Loss is a universal experience and an underpinning of many therapeutic issues. The client who has just lost a job, the parents whose son is addicted to opioids, the client whose long-term relationship unraveled, and the client who received a devastating health diagnosis all have loss in common.
As a professional counselor and bereavement trauma specialist, I am sensitized to the ways that loss informs clients’ worldviews and emotional struggles. And as a grief survivor, I am aware of the unique ways in which loss can serve as a catalyst for growth. An African proverb captures this sentiment when it says, “Smooth seas do not make for skillful sailors.” But this raises questions: Is growth possible for everyone, and how do counselors help clients grow after a traumatic loss?
Posttraumatic growth: What is it?
Posttraumatic growth (PTG) is an approach that informs our practice as professional counselors. Richard Tedeschi and Lawrence Calhoun, who pioneered much of the research and theory on PTG, define it as positive change that follows the struggle after some kind of traumatic event. PTG represents change that occurs after a life crisis rather than during it. It usually involves longer-term change that occurs over an extended period of months to years as individuals cope with crisis by developing ways of thinking, feeling and behaving that are different from what they relied on prior to the life-changing event.
PTG is not the same as personal development or maturity. It may be thought of as something that occurs somewhat spontaneously as the result of trying to cope with a challenging life experience of seismic impact. Evidence of PTG does not imply that the loss or traumatic event was somehow desired.
Approximately 10% of loss survivors stay mired in grief, guilt and despair for an extended period of time following their loss. Clients who experience these emotions, coupled with an intense yearning for who or what was lost, might be suffering from complicated grief, which requires a particular kind of professional treatment (see complicatedgrief.columbia.edu). The majority of loss survivors do not get stuck in acute grief, however, and report some measure of growth during recovery from loss. For many of these survivors, growth may coexist with distress.
Research summary: What do we know?
In 1996, Tedeschi and Calhoun’s research resulted in the Posttraumatic Growth Inventory, a 21-item self-report measure that yielded five empirically derived markers of PTG:
1) Improved relationships with others
2) Greater appreciation for life
3) New possibilities for one’s life
4) Greater awareness of personal strengths
5) Changes in spirituality
These five markers of growth have been reported by a variety of survivors, including prisoners of war, veterans with posttraumatic stress disorder, people diagnosed with cancer or other life-threatening illnesses, people who became paralyzed from accidents, and those who have lost spouses or life partners. Although much of the research has been conducted with people living in the United States, other studies have explored PTG with individuals in other countries.
Among current findings on PTG, Tedeschi and his co-authors cited the following in their 2018 book Posttraumatic Growth: Theory, Research, and Applications:
- About 30% to 60% of survivors report some experience of PTG following a difficult life event.
- PTG is both a process and an outcome.
- PTG is generally a stable phenomenon over time.
- PTG is more evident in those individuals who score higher on measures of extraversion and openness to experience and is also related to optimism.
- There are both universal aspects and culturally specific characteristics of PTG.
Critics of PTG point out that self-reported or perceived growth is not necessarily the same as actual growth. Some of the conflicting findings on PTG seem to be the result of differences in how growth is defined and measured across studies.
Growth-promoting practices with loss survivors
There has been less research about specific interventions and techniques that might facilitate PTG in survivors, although a predominant feature of a growth-oriented therapeutic approach involves working with client stories or narratives. The following practical strategies can be used to help facilitate growth with loss survivors.
Create a safe therapeutic environment. Traumatic loss erodes a sense of security and thrusts survivors into the middle of unfamiliar circumstances. Social support is crucial, yet many people in survivors’ social networks may be uncomfortable with grief or may offer well-intentioned comments that feel offensive to the survivor. Counselors’ first task is to provide a safe container that is comforting and companionable for loss survivors. Creating a therapeutic environment in which we listen closely and hold up a mirror to reflect these clients’ experiences will help loss survivors feel known.
Use self-care practices. Traumatic loss may disrupt the rhythm of survivors’ connections. One way to help loss survivors reestablish bonds with others is to encourage them to grow a new relationship with themselves. We can help clients do this by recommending effective self-care practices such as movement and exercise, adequate sleep, and the intake of nourishing food. In the 2012 book The Emotional Life of Your Brain, Richard Davidson points out that a lack of consistent self-care practices sabotages our ability to regulate our bodies and emotions. Mindfulness and self-compassion are additional self-care practices that can be used by loss survivors who feel emotionally flooded with anger, guilt or anxiety. Teaching self-compassion and mindful meditation to these clients can help them reestablish a connection with themselves and, ultimately, with others. These tools also enhance clients’ equilibrium, making further work toward growth possible.
Explore client narratives. An important part of therapy with loss survivors involves exploring their narratives or stories. PTG occurs most often with clients who create an adaptive narrative in which they are able to see themselves as survivors rather than victims. The following items play integral roles in exploring client narratives.
Timelines: Initially, clients can construct a timeline of their lives with significant events marked at various ages. Timelines provide critical clues about pre- and post-loss stressors as well as the loss event itself. Clients who have been subjected to many pre-loss stressors often have more difficulty discovering growth. Using strength-oriented queries when asking clients to review their timelines is useful. For example, “Juanita, I noticed you had a miscarriage when you were 20. How did you cope with that? What tools did you find that helped you through that loss?”
Clues of growth: Many clients are so affixed to the trauma of the event that it’s hard for them to detect anything positive about their story. Counselors can be most helpful by noting clues of growth and healing in clients.
For example, James, an African American in his mid-20s, is discouraged because he has been through multiple losses. The house he once lived in with his grandmother was recently obliterated by a tornado, and now she is in the hospital with multiple injuries. In addition, the business he started just folded. In recounting his narrative, James mentions that a local church has offered to help rebuild the home, and a nearby car dealership just offered him a job. He says having others reach out to him with offers of assistance feels so unfamiliar that it’s starting to change his opinions about the world and other people. Although he doesn’t identify this as an indicator of growth, his counselor does by pointing out ways in which James’ views of himself, other people and the world are shifting in a new direction.
Cultural context: Exploring client narratives within a cultural context is also crucial. Some clients may present narratives of cultural losses rather than individual losses in instances in which they have faced significant discrimination based on their race, ethnicity, gender, age, ability status or sexual orientation. It is important for counselors to be aware of the ways that clients’ cultural affiliations affect their lives and their views of traumatic loss and healing.
For example, James reveals that he has been working odd jobs since he was 14 to support himself and his grandmother, whose only source of income is a small Social Security check. James confides that this elevated level of financial stress and the recent losses he has experienced make him feel more vulnerable as a black man living in a predominantly white rural community.
Journaling: Counselors can also facilitate client narratives by encouraging the use of journaling as an adjunctive therapeutic intervention. Therapeutic journaling is a tool developed by James Pennebaker, who says that writing about traumatic events reduces stress and strengthens immune cells. Consistent journaling is most effective, but 15 to 30 minutes of journaling several days a week can be more productive than daily journaling, which may produce more rumination than growth, according to Pennebaker. When working with survivors of loss, counselors typically instruct these clients to write about their deepest thoughts and feelings regarding their loss.
Case example: Sharon
Sharon is a 62-year-old woman whose live-in partner of 40 years died of a sudden heart attack. Sharon resides in rural Appalachia, where she had lived with her now-deceased partner for many years. She has no children, and her one brother lives hundreds of miles away. Sharon stopped working in a dental office seven years ago to help take of her partner, who had uncontrolled diabetes. She has no real friends and reports that she has rarely been out of the house in the past seven years. She says that she has no neighborhood acquaintances or memberships in any social groups.
In the first several counseling sessions, Sharon sobs and indicates that she has no idea how she will go on after losing her partner. She has limited income but no real expenses other than rent and utilities. She insists that she does not want to return to work and has sufficient income to meet her monthly obligations. She presents herself as something of a loner and describes herself as isolated.
Sharon came to the community counseling center at the urging of her brother, but she is unsure that grief counseling can be helpful to her. Short of bringing her partner back to life, she doesn’t know how talking and crying about her loss will accomplish anything. She is not having trouble sleeping but feels compelled to get out of the house during the day. She drives around randomly and visits local discount stores just to have someplace to go.
Sharon becomes more interested in counseling when a grief support group is offered, and she attends several sessions. She returns to individual counseling in a much more animated state and is even able to laugh. Having made several friends in the grief support group, Sharon reports that the group has helped her feel less alone. She is able to construct a grief timeline in counseling and is amenable to doing occasional journaling when she has bursts of grief. Over time, she pursues recommendations for joining a local gym and a book club at the public library.
Four months into individual counseling, Sharon becomes interested in volunteering at a local animal shelter and starts doing so on a weekly basis. Several months later, she feels like a different person. She says she is ready to stop coming to individual counseling sessions but will continue attending the grief support group.
Not all grief survivors experience the kind of growth that Sharon experienced — or so quickly. Even though she continued to miss her partner terribly, her life as a caregiver for the past seven years had precluded her from developing much life satisfaction for herself. Her ability to make friends and develop social connections and her volunteering activities with the animal shelter gave her a great deal of self-efficacy and provided positive ways to deal with the absence of her partner.
Some people will not cope with loss as effectively as Sharon did. Those who experience losses associated with violence or who have coexisting diagnoses such as depression, anxiety or substance disorders are more likely to go through an extended recovery period for healing. In addition, many grief survivors feel guilty for experiencing any kind of satisfaction, as if it amounts to some kind of betrayal of the person who is no longer here.
At the same time, it is not uncommon for grief survivors to reevaluate and shift their priorities in life, in part because their life circumstances have changed. For example, Emilee lost her spouse Roberto, who was a retired military officer and active in veterans’ affairs. Roberto had spent his retirement years traveling internationally in support of this cause. Emilee had rarely accompanied him because of her fears of terrorism and plane crashes. After Roberto’s death, however, Emilee decided to engage with the same veterans’ foundation that Roberto had been active in and found herself traveling all over the globe. Emilee wanted to preserve her spouse’s legacy and share her own gifts with a larger number of people. Loss survivors such as Emilee and Sharon who find ways to give back or volunteer are more likely to report narratives of growth.
Being attuned to growth
Potential for growth exists when clients uncover meaning from their loss and construct narratives that fit into their worldview and sense of self. Skilled counselors can serve as guides to help survivors make sense of what has happened. No survivor should ever be pushed to grow, but having a counselor attuned to growth may be the missing piece that helps clients become more resilient in the face of traumatic loss.
In my own experience as a grief survivor following a series of personally devastating losses, awareness of my growth sneaked up on me. It was as if a dimmer switch got turned up again as my outlook and mood shifted in a positive direction. I include this because being attuned to indices of growth may be one of the best ways that we can help clients recognize growth possibilities and emerge from the darkness of a traumatic loss to find light again. As Jon Kabat-Zinn, founder of mindfulness-based stress reduction, has said, “You can’t stop the waves, but you can learn to surf.”
Sherry Cormier is a licensed therapist, certified bereavement trauma specialist, and former faculty member at the University of Tennessee and West Virginia University, as well as being a public speaker, trainer and consultant. She is the author of Counseling Strategies and Interventions for Professional Helpers (ninth edition), senior author of Interviewing and Change Strategies for Helpers (eighth edition), and co-producer (with Cynthia J. Osborn) of more than 100 training videos for Cengage. Her newest book is Sweet Sorrow: Finding Enduring Wholeness After Loss and Grief. Contact her through her website, sherrycormierauthor.com.
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