person posing as the husband with a troubled marriage had an email address with a major Internet provider and that the messages were well-written and detailed. The prospective “client” and the counselor emailed back and forth for weeks.

The LPC says it seemed like this person was somewhat familiar with the counseling profession. He knew the right questions to ask about her services and what they would cover in sessions.

She believes counselors are particularly vulnerable to this type of fraud because they are hard-wired to be empathic helpers. In addition, they are also used to normalizing the abnormal, she says. Because counselors often interact with people who are facing significant life struggles or are mentally ill, they are less likely to question atypical actions such as a person not returning phone calls, sending messages out of the blue or writing an email that is hard to decipher, she explains.

But the experience of being scammed has left her feeling hurt and vulnerable, the counselor says.

“I go out of my way a lot for my clients and sacrifice my time a lot more than I probably should because I want to help somebody,” she says. “I think that’s part of counseling. In order to be empathetic and compassionate to people and promote healing and wellness, a lot of time our time gets sacrificed. … In order to have a business, your clients’ needs sometimes have to come first, if not in line with our own needs.”

The experience does have a silver-ish lining, however. After the reality of the scam settled in, the counselor took time for self-reflection and re-evaluated her business practices. Going forward, she says she will be cautious about screening potential clients and will request information such as an address, an emergency contact number, the name of the client’s primary care doctor and other details before scheduling appointments.

“I would like to try and speak to people on the phone, prior to setting anything up — do phone consultations to validate that they’re real people,” she says.

“I’ve always felt like [counselors are] people who are trying to make the world a better place,” she says. “Why would anyone want to defraud us?”





ACA members: Facing a dilemma about ethics, business practices or risk management? Contact the ACA Ethics and Professional Standards Department at (800) 347 6647, ext. 321 or email:






Bethany Bray is a staff writer for Counseling Today. Contact her at


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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.