Monthly Archives: May 2021

The unique challenges that face immigrant clients from Africa

By Stephen Kiuri Gitonga May 10, 2021

Immigrants to the United States have one goal in common: to attain the American dream. For many, this dream means leading a life with fewer struggles than they experienced in their countries of origin. Africa is the second-largest continent in the world, stretching from Senegal to Somali (west to east) and Tunisia to South Africa (north to south). It has 54 countries and a population of approximately 1.3 billion people. There are about 3,000 African tribes, each of which speaks its own language or dialect.

The most widely spoken languages in Africa include English, Arabic, Swahili, French, Portuguese, Akan, Hausa, Zulu, Amharic and Oromo. It can be easy for counselors in the United States to assume that one Black client is like the other Black client, when in fact one might have been born and brought up in the U.S. and the other might be a first-generation immigrant from Africa. Such an assumption would be disadvantageous to clients from Africa because their varied and diverse experiences would be ignored. If these experiences contribute to the client’s presenting problem and yet are disregarded or overlooked by the counselor, then treatment of the presenting problem would be challenging or even elusive. 

It is important for counselors to take stock of the unique challenges that afflict immigrants from Africa and could complicate their lives in the United States. Mental health counselors are encouraged to pay special attention when working with this population to address the presenting mental health problems and other issues unique to these clients that, if left unaddressed, could have a negative impact on their well-being.

Culture shock

Relocating from Africa to the United States is likely to be a culture shock for the immigrant client. In fact, many immigrants from Africa experience culture shock even before they travel to their new country. 

The process of securing a visa to travel to the U.S. is a daunting experience that takes months — and sometimes years — to complete. Applicants physically go to the U.S. Embassy offices in their countries or regions to attend interviews and complete official paperwork related to their travel. At these offices, they are likely to see armed white police officers in full gear, complete with duty belts, guns, sunglasses and other items dangling from the belts. Applicants may feel intimidated by the sight of these officers, having previously been accustomed to seeing Black police officers carrying gear that is less threatening. 

The interview determining potential receipt of a travel visa can go either way, and applicants are aware that if they are denied, they will not necessarily learn why they were not issued visas. Issuance of a visa is the prerogative of the immigration office. There is no provision for explanations in cases of denial, although candidates can submit new applications for consideration in the future. 

Once African immigrants actually travel to the U.S., they are likely to experience culture shock in multiple ways. Depending on such factors as their previous experience with international travel, their country of origin and the port of entry to the U.S., new immigrants may be shocked by the size of the cities, highways, forests, rivers and lakes, and the sheer amount of food that gets served on a plate. They also observe that cars generally carry fewer occupants than they are used to and that there are more people driving up and down the streets than people walking or using public transportation. Immigrants from Africa also quickly realize that they are a minority race in the United States — a stark contrast to their majority status in their country of origin.

Another cultural experience that may be shocking for the new immigrant from Africa is the sole use of English to communicate. Code-switching, which is common among people who are bilingual, is not possible when English is the only language in use. Other things they learn or observe include the high cost of living, differences in dressing, the prevalence of low-context interpersonal interactions, driving on the right side of the road, a love for sports that are unique to Americans, people who are homeless, panhandlers on the streets, and the menace of opioids, to name but a few. 

The COVID-19 pandemic has introduced another complication to the cultural experiences of immigrants from Africa. In line with their social nature, these individuals support one another whenever a member falls sick by visiting and helping with child care, cooking and other household chores. COVID-19 safety guidelines do not allow people to congregate, especially around someone diagnosed with the disease. While the COVID-19 pandemic was peaking, it was common for people to be buried in communal graves. From an African context, it is uncommon for a person to die and for the bereaved family to be unable to complete all the rituals associated with funerals. It may take time for immigrants from Africa to come to terms with these tragic experiences.

Past and present trauma

Depending on their country of origin, some immigrants from Africa may have preexisting posttraumatic stress disorder or other disorders that have gone untreated from such events as war, physical abuse, sexual abuse, accidents, displacement, political violence, intertribal clashes or terrorism. There is ongoing instability in such countries as Somalia, South Sudan, Chad, Ethiopia, the Democratic Republic of Congo, Libya and the Central African Republic, with many casualties every year. In Nigeria, there is ongoing violence instigated by the terrorist organization Boko Haram. 

Survivors of these instabilities may end up immigrating to the U.S. as refugees or enter the country under another status. Their traumatic experiences in their countries of origin, compounded by new traumatic experiences in the new country to which they have immigrated, can be challenging to treat. Many of these individuals may be unaware that they even have a treatable condition. 

Loneliness

Research points to the seriousness of loneliness to one’s mental health. People immigrating to the U.S. may suffer prolonged periods of loneliness before they form meaningful relationships within their host communities. Loneliness can be compounded by cases of rejection, discrimination, isolation, stereotyping, microaggression and so on in their new communities.

They are often unable to communicate on a regular basis with family members back in their country of origin because communication by mail can take a long time and international phone calls are expensive. Loneliness, coupled with other problems, can lead to depression or degenerate to suicidal ideation for this population. 

Language

Only a small minority of immigrants from Africa report English to be their first language. Most of them have learned other languages before English. Student immigrants from non-English-speaking countries encounter fewer problems because they are usually enrolled in English classes during the first semester of their respective programs. Others who were fluent in English in their country of origin are often surprised at how different American English is from other English dialects and accents. 

Fluency in language is important for self-expression and self-esteem. Immigrants who struggle with the English language might have a harder time adjusting to their new life in the U.S. Another disappointment they typically experience is inability to code-switch — i.e., switch from one language to another — like they were used to doing before their relocation. This is because most of the members of the majority culture with whom they now interact speak only in English. 

New identities

Immigrants from Africa are faced with changing their identities in multiple ways upon arrival in the U.S. For example, in their country of origin, there may have been certain activities and roles such as child care, cooking, driving, mowing the lawn, financial management and so on that were classified by gender. In the U.S., these responsibilities are more commonly shared between men and women. 

If African immigrants were wealthy back in their home country, they likely had employed the services of a live-in houseworker to help with such chores as child care, cleaning, laundry and cooking. These chores must now be shared between the couple irrespective of their gender. Assignment of these responsibilities is often a major source of discord among couples who have emigrated from Africa. That is because in many cultures in Africa, it is the responsibility of the woman to cook, clean, do laundry and take care of the children, irrespective of her other daily roles and responsibilities. Once the couple has immigrated to the U.S., it is often difficult for their families back in their country of origin to understand this new setup of shared responsibility. Families in the country of origin will often comment that the immigrants have lost their cultural identity.

Loss

Immigrants from Africa experience multiple losses as they settle in their new country. Examples of losses include identity, wealth, social status, family bonds, language, cultural traditions, freedom, innocence, traditional food, life goals, favorable climate and familiarity. Depending on the impact of these and other losses, immigrants from Africa may need mental health help to cope. 

It has been particularly challenging for African immigrants during the COVID-19 pandemic to deal with the resultant losses. They are used to living a social life in which they congregate for no apparent reason. During the pandemic, they have largely lost this aspect of their culture because of restrictions on in-person socializing. Likewise, when fellow community members are hospitalized, they cannot be visited. When people die from COVID-19, there is added pain due to restrictions on viewing the deceased or completing traditional funeral rites. Additionally, at the height of the pandemic, people who died from COVID-19 were buried in mass graves, while others were cremated. These are not common practices among many cultures from Africa.

Family relationships

There is a common tradition in Africa alluding to the fact that it takes a village to raise a child. Extended family members, relatives and neighbors are all expected to be involved in the well-being and development of growing children. Immigrant couples do not typically have the luxury of the village caring for their children in the U.S., whose dominant culture is individualistic rather than collectivistic. If these parents are busy at work, college or with other commitments, they take their children to day care for a fee because they are no longer surrounded by close family members or friends who would have cared for their children. This can become a major source of family relationship problems for immigrants from Africa, particularly when these fathers must change their traditional attitudes and beliefs to share responsibility for child care. 

Parenting is another source of strained relationships among African immigrant families. This is in part because the village is now absent, and the couple is left to care for their children with little outside help. In addition, parenting styles in the U.S. are different from parenting styles in Africa. African parents’ cultural practice of disciplining a child may be construed as child physical abuse in the U.S., potentially landing these parents in trouble with the law.

In Africa, the cost of raising a child is low in comparison with the U.S. For this reason, immigrant couples may decide to have fewer children or not have children at all. There are also differences between the first generation and second generation of immigrants from Africa. Second-generation children have greater exposure to the mainstream majority culture and are more likely to be influenced by it. Attempts by the parents to teach the second generation the value of maintaining their culture is often met with resistance, and this can strain family relationships.    

The American dream

The common belief among aspiring immigrants from Africa is that the American dream is easily attainable. Some interpret the dream to be good education, wealth, good health, affordable health insurance and stable income. 

While some immigrants do attain the American dream, others struggle. For the latter, the lack of attainment may become a source of self-pity, shame and guilt, particularly because their family back in their country of origin may not understand that not everyone in the U.S. is wealthy. Some begin to question why they immigrated and may consider immigrating back to their countries of origin. Problems could then arise if communication within the family is not effective.

Racism

The Black Lives Matter movement has unearthed social ills that have plagued the United States for many years. As a marginalized population, immigrants from Africa may be the targets and victims of discrimination, racism, bigotry, hatred, microaggression and other social ills often propagated by institutions that are supposed to protect them. 

Now that these ills have been widely exposed, there is a possibility that they will become added sources of anxiety and associated mental health issues. Questions may arise for these immigrants regarding how safe it is to continue living in a country where they are openly not wanted. Family and friends in their country of origin may begin to have similar questions and feelings and urge them to return home.

Education

When immigrants from Africa enter the U.S. on an F-1 student visa, they are expected to maintain their student status and follow the strict guidelines from the U.S. Citizenship and Immigration Services until they complete their studies. Some of the stipulations include maintaining full-time student status by taking the required number of courses per semester and maintaining passing grades. They are not allowed to seek employment without authorization. Such authorization, when granted, permits them to work for 20 hours per week on campus. 

The cost of higher education for international students is high. Many students are not able to afford tuition to complete their studies and may end up dropping out of school. When that happens, they lose their student visa status and begin the cat-and-mouse game of evading U.S. Immigration and Customs Enforcement for violating their immigration status. 

Students who complete their studies are granted the opportunity to apply for a change of status to become U.S. permanent residents, especially if they have completed graduate studies in high-demand programs such as software engineering, nursing, medicine, computer science and so on. The process takes time, but it is the safer route that most students follow to ensure their continued stay in the country and their eventual attainment of the American dream. Before that happens, they live in constant fear of being deported.

Acculturation

Over time, continued interaction between immigrants from Africa and the majority population in the U.S. results in acculturation. Immigrants pick and choose aspects of the majority culture to adopt and aspects of their respective cultures to retain. In a symbiotic and ideal relationship, the majority culture picks aspects of the immigrant population to adopt as well. It is important that counselors working with immigrant clients from Africa encourage them to maintain aspects of their culture that are meaningful to them, lest they lose their identity completely.

Another source of family conflict may happen when children abandon some of their family’s cultural aspects in favor of aspects of the majority culture. This occurs during the preteen and adolescent years when they are developing their identities, often influenced by the majority culture. It becomes a problem if their parents are not in favor of the adopted tenets of the majority culture. 

Drug and alcohol use

Alcohol in most African contexts is used to serve social and traditional purposes. With the mainly communal lifestyles, people look out for one another to avert misuse in a “brother’s keeper” sort of way. But these close relationships are largely or completely absent in African immigrants’ new country of residence. Here, they do not have close friends or family members to keep an eye out for them or with whom they can share their problems. 

Without education and awareness of mental health counseling, some immigrants from Africa turn to self-medication with alcohol, drugs or both. Addiction is now a serious problem afflicting African immigrants, and it is good practice to assess for drug and alcohol use, even if this is not the presenting issue brought to counseling. Left unchecked, drug and alcohol dependence could easily degenerate into a generational problem that afflicts current and future generations.

Treatment guidance

Professional counselors should consider the following items when working with clients who are
African immigrants.

> Assessment: Effective treatment begins with a thorough assessment. In addition to the issues brought to counseling, it is important for mental health counselors to assess for other issues that are not so obvious. For immigrant clients from Africa, counseling may still be a new concept. They might not be comfortable sharing their problems with strangers. Hence the need for counselors to select assessment instruments and procedures that are less intrusive. 

> Rapport: Research points to the significance of developing therapeutic rapport with clients early in the counseling process. It is also necessary to maintain this relationship throughout the counseling process. It will likely require additional effort to build and maintain a trusting relationship when working with immigrant clients from Africa because counseling may be a new concept for them. In addition, it may be necessary to educate these clients on what mental health counseling is all about and their roles and responsibilities in the counseling process. 

> Cultural sensitivity: Mental health counselors are cultural beings, and they bring their culture to the counseling relationship. It is vital for counselors to be constantly aware of their culture, including the biases, beliefs and stereotypes that they hold about immigrant clients from Africa. It is also imperative that counselors refrain from imposing their culture on these clients. 

It is beneficial for counselors to learn about the unique culture of their immigrant clients from Africa by setting time aside for cultural immersion and attending ethnicity-specific cultural activities from time to time. They will then use ethnicity-specific and evidence-based interventions to work with these clients. 

> Self-care and wellness: Mental health counseling can drain our emotions and energy. Therefore, mental health counselors should engage in a self-care regimen, maintaining regular self-care activities and schedules, to reenergize. Likewise, it may be helpful to educate our clients who are immigrants from Africa on how to engage in self-care and identify wellness strategies for their improved mental health and enhanced overall health.

 

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Stephen Kiuri Gitonga is an assistant professor in the clinical mental health counseling program at Lock Haven University in Pennsylvania. He is a licensed clinical mental health counselor licensed to practice in Idaho, Kentucky, Utah and Pennsylvania. Contact him at skg200@lockhaven.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

Untangling trauma and grief after loss

By Lindsey Phillips May 4, 2021

Death, loss and grief are natural parts of life. But when death arrives suddenly and unexpectedly, such as with suicide or a car accident, the overlap of the traumatic experience and the grief of the loss can overwhelm us. 

Glenda Dickonson, a licensed clinical professional counselor in private practice in Maryland, describes traumatic grief as “a sense-losing event — a free fall into a chasm of despair.” As she explains, the experience of having their everyday lives ripped apart by a sudden and unexpected death can cause people to go into a steep decline. “They are down there swirling,” she says, “experiencing all the issues that are part of grief — shock, disbelief, bewilderment.” 

In some cases, people get stuck in their grief and can’t seem to find a way forward. And in certain instances — such as when someone loses their child — individuals may not even want to get out of that state because, for them, it creates a sense of leaving their loved one behind and moving on, adds Dickonson, a member of the American Counseling Association. 

Elyssa Rookey, a licensed professional counselor (LPC) at New Moon Counseling in Charleston, South Carolina, worked with a client who had experienced two traumatic losses. When the client was 15, his stepfather died from suicide, and when the client was 20, his mother died on impact in a car accident. After the death of his mother, the client started having nightmares and became anxious about the possibility of losing other loved ones in his life. 

Rookey noticed that the client used “I” statements frequently in sessions: “I should have done more to help them. I shouldn’t have said that before she left.” The client blamed himself for their deaths and thought that he was cursed, says Rookey, who specializes in treating trauma, grief and traumatic grief. 

His mother’s death also triggered the client’s feelings of abandonment in connection with his biological father, who had left him when he was a child. At times, the client wanted to avoid others and be alone, but that subsequently increased his feelings of isolation and fear of additional loss. He also hosted feelings of anger about having to “grow up” and assume adult responsibilities, such as paying a mortgage and keeping a piece of property maintained, before he was ready. In many ways, Rookey says, he was “stuck” in the trauma and avoiding the feelings of grief and loss. 

Identifying traumatic grief 

Not every sudden or catastrophic loss results in traumatic grief. Some people experience uncomplicated bereavement. But others may show signs of both trauma and grief. They might avoid talking about the person they lost altogether, or they might become fixated on the way their loved one died.  

Because of the trauma embedded within the grief, it can be challenging to differentiate between posttraumatic stress disorder (PTSD), grief and traumatic grief. “PTSD is about fear, and grief is about loss. Traumatic grief will have both, and it includes a sense of powerlessness,” Dickonson explains. “A person who is experiencing traumatic grief becomes a victim — a victim of the trauma in addition to the loss. … They will assume those qualities of experiencing trauma even while grieving the loss.” She finds that people who have traumatic grief tend to talk about experiencing physical pains, have trouble sleeping and are anxious.

People experiencing traumatic grief could have distressing thoughts or dreams, hyperarousal or anhedonia/numbness, says Nichole Oliver, an LPC in private practice at Integrative NeuroCounseling in Chesterfield, Missouri. She notes that some of the symptoms can be confused with other mental health issues. For example, a person going through traumatic grief may have a loss of appetite and trouble sleeping (which can resemble signs of depression) or have great difficulty focusing (which can look like a sign of attention-deficit disorder). 

On its website, the Trauma Survivors Network lists common symptoms of traumatic grief, which include: 

  • Being preoccupied with the deceased
  • Experiencing pain in the same area as the deceased
  • Having upsetting memories
  • Feeling that life is empty
  • Longing for the person
  • Hearing the voice of the person who died or “seeing” the person
  • Being drawn to places and things associated with the deceased
  • Experiencing disbelief or anger about the death
  • Thinking it is unfair to live when this person died
  • Feeling stunned or dazed
  • Being envious of others
  • Feeling lonely most of the time
  • Having difficulty caring about or trusting others 

Rookey, who also works for the South Carolina Department of Mental Health in partnership with the Charleston County Sheriff’s Office, always screens for trauma because clients may have underlying issues that affect or complicate their grief. When working as a counselor in Miami, she noticed that some adolescents who were court referred for their substance use had also experienced traumatic loss (having a friend who was shot and killed, for example). In these cases, counseling sessions focused on grief, PTSD and anxiety in addition to the issue of substance use, she notes. 

Rookey first meets with clients to get a better sense of their story. These conversations often lead her to ask questions such as “Have you ever felt this sense of loss or fear in the past?” The questioning helps uncover underlying issues that may be affecting the person’s ability to grieve in a healthy way, she explains. For example, a client might reveal that the way they’re currently feeling reminds them of how lost they felt after their parents’ divorce. This may lead to the discovery that the client never fully dealt with that loss at the time, and that is now affecting how they are processing this new loss.

A new layer of loss

“COVID-19 brought a brand-new dynamic to grief,” says Dickonson, who specializes in treating trauma, bereavement, traumatic grief and mood disorders. “People have lost jobs, relationships, businesses and homes. … There is an endless sense of loss that keeps coming on.”  

The pandemic has also added a layer of trauma to expected grief because it has restricted the ways that people are able to mourn death. Rookey, who is also an LPC in Florida, had a client whose husband died not long before the COVID-19 virus reached the United States. After the husband’s death, the client moved from Florida to South Carolina, where her husband was from, because he had always wanted their children to live there. A few months later, the client’s aunt in Puerto Rico died from natural causes, but because of quarantine restrictions, she was unable to travel to attend the funeral. All of these circumstances left the client feeling helpless, frustrated and isolated, Rookey says.  

The COVID-19 pandemic has severely curtailed people being able to grieve communally, which can make even anticipated deaths more traumatic, Rookey notes. 

“Losing a loved one to COVID-19 could definitely complicate the grieving process when people are unable to say goodbye or to be with their loved one when they pass,” says Tamra Hughes, an LPC in Centennial, Colorado. “Those experiences can torment a person who is trying to come to terms with the loss.” 

“And COVID-19 is front and center in all we see and do right now. So, there is a constant reminder of the circumstances of the loved one’s death,” she continues. “These cues can all act as triggers for the client, eliciting negative emotions, physiological reactions and trauma responses.”

Grief is personal

Everyone grieves differently, so identifying traumatic grief in clients is not always a straightforward matter. Hughes, an ACA member who specializes in grief, traumatic grief, trauma, complex trauma and anxiety, says no two cases are the same in grief work. She approaches her work through the lens of the adaptive information processing model of eye-movement desensitization and reprocessing (EMDR) therapy. Among the areas she considers are the client’s level of stability in their life, their attachment style and their mental model of the world. These factors affect the way they manage adversity and trauma, Hughes explains. 

Working as a counselor at a funeral home helped Oliver, an ACA member who specializes in PTSD and grief, understand and appreciate how people’s social and cultural factors (such as personality, spirituality and race/ethnicity) affect how they approach loss and mourning. For example, under some religious beliefs, shame is attached to suicide, whereas others may celebrate it as a brave act. And while some people consider crying a weakness, certain cultures incorporate wailing into their funeral ceremonies. 

Hughes, the owner and therapist at Greenwood Counseling Center, knows that some clinicians are afraid to ask clients about their spiritual beliefs regarding death. She encourages counselors to ask difficult questions such as “What do you think happens to people after they die?” Otherwise, “it becomes the elephant in the room,” she says. “It’s not about putting your own religious or spiritual beliefs on the client. It’s about understanding the [client’s] context … because then you can work within that framework to help them through the grief.” 

Legal proceedings connected to homicides can further complicate a person’s experience with grief. Sometimes people assume that the best way to process their grief and heal is through seeking legal justice, Rookey says. But often, their grieving doesn’t really begin until after they separate the legal aspect from their own grief and trauma, she observes. 

Oliver uses individual clients’ unique life experiences to tailor her psychoeducation efforts and counseling techniques. For example, she may explain trauma symptoms to someone who works in information technology by comparing their body to a web browser that has too many open tabs. This visualization helps the client understand why their body and emotions are overloaded. Then she’ll ask the client to pick which two or three tabs they want to prioritize and work on that session. 

Oliver also has clients put together a playlist of songs that express their current mood and their feelings of mourning, which may be difficult for them to convey verbally. In session, clients can use these songs to explain the way they are processing their grief in that moment. That helps regulate the limbic system, which is the part of the brain involved in behavioral and emotional responses, she says. Oliver also keeps a three-ring binder of images — such as a person bent over in shame or a person torn in half between their heart and brain — in her office. Sometimes she asks clients to select an image that resonates with them as a way to jump-start their conversation. 

Unspoken words 

People may come in for counseling immediately after a sudden loss, or they may wait weeks or even months before seeking help. If the counselor does begin working with the client soon after the loss, their main goal during those first two or three weeks of therapy should be to “hear” the client’s loss and validate their feelings, Hughes says. Counselors could offer some guidance for coping and self-care, but she cautions against making suggestions about how to “heal” because that can sound dismissive. 

Dickonson finds “sacred silence” — silently sitting and being present with a client — a useful tool when working with traumatic grief. “We have to develop the capacity to sit with our client’s anguish, to stay fully present but not be intrusive, and to speak but also know how to be quiet and fully connect. We don’t have to break the silence. … Sometimes that’s what they need. They just need us to be there with them and show them that we care,” she says. 

Dickonson also keeps a tissue box within reach of clients in case they want it, but she does not offer them a tissue if they start crying. “Tears are very cathartic, and if I give you a tissue, it can [insinuate] that it’s time to stop crying,” she explains.

Hughes eventually provides clients with a space to voice unspoken words — what they would have liked to say to their loved one and what they think their loved one would have said to them. “There’s something about articulating it and speaking those words [out loud] … that contributes to helping the brain reconcile some aspects of [the grief],” she says. It also provides clients with an opportunity to get closure on something that feels so abrupt and unfinished, she adds. 

One technique that Dickonson uses with some of her clients as they begin emerging from their grief and have started their journey to posttraumatic growth is to assume the voice of the deceased and then write or record how they believe their loved one would comfort them. As a prompt, she asks clients, “What would your beloved say to you if they were here right now?” 

As clients share their interpretation of their loved ones’ words, Dickonson watches the way their face changes at certain parts and then asks, “How did you feel when you heard what your loved one might have said to you?” She finds this exercise often leads to productive discussions and helps clients give voice to things they might feel guilty for saying themselves. 

Processing the trauma 

When Hughes helps clients process life challenges, including traumatic grief, she addresses their trauma through EMDR. Hughes is an EMDR therapy trainer, the owner of EMDR Center of the Rockies, a member of the board of directors for the EMDR International Association (EMDRIA) and an EMDRIA-approved consultant. “EMDR helps the brain to organize information in a way that is more adaptive. In the case of traumatic grief, it can help foster healing and closure in the grief process,” she explains.

If conflict existed in the relationship with the person who died, clients may need to work through challenges that they had or feelings of guilt or shame that can be present following the loss, Hughes adds. 

A traumatic loss can also trigger a past trauma, which might be the underlying reason for the client’s current complicated grief response, Oliver says. She once worked with a man whose mother had just died. Although their relationship had been strong at the time of her death, the client’s mother had been abusive when he was a child. Her death triggered this past childhood trauma, causing the client to feel not only grief over her loss but also anger for the past abuse and guilt about the relief he felt for no longer having to care for her. The client was afraid to admit these complex feelings to Oliver because he was ashamed for feeling resentment, anger and relief when he thought he should be feeling only grief. The client’s cognitive dissonance disrupted his ability to grieve in a healthy way and further anchored him in a complicated grief response, Oliver notes. She validated his feelings and reminded him that expressing the full range of his emotions didn’t mean that he was attacking his mother’s memory. 

Rookey has used exposure therapy to help clients process unresolved trauma around losses that they experienced firsthand. But she cautions clinicians not to use the approach if they think it could be triggering for a client, especially if the client doesn’t have a good support system. 

Rookey used the approach with a woman who became triggered by the sound of sirens after she watched her partner die from a traumatic accident. While the woman was sleeping, her partner went outside to smoke, and he was shot after being caught in the middle of a botched burglary. By the time the woman woke up and realized what was happening, her partner had crawled inside the kitchen and was slowly dying. She called 911 and held him while she waited for the ambulance. 

It wasn’t just the grief of loss that was traumatic for the client, Rookey explains. It was the trauma of repeatedly asking herself, “Why didn’t I do something to help him?” 

The client began to operate in survival mode and avoided thinking about her loss. But sirens became a trigger for her. When she heard them, she would run to a bathroom and cry. So, Rookey decided to use in vivo exposure to help the client retrain her body and mind to get to a healthy state again. 

First, Rookey asked the client, who worked near a hospital, to step outside whenever she heard an ambulance and listen to the sirens while engaging in calming activities such as deep breathing. After the ambulance passed, the client would repeat positive affirmations (e.g., “It wasn’t that bad”). This slowly exposed the client to the trigger in a safe way. After the client was comfortable hearing the sirens outside her work, Rookey had the client record herself recounting the traumatic incident as if she were reliving it, and she replayed this recording every day. “It’s a way to show your body you can get distressed, can get triggered, can be fearful, but you will be OK,” Rookey says.  

In session, Rookey asked the client what parts of the story affected her most. This questioning helped Rookey discover that the client’s guilt over not preventing her partner’s death was what was holding her back from fully grieving and moving forward. They worked together to reframe the event to help the client realize she was not responsible for the death: Her partner always stayed up late and smoked a cigarette before bed. She had called for help. There was nothing else she could have done. 

Creating new meanings 

What makes a loss traumatic is not only the way the person died but also the meaning attached to the death, Oliver says. She worked with a woman who had developed an irrational thought attached to her son’s traumatic death. The son had been struggling with a drug addiction for a decade, but the night before he died from suicide, they had had a fight and the mother had said some unkind things. She blamed herself for his death. 

“Her core belief [that she was responsible for her son’s death] kept her anchored to the pain of the grief, so we couldn’t process the grief until we relinquished that belief,” Oliver says. 

To begin the process of untangling the client’s negative belief from her grief, Oliver presented another contributing factor to the son’s death. She told the client, “Numerous research studies reveal complex neurobiological changes in the brains of individuals who have completed suicide. Postmortem autopsies reveal that these individuals have 1,000 times the cortisol in the brain, and other systems such as the HPA [hypothalamic-pituitary-adrenal] axis, receptors and neurotransmitters are not functioning normally. That means they do not have access to the prefrontal cortex, the reasoning part of the mind.” 

That information comforted the client. When addressing traumatic grief, it’s often about planting seeds of hope and disentangling the fragmented pieces in people’s minds, Oliver says.  

Oliver continued to help the client find and connect the fragmented pieces through memory reconsolidation, which is the brain’s innate process for transforming short-term memories into more stable, long-lasting ones. Oliver had the client recall the memory of her son’s death, and then they created mismatched experiences in the brain by pairing the client’s belief that she was responsible for her son’s death with the contradictory information that she had supported him through rehab and that he had attempted suicide previously. 

Recalling this information caused a clash with the client’s cognitive distortion that the son’s death was all her fault, Oliver explains. The process helped the client integrate more pieces of the puzzle until she had a clearer picture of the event and was able to get “unstuck” from the negative thought. As a result, the emotionally charged memory (the client’s self-blame) moved from the amygdala to the hippocampus, reducing the trauma response by creating new learning (the realization that her son’s death was not her fault), Oliver adds.

Finding a way forward 

After mitigating the trauma of their loss, clients are ready to take a step forward. “With traumatic grief, it’s about making meaning of the death and who they are now,” Rookey says. “They were on one course … and it got skewed, and now they’re on a parallel path.” After processing through the trauma and grief of the loss, she has clients visualize themselves moving forward on the different path. The exercise encourages them to think about their future and gives them some meaning as they start down this new path, she says. 

Hughes believes the goal is “to get to a place where the grief is replaced by increases in the positive memories of the person and the essence of who they were.” People will still feel sadness about the loss, but this feeling should be more manageable and is coupled with gratitude for the time shared with the loved one, she explains. 

With counseling and support, clients can emerge from the “chasm of despair” — the steep decline they fall into after the traumatic loss — and begin to transform their pain into something positive and potentially powerful, Dickonson says. That might include being more involved with their families, developing a greater appreciation for life or even embracing new opportunities that emanate directly from the traumatic event. “They still feel the sadness,” Dickonson says, “but they are ready to move forward.”

This is when counselors could encourage — but not push — clients to continue their transformation process from the sense-losing free fall to a sense-remaking journey, Dickonson advises. Counselors should also be mindful that when clients come out of the grief abyss, they may replace their grief with another unhealthy coping behavior, she cautions. So, counselors have to continue to support clients as they start this journey forward. 

Rookey and her client who lost his stepfather and mother all before he turned 21 had to address his negative beliefs about his responsibility in their deaths before he could find a way to move forward and grieve in a healthy way. By the end, the young man’s guilt and anger had lessened. He sold his mother’s home, bought a truck and set up autopay for his bills. These were small steps toward him carving out his new identity and moving forward on his parallel path.

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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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.