Tag Archives: disenfranchised grief

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

In my work as an outpatient mental health counselor, I have encountered numerous clients over the years with stories about reproductive loss. Not only were these stories fraught with sadness and grief, but some of the individuals were still experiencing acute grief even several years later.

As I branched out into my role as a researcher during my doctoral study, these stories stayed with me. So, I began a line of inquiry on reproductive loss that started with infertility and the accompanying grief. Since then, my research on infertility and miscarriage grief has resulted in numerous professional conference presentations and guest lectures. The purpose of this article is to share information that I have learned about those with infertility and to provide methods for best practice in counseling with these clients.

Infertility is generally defined as a condition of the reproductive system that inhibits or prevents conception after at least one year of unprotected sexual intercourse. To account for the natural decline of fertility with age, the time frame is reduced to six months for women 35 and older. According to the Centers for Disease Control and Prevention (CDC), about 12% of women between the ages of 15 and 44 have “difficulty getting pregnant or carrying a pregnancy to term.” Infertility can affect both men and women, despite a common misconception that infertility is a woman’s condition. Infertility in men may be caused by testicular or ejaculatory dysfunction, hormonal disorders, or genetic disorders. In women, infertility may be caused by disrupted functioning of the ovaries (such as with polycystic ovary syndrome, a condition that prevents consistent ovulation), blocked fallopian tubes, or any uterine abnormalities (such as the presence of fibroids).

Infertility can be categorized into one of two subtypes. Primary infertility refers to when a woman has never birthed a child and thus has no biological children. Secondary infertility refers to when a woman experiences the inability to birth a child following the birth of at least one other child. Both forms of infertility produce a cyclical pattern of strong emotion that is often referred to as a “roller coaster.”

Medical interventions

A number of available interventions may be used to increase the chances of becoming pregnant. The best course of treatment will be different for each couple and may depend on considerations such as whether the infertility is male factor or female factor, the cost and availability of insurance coverage, and cultural customs or beliefs. Some couples decide that pursuing any kind of medical treatment is not the right course of action for them. For others, medical treatment may include any of the following interventions.

  • Medication may be prescribed to stimulate ovulation or follicle growth in the ovaries, increase the number of mature eggs produced by the ovaries, prevent premature ovulation, or prepare the uterus for an embryo transfer.
  • Surgery may be necessary, perhaps to clear out blocked fallopian tubes or to remove uterine fibroids.
  • Intrauterine insemination (IUI), also known as artificial insemination, is a procedure in which sperm are inserted directly into the woman’s uterus. The woman may or may not be taking medications to stimulate ovulation before the procedure.
  • Assisted reproductive technology (ART) refers to fertility treatments in which eggs and embryos are handled outside of the body. This excludes procedures in which only sperm are handled (e.g., IUI). The most common and effective ART procedure is in vitro fertilization (IVF).

Undergoing IVF treatment requires a strong physical, emotional and financial commitment. Generally, medications are prescribed to stimulate egg production and may include a series of self-administered injections. Eggs are removed from the ovary using a hollow needle, and the male partner is asked to produce a sperm sample (or a sperm donor may be used). The eggs and sperm are combined in a laboratory, and once fertilization has been confirmed, the fertilized eggs are considered embryos. About three to five days after fertilization, the embryos are placed into the woman’s uterus via a catheter in hopes of implantation. The CDC reports that women under the age of 35 have a 31% chance of conceiving and birthing a child with the use of ART; the chances are closer to 3% for women ages 43 and over.

The IVF process can be a highly emotional time for the woman and the couple, marked by moments of excitement, hope, disappointment or uncertainty. The IVF cycle may be canceled if certain problems develop along the way, such as having too few or no eggs to retrieve, the eggs failing to fertilize, or the embryos not developing normally. Any of these situations may produce a sense of loss for the woman or the couple. After the embryo transfer, it is generally recommended to wait 10-14 days before testing for pregnancy. In some circumstances, a chemical pregnancy takes place. This is when implantation happens that results in an initial positive result, but then the pregnancy does not progress. In other words, a very early miscarriage occurs.

This section on medical interventions is important to include because these interventions are part of the infertility experience and may affect the emotional or mental health of the client. This is true even for women and couples who choose to not pursue treatment; at the end of the day, a decision was made and they must cope with the implications of that choice. Professional clinical counselors who are knowledgeable about the available medical interventions will have better context for recognizing the myriad decisions that these clients face and the potential losses that may occur throughout the process.

The invisibility factor

Take a moment to think about the grief that occurred for you after the death of a loved one. The relationship you had with your loved one was probably clearly defined, and you have memories of that person to look back on. The loss is easily identified and articulated, not only by you but by others who were aware of the death. You most likely had many people express sympathy and give you their condolences, perhaps verbally or by sending flowers. You may have taken time off work for bereavement and attended a ritual such as a visitation ceremony, wake or funeral that helped to facilitate your grief. Your loss was likely recognized, acknowledged, validated and supported in a multitude of ways.

Now think about the losses associated with infertility. One of the major losses is that of the imagined or expected family. Women with primary infertility, who do not have biological children, face the loss of the entire life stage of parenting. This may include pregnancy, passing on family or holiday traditions, and passing on the genetic legacy or surname, plus the eventual loss of other life stages such as grandparenthood. Counselors should recognize that meaning is often attached to these losses which further compounds the pain. For example, not being able to experience pregnancy means that the woman is also excluded from cultural pregnancy milestones such as going to the first ultrasound visit, thinking of fun and exciting ways to announce the news to family and friends, participating in a baby shower, and throwing a gender reveal party. With infertility, the loss comes from an absence of something that has never been rather than the absence of something that used to be.

The stigmatization surrounding infertility contributes to an atmosphere of silence and invisibility. Infertility and its accompanying losses are not as outwardly visible and may not be well known or understood by others unless the woman discloses them herself. Many women who experience infertility feel a sense of failure or self-blame toward their bodies, and some may withdraw socially, isolate, or struggle with their identity and sense of self. The stigma surrounding infertility can make it difficult for women to reach out for support. As a result, they find themselves navigating the experience alone.

When a woman does talk openly about her infertility, other people may not respond in ways that are validating or compassionate, which may make the situation worse than if she hadn’t disclosed at all. For example, comments such as, “Just relax,” and, “Give it time,” minimize the woman’s pain and invalidate her grief. Asking, “Have you tried (fill in the blank)?” or “Have you considered adoption?” implies that the woman is not trying hard enough to find a solution or that what she has tried already is inadequate. Most of the women with infertility I have encountered over the years acknowledge that people generally mean well and offer such comments in an attempt to provide hope or to decrease their own feelings of discomfort when talking about infertility.

Facilitating the grieving process

Professional counselors have a responsibility to provide compassionate and competent mental health treatment. Each infertility journey is unique, and counseling interventions should be tailored to fit the individual needs of every client. Taking clients’ cultural, religious or spiritual backgrounds into consideration, several interventions may be used to effectively assist these clients through their grief.

  • Counselors, first and foremost, can be present and listen. Typically, this is what is missing when family members, friends, co-workers, doctors or strangers offer comments that end up being hurtful or invalidating to the person or couple experiencing infertility. We do not have to have the answers — even as counselors. Just be there.
  • Counselors can assist clients in articulating what they need from others around them. This may also incorporate methods for helping clients increase their assertiveness or self-confidence.
  • Counselors can help clients redefine their life expectations and conceptualizations of womanhood, family and mothering. This may also include processing how clients perceive lost embryos, chemical pregnancies or miscarriages to fit within the family unit.
  • Counselors can help clients manage the roller coaster of emotions and ongoing stress as they are trying to conceive, rather than focusing on finding closure. Closure usually implies resolution, which may not be possible with the prolonged nature of infertility and the treatment process.
  • Counselors can assist clients in developing their own rituals while trying to conceive, undergoing fertility treatment, or after making the decision to stop treatment. For example, a woman once told me that she threw a party after she and her husband decided to stop IVF treatments. The party signified taking control over their decision to remain child-free and served as a celebration of the effort it had taken to come that far. 
  • Counselors can explore appropriate methods of client self-care, including engaging in hobbies, participating in creative or social activities, and even taking breaks (as needed) from trying to conceive or pursuing medical treatment.
  • Counselors can connect clients with appropriate resources. It may be necessary to provide clients referrals to group counseling if they wish to connect with others who have similar stories, or to couples counseling if they are struggling in their relationships. In addition, location or cost can be barriers to clients obtaining the services that would work best for them, so counselors who are knowledgeable about online resources can provide these options. Collaborating with other health care professionals with whom the client is working can also provide more comprehensive treatment.

This is not, of course, an exhaustive list. Grief is a personal experience. Which methods are the best fit for your client should be explored in a therapeutic setting that considers both individual and cultural contexts.

What do counselors need to remember?

Imagine that you are working in a private practice when you meet a new client experiencing infertility. You are a master’s-level clinician and are fully licensed in your state. You have taken one class in your graduate program on grief and loss but have no further specialization or experience with infertility. The client has heard numerous comments, questions and suggestions throughout the years regarding her infertility. She is unsure of how counseling might help, but she feels the need to seek support.

This scenario, while general, is a realistic picture of a possible situation that any clinician could experience. As such, I will provide thoughts on what every counselor should keep in mind when it comes to the areas of infertility grief. I am not attempting to reinvent the wheel when it comes to essential counseling tools; rather, I am striving to provide context for effectively using these tools with clients affected by infertility.

>> Convey empathy and understanding. If I could share only one thing I have learned in my work with women affected by infertility, it would be that so many of them feel and believe that you cannot possibly understand what infertility is truly like unless you have been through it yourself. Many women have asserted to me that they just need someone willing to sit with them through the anguish. Counselors who are attempting to provide encouragement and hope may instead end up inadvertently dismissing their clients’ pain or minimizing their grief. It is also possible that counselors end up avoiding a deeper exploration of the experience completely because they do not know what to say. Do not underestimate your basic counseling skills when working with these clients. Acknowledge, reflect and empathize.

One way that counselors can suggest understanding is through the careful use of language. For instance, matching the client’s chosen language of “baby” or “child” is more appropriate (and accepting) than using the more medically correct terms of “embryo” or “fetus.” Language can also offer a reframe from a label of “an infertile woman” to “a woman affected by infertility.” This choice of words depersonalizes the condition and acknowledges that her identity is separate from the condition.

>> Become familiar with client issues related to infertility. Clients who talk about their infertility journey will use a variety of terms and acronyms. For example, you may have clients talk about the time they were “TTC,” which stands for trying to conceive. They may also mention medications, medical procedures or basic biological functions with the assumption that the counselor is generally informed on these topics. Although asking clarifying questions of clients can help paint a clearer picture of their experience, it is not the client’s job to educate the counselor. Take the initiative early in the working relationship with a new client to learn about infertility in areas in which you are deficient. That way, you will be able to understand the client’s journey and experience in greater context.

>> Validate the loss. The invisibility of infertility may cause some women to wonder whether their losses are real or valid. For example, I met a woman during my research who had elected to try IVF after three years of actively trying to conceive, and she gave birth to a healthy baby after just one round. Still, she felt a sense of loss over the fact that her memories of the conception did not entail a moment of passion and love, but rather recollections of shame and fear. She referred to her husband having to masturbate in isolation to provide the needed sperm sample and her experience of lying on a cold table waiting for the doctor to transfer the embryo. She did not feel that she could verbalize this sense of loss to others, however, because it might make her sound ungrateful. A counselor could validate the loss of the ideal conception story and help her articulate feeling both sad for that loss and grateful for her baby at the same time.

The invisibility of infertility also means that some women may not have the vocabulary to identify and articulate their losses. Women with primary infertility endure the losses of pregnancy, delivery, parenthood and eventual grandparenthood but may not be able to understand for themselves that they are mourning the loss of an anticipated and desired life stage. Counselors can assist clients with developing language for their losses if they are struggling to verbalize their grief.

>> Get comfortable. Discussions about infertility may overlap with other taboo topics such as sex, masturbation, miscarriage and abortion. Many of the women I have met who have been affected by infertility have had miscarriages along the way. This brings about an additional — but connected — situation of grief and loss. Talking about miscarriage can be difficult to do without also bringing up abortion, given overlapping language (e.g., spontaneous abortion) and medical procedures (e.g., dilation and curettage). These topics can be slippery territory for personal bias, but counselors should regulate their own reactions and practice reflection to maintain appropriate neutrality and support. Engaging in self-care can be particularly important when counseling those affected by infertility.

Challenging infertility stigma

More and more, childbearing is being viewed as a choice rather than a societal or marital expectation, yet not having children is still considered to be somewhat taboo. Women are socialized from a young age to prepare for eventual motherhood through childhood play that often fosters a nurturing and caretaking role. Other cultural narratives suggest that women have an ability and responsibility to control their fertility. This contributes to self-blame and shame when they are unable to conceive. Infertility is infrequently discussed publicly and thus carries a sort of social stigmatization. Counselors can contribute to destigmatizing infertility by normalizing conversations about infertility, challenges to conception, fertility treatments, and miscarriage.

Stories related to infertility gained widespread media attention throughout 2018. That March, a fertility clinic in Ohio experienced a technical malfunction that caused the destruction of more than 4,000 eggs and embryos, a loss that most certainly had potentially devastating implications for the affected families. Then, in August, a rare visual of the emotional and physical struggle of trying to conceive was captured in a photograph that went viral of a newborn baby surrounded by the 1,616 IVF needles that it took to conceive her. In the months that followed, actress Gabrielle Union opened up about her emotional fertility journey that included numerous miscarriages and surrogacy, and former first lady Michelle Obama revealed her story that included miscarriage and IVF to conceive her two daughters.

These stories bring visibility to infertility and normalize conversations about the challenges that can come with attempting to get pregnant. Counselors can contribute to destigmatization by engaging in discussions and posing curious but sensitive questions about how resources and support can be bolstered for affected women and couples.

Conclusion

Each infertility story is unique, and no one-size-fits-all solution exists when it comes to helping women and couples work through their infertility grief. Whereas an obvious loss from the death of a loved one usually includes rituals and social support, the invisibility of infertility makes it difficult to identify the losses, often leaving women affected by these losses to deal with them in silence and isolation. Counselors can help clients find the vocabulary to articulate the losses they are grieving, give voice to what they need from the people around them, and create ways to process their grief in a warm, nonjudgmental atmosphere.

 

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Tristan McBain is a licensed professional counselor and licensed marriage and family therapist. She is a recent graduate from the Counselor Education and Counseling Psychology Department at Western Michigan University in Kalamazoo. Contact her at tristanmcbain@gmail.com.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Letters to the editor: ct@counseling.org

 

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Related reading on this topic, from the Counseling Today archives: “Empty crib, broken heart

 

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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.

Grieving everyday losses

By Laurie Meyers April 24, 2019

As a society, we think we know what loss is: the death of a parent, partner or child; the destruction of a home through disaster; the shattering of finances through bankruptcy. These are tangible, recognized — sanctioned, if you will — losses. But counselors know that in reality, life brings myriad losses, many of which go unrecognized, unacknowledged and, most importantly, unmourned. The damage caused by these accumulated losses — sometimes referred to in the popular lexicon as “emotional baggage” — often brings clients to counselors’ doors wondering why they’re in so much pain.

In 1989, American Counseling Association member Kenneth Doka, who has written numerous books on grief and loss, established the phrase disenfranchised grief, which he defines as grief that is experienced by those who incur a loss that cannot be openly acknowledged, publicly mourned or socially supported. Disenfranchised grief may result from the loss of a relationship, the loss of identity or ability, pet loss, or even the loss of “giving up” an addiction.

“This unrecognized loss can be happening all around us but, because of the lack of acknowledgment and support, we wouldn’t know about it,” says ACA member Barbara Sheehan-Zeidler, a licensed professional counselor in Littleton, Colorado, whose practice specializes in grief and loss.

She gives the hypothetical example of a woman who is about to move to a thriving new town to start a higher paying job with great benefits. The woman has spent the past 20 years raising her family and creating a great life for her children, but now she is ready to move on. She is excited about entering this new phase in her life and meeting new people. At the same time, the woman is experiencing a lingering and persistent sense of sadness that she can’t explain.

What the woman is experiencing, Sheehan-Zeidler explains, is disenfranchised grief, which can affect clients in numerous ways:

  • Physically: Headaches, loss of appetite, insomnia, pain and other physical symptoms
  • Emotionally: Feelings of sadness, depression, anxiety or guilt
  • Cognitively: Obsessive thinking, inability to concentrate, distressing dreams
  • Behaviorally: Crying, avoiding others, withdrawing socially
  • Spiritually: Searching for meaning or pursuing changes in spiritual practice

In the example, the woman was not recognizing the losses of community, familiarity, social status and spiritual support from her local church that would come with moving, Sheehan-Zeidler explains. Once the woman actually identified and named those things as losses, the counselor was able to validate and explain her symptoms of insomnia, guilt, absent-mindedness, crying, indecisiveness, pervasive sadness and avoidance of social situations. This allowed the woman to grieve her losses and settle into her new life, Sheehan-Zeidler says.

“When we do not process unrecognized or disenfranchised losses, we run the risk of creating a narrative that is tainted with unprocessed feelings and unresolved grief,” she says. “Their Weltanschauung, a German word for worldview, is corrupted with an emotional burden that influences their beliefs and ability to connect. Consequently, they may be limited in projecting self-confidence needed to secure a new job or challenged to join a new social circle due to feelings of depression or unworthiness.” Unrecognized grief from the loss of a job, health or lifestyle can also cause secondary losses, such as damage to one’s self-esteem, a sense of shattered dreams, and lost community, she adds.

Sheehan-Zeidler helps clients process their grief through a variety of rituals. “I invite clients to create a special time, maybe 5 to 15 minutes daily, for the purpose of ‘being with’ their emotions and thoughts,” she says. “During this dedicated time, I suggest clients find a comfortable and private place to sit, journal their feelings and thoughts, light a candle, have soothing music, enjoy a cup of tea, and maybe have a special shawl or blanket to be used during these ‘time-to-mourn’ moments. Or maybe the client is more active, in which case I’d invite them to mindfully walk in a calming place where they can be with their thoughts and feelings as they reflect on their loss.

“The purpose of this time-to-mourn ritual is to create comfort around you and encourage the feelings to come forward in a planned way so we lead the dance with grief and mourning, and not the other way around. Additionally, as grief can come in unexpected waves, if we have a ritual in place, then we can put the ‘surprise’ grief aside, noting that we will visit with it the next time we are sitting or walking in our special place dedicated to honoring and processing the grief and mourning.”

Sheehan-Zeidler also recommends that clients drink plenty of water and get adequate sleep — taking naps if needed — as their minds and bodies process the loss. Finally, she reminds clients that their grieving process will include bad days, but also good ones.

Losing my addiction

“Put simply, disenfranchised grief is grief that is not acknowledged or valued by society,” says Julie Bates-Maves, an ACA member and a former addictions counselor. “Losses that are not seen as legitimate or worthy of our sadness or grief fit here.”

Addiction may be the king (or queen) of losses that are not typically viewed as legitimate or worthy. “Some people … don’t think that losing something ‘bad’ should hurt, but it does,” Bates-Maves says. “If we think about the functions of an addiction — that is, what they can provide for people — you start to see how hard they would be to give up.”

Bates-Maves notes all the ways in which addictions can fulfill people’s needs, albeit in unhealthy ways. “Addictive patterns often bring pain, but it’s a pain that’s familiar,” she notes. “They bring routine, even if it’s an unhealthy one. [It’s] the illusion of power and control over one’s body and mind: ‘I want to feel or think differently, and I know how to accomplish that.’”

Addiction can also provide companionship or escape from a sense of loneliness, whether through friends who also use, through distraction, through numbing (both physically and emotionally), or through the sense of energy and excitement that using substances can provide, Bates-Maves explains. “Losing any of that would be, at best, uncomfortable [and], at worst, unbearable,” she asserts.

“In my own clinical work and in speaking to other counseling professionals and clients, I have noted little discomfort or objection to exploring the negatives of an addiction with clients,” Bates-Maves says. “Notably, I have encountered hesitation or overt avoidance of the ‘positives’ of addiction, [such as] ‘don’t speak of the glory days’ or ‘don’t encourage clients to focus on what they miss; instead focus on what they have to look forward to in recovery.’ Consider this though — what if the ‘glory days’ are the only time the client felt powerful, or safe, or noticed, or admired, or skillful?”

When entering recovery, clients not only contend with the addition of a new set of behaviors, thoughts and feelings, but also an absence of “glory,” Bates-Maves continues. She believes that talking about the “positives” of addiction can help clients in recovery tackle challenges such as reestablishing a sense of their own identity, learning how to connect with others, and filling in any social skill deficits.

“Inviting reflection on the ‘glory’ of it all is a chance to observe a client reminisce about a time when they felt more worthy,” she explains. “If self-worth is centered on the addiction or a component of it, we need to know so we can help them redefine and reconstruct who they are, not just what they do. Losing an addiction is not simply losing a substance or behavior. It’s losing a way of surviving that our body and mind have become settled in. It can be a tremendous loss.”

As Bates-Maves points out, losses can occur anywhere along the addiction and recovery spectrum: prior to addiction; during addiction; during detoxification, treatment, initial, mid- or advanced recovery; prior to a lapse or relapse; and after a lapse or relapse. Some losses, such as a negative alteration in personal appearance or losing custody of children, may be the direct result of the person’s addiction. Other losses, such as the death of a parent, may happen separately from the person’s addiction but will still affect a client’s addiction or recovery, Bates-Maves emphasizes.

Other experiences common to people working to move from addiction to recovery include:

  • Loss of comfort: The person can no longer rely on his or her addictive pattern as a coping mechanism.
  • Loss of power: Choices are often restricted in recovery, and it’s not always OK to make a “bad” choice.
  • Loss of identity: The person may wrestle with the question, “If I’m not an addict, who am I?”
  • Loss of pain relief: The person may ask, “How am I supposed to manage my pain now? I don’t know any other ways that work as well as _________ does.”
  • Loss of perceived choice: Because substance use is no longer an option, the person has to find another way to live, cope and function.

“It can feel like the rug has been pulled out from under them, and some can flounder in the absence of the structure of an addiction,” Bates-Maves says.

“Also consider the more commonly talked about losses, like loss of lifestyle or [loss of] ‘using’ friends,” she adds. “While it may be healthy to move away from people who remain stuck in unhealthy patterns, it’s certainly not easy. As a counselor, I believe that people have a ton of worth, even in the presence of an addiction or negative behaviors. If I’m told to walk away from the positives of a relationship because there are also negative behaviors, I’d struggle. Clients deserve to struggle with that too. Health and happiness are not always the same thing. If I have the choice to be alone and healthy or to be in the company of others and unhealthy, I’d waiver — particularly if others forced me in one direction or another.

“I think it’s important that counselors really sit with what’s being asked of someone when they’re told they must now avoid people who are still using. Allow for the struggle and encourage clients to grieve the loss of good people who are still stuck. Don’t lose sight of the loss and grief there. Value what’s being lost or taken away instead of encouraging — or sometimes mandating — the death of a relationship. And talk about it. Balance is key. Talk about why some losses are needed, and validate that they’re painful. Allow the pain, allow the struggle, and help clients to cope with them as they move toward something different.”

Losses that are controllable — meaning that clients have some say over their occurrence — can actually foster hope in clients that there will be a chance for repair or course correction once they have adopted a new way of living, Bates-Maves says. Examples of losses that might be controllable include legal problems or convictions, family ruptures, loss of employment and financial problems.

However, even with new skills and hope, there is no guarantee that clients in recovery will be able to fix or recoup all that they have lost, she cautions. For that reason, counselors need to help these clients “sit with that and explore both options: How can I learn to be OK and heal if this is changed or fixed? And how can I learn to be OK and heal if this stays broken or less than I hope?”

“The key lesson there is that clients can reconstruct a meaningful life in recovery, even if some components never return to what they once were,” Bates-Maves says. “It’s about moving ahead and grieving what doesn’t move with you. Again, balance. Growth is often painful, and we want to value the pain and loss that come with growth. Knowing that some relationships have been damaged beyond repair might be very painful and a point of personal despair, but it can also be framed as a powerful motivator. We can mourn the past and work to repair the damage that’s done, and we can work to not repeat it. I think our main task as counselors is to help frame the pain as useful and informative. What people hurt about reveals what they value. It also reveals what they don’t want to repeat. Both elements are quite useful to a counselor in helping a client figure out where they want to go and how to start getting there.”

“I think the most important thing for counselors to remember is that change is really hard,” she emphasizes. “That may seem obvious, but consider how often we forget it. Sometimes clients are kicked out of treatment because they’ve lapsed or relapsed. Other times there are mandates about [whom] one can spend time with and [whom] one cannot, requirements for employment, etc.”

Continuing not to engage in addictive behavior, forging relationships with people who don’t use substances, and gaining and maintaining employment are all healthy goals. However, clients need to process many of their losses — particularly those connected to self-worth and self-efficacy — before it is possible for them to achieve those goals, Bates-Maves says.

“Give people credit for the pain that comes with change, and give them space to talk about it,” she urges. “Talk about how health and happiness aren’t the same thing [but] that the work of counseling is to make them closer. Talk about how in order to move forward, we often have to let go and how hard that is, even when we’re letting go of ‘bad’ things. Focus on where someone is and not only where we/they/you want them to be. If we want to help people move forward, we have to understand what’s keeping them where they are currently. But mostly, give people credit for the pain that comes with change, talk about it, and help them grieve.”

A question of identity

As a certified rehabilitation counselor and someone who sustained a spinal cord injury more than 30 years ago, ACA member Susan Stuntzner knows a lot about the losses and grief that come with disability. 

“At the time, I was paralyzed from the waist down, but within two months, I achieved some mobility and enough to walk with below-the-knee ankle-foot-orthotics [AFOs],” she recounts. “While learning to walk was a fantastic high point of the rehabilitation process, an equally important aspect was figuring out my new or different capabilities. More specifically, I learned I could not run, which is something I used to enjoy; lift more than 25-30 pounds; and that I had to push or pull things rather than lift as a means to move objects. I learned it was probably not a good idea to stand indefinitely and the importance of recognizing and honoring what my
body could do rather than expect me to do things in exactly the same way as I could before.”

Stuntzner also grappled with an issue that is particularly common among women with disabilities whose physical appearance is altered, either through injury or a disability present at birth: body image and attractiveness.

“Again, going back to my own experience, while muscles in my thighs worked, those below my knees did not. This meant my feet and ankles did not either,” she says. “Thus, there was a change in how I initially saw myself and my calves, as these did not have muscle return but they were an attached part of my body. Changing the way I viewed myself was difficult and a form of loss, as I was 19 years of age and highly conscious of fashion and, in particular, shoes. In short, I loved cool shoes and I still do. However, the partial paralysis below my knees meant I now had to wear AFOs and could no longer wear the stylish shoes I had so loved. While some of this may sound trivial, fashion and shoes — again, I was 19 years of age — was important to me, and this change represented a form of loss, along with the attention that my AFOs brought to the stranger passing by.”

“My own story is only one of many, as each person who lives with a disability — visible or invisible — has a story or set of experiences,” Stuntzner says. “For some, it may be cognitive changes [such as] memory, learning, recall, traumatic brain injury. For others, it may be health conditions [such as] irritable bowel syndrome, heart conditions [or] chronic obstructive pulmonary disease that disrupt daily activities and events. Other people live with sensory disabilities — loss of vision or hard of hearing. People who are hard of hearing but not deaf face challenges because people sometimes report not feeling as if they fit anywhere; they are not deaf, nor are they a part of the ‘hearing’ sector due to some of the limitations they experience.”

Regardless of a person’s specific set of circumstances, it is important that the person views themselves as a “whole” person, recognizes their assets and strengths, and builds upon those assets and strengths, Stuntzner says. Identifying one’s abilities, strengths and talents regardless of disability and functional limitations is a key part of what rehabilitation counselors help people do, she adds.

Counselors can help these clients grieve by listening and supporting them emotionally and psychologically as they work through the changes brought about by their disability, Stuntzner says. Counselors should understand that adjustment and grief are individualized processes and that two people with very similar conditions and functional changes may cope and adapt very differently, she notes. They also may require different therapeutic approaches to help them move forward. One size does not fit all based on disability type, Stuntzner emphasizes. It is important to view the person as a whole individual and to help people learn to see themselves as capable individuals comprising many different aspects and interests.

“Another key component of working through loss is helping people work through their negative thoughts and feelings, and experience successes, while living with a disability so they develop a strong internal locus of control and a sense that they can effect change in their life and create the life they seek,” Stuntzner says. “In short, it is about empowering people to discover who they are or who they can be in spite of the disability. As people become empowered, they learn to find their voice and own it and use it to help themselves and others. It is through this process that people oftentimes heal and learn to see the bright side of living with a disability.

“By bright side, I mean they learn to see the positive ways their life has changed or can change, and many find a higher purpose through the experience of living with a disability. However, this is a process, one that may begin with grief and loss, then morph into a personal and/or spiritual journey where people discover ways to grow and sometimes access their higher purpose or sense of self. It is on this journey that people find healing.”

Not just a pet

According to the American Veterinary Medical Association, at the end of 2016 (the latest year for which statistics were available), nearly 57 percent of American households had pets. Surveys have shown that the majority of people among that 57 percent also view their pets as part of the family. Yet many people do not regard the death of a pet as a “legitimate” loss. Indeed, those who have suffered the loss of a pet may not recognize their own grief, says licensed clinical professional counselor Cheryl Fisher, an ACA member whose counseling specialties include grief and loss.

In Fisher’s experience, it is not unusual for new clients to present with issues such as depression, anxiety or stress, and when talking about why they are seeking therapy, mention — almost as if it were a side note — “By the way, I just lost my cat.”

Fisher recalls a client who had come to her for grief counseling after the death of a relative. As Fisher listened, she realized that the client’s loss extended beyond that one death and that she was experiencing complicated grief.

The woman mentioned in passing that she rescued feral cats, two of which had died recently. These street felines were not easily domesticated, so the woman’s interactions with them had mainly been restricted to feeding them, Fisher notes. Yet the woman kept collecting them.

The client was very isolated. In fact, the recently deceased relative had been her only remaining family member. Except for the cats. As limited as her relationship was with them, the feral cats were her family, and she was grieving those losses as well.

“People are sheepish about sharing their grief, but our animals are the most vulnerable members of our families and also the most unconditional and accepting,” says Fisher, who shared the experience of losing her beloved dog Lily in her CT Online column, The Counseling Connoisseur (“Pet loss: Lessons in grief,” April 2017).

As she tells clients who are grieving (sheepishly or not), the relationships that people have with their pets — whether dogs, cats, fish or fowl — are strong not just emotionally but biochemically. In interacting with their pets, people feel a release of oxytocin, the hormone responsible for feelings of closeness and attachment.

Fisher also asks these clients to tell their “pet story.” She begins by asking how they met their pets. Fisher says the adoption or birthing story is very significant to the pet–human bond, and when clients start to recount it, they get very passionate as they open up to those memories.

“I always want to know the pet’s name, what kind [of animal it was], what the client liked to do with them and if they have pictures,” Fisher says. “It’s like traditional grief therapy — I’m helping them talk about their loved one.”

As clients talk, Fisher will say things that highlight the significance of their relationship with their pet. For example, she might say, “It sounds like Sadie stood right by you through the divorce.”

Fisher says she can almost see clients exhale: “You get it. I didn’t realize this was so important. She wasn’t just a cat!’”

Fisher also helps clients find ways to stay connected to their pet by giving examples of rituals that others have used. She urges clients to think about their relationship with their pet and the type of remembrance that would fit that bond.

For Fisher and her husband, it was taking Lily’s ashes to the beach where they and their goldendoodle had so often visited and played. “She loved the beach,” Fisher notes.

Some clients create scrapbooks with items such as their pet’s adoption papers and first pictures. Fisher included all the condolence cards she and her husband received in the wake of Lily’s death.

One of Fisher’s clients honored her cat, who loved to look out the window at birds, by constructing a special birdhouse that held pride of place next to the pet’s perch.

Fisher also mentions a video she saw at a conference on children and grief. It was called “Bridget’s Loss,” and in it, a little girl says goodbye to her fish in a “ritual flush.”

Fisher describes the scene: The mother, who filmed the video, asks her daughter if there is anything she wants to say before flushing the fish. The girl says, “Sammy, you were a good fish. You always did good fish things, and now you will be able to go with all the other fish, and I will see you in another time in heaven or wherever.”

The key to grieving pet loss is to have some kind of goodbye ritual, Fisher says, even if it is something completely private that involves only clients and their pet.

 

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Additional resources

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

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Webinars (aca.digitellinc.com/aca/pages/events)

  • “An Overview of Military Service Members and Their Families: How Mental Health Professionals Can Best Serve This Population” with John P. Duggan and Odis McKinzie (WEB17002)

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “When Grief Becomes Complicated” with Antoinetta Corvasce (ACA252)
  • “Love and Sex and Relationships” with Erica Goodstone (ACA231)
  • “Disability Awareness” with Robbin Miller (ACA196)
  • “Counseling Military Families” (ACA139)

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@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.

Counseling Connoisseur: Thanatechnology – Grief and loss in a digital world

By Cheryl Fisher June 8, 2018

Thanatechnology: Any kind of technology that can be used to deal with death, dying, grief, loss and illness.

 

Kelly (an alias), an eighth-grader, sits with her friends in the school auditorium as her principal calls out the names of each of her classmates who were killed in the recent shooting. To honor the lives of these young people, the school is hosting a remembrance ceremony. As tears run down her face, Kelly huddles close to her schoolmates and clicks away on her phone posting messages on several social network sites and a memorial site that she and her friends created. A text message pops up from a boy she met on one of the sites. He is a survivor of a school shooting that happened a couple of years ago — he understands.

Tony’s (alias) phone vibrates, rousing him from his slumber. He looks at the clock – it’s 2 a.m. He has to be up for school in just a few hours. He squints, trying to read the alert on his phone. Another teenager has died from drug overdose. He heaves a mournful sigh and turns on the bedside lamp. His phone begins to blow up with social media posts. The deceased didn’t attend his school but is related to his girlfriend’s best friend. Tony attempts to return to sleep, but he keeps thinking about the teenager [and] wondering why it happened.

Without a doubt, the youth of today are often exposed to significant and traumatic losses. Traditionally, we have marked death with rituals such as funerals and memorials and grieved with the support of counseling, faith communities and neighbors. In more recent years, technology has provided additional ways to remember and mourn, such as creating online memorials, seeking distant or virtual grief counseling and connecting with family, friends and even strangers without geographical limitations. It erases time and distance and allows for virtual experiences and expressions that promote a narrative that lives forever.

Digital Presence and Youth

In Dying, Death, and Grief in an Online Universe, researchers Kathleen R. Gilbert and Michael Massimi observe that digital technology can “bring people together for social support, provide information, and offer a venue for conducting grief work such as telling stories or building digital memorials.”

In another section of the book, researcher Carla Sofka writes that young people are even more likely to seek grief support online. Sofka explains that the internet, social media and other digital platforms are where younger generations are most comfortable because they provide opportunities for social interaction; a sense of independence and privacy; the ability to express and form their own identity; a sense of community that includes those that are marginalized; and instant alerts and communication. All of these elements allow youth to seek and find like-minded communities that can provide immediate support and strategies for coping with myriad life issues — including death and dying, and grief and loss.

 

Social Interaction

Online bereavement forums and chat rooms provide a sense of social connection with users. Sites such as Caring Bridge allow multiple users to maintain a virtual journal offering information and capturing narratives that are accessible to members. Tumblr, Facebook and Instagram create spaces where youth can just “hang out.” Video calling technology such as FaceTime and Skype bridge the distance between users and promote interaction and communication. Additionally, grief counseling may be offered via video, phone, chat or email formats.

Independence and Sense of Privacy

Teens turn to technology to carve out a private space for self-expression. However, research indicates that internet use often provides the illusion of anonymity, which may encourage a false sense of privacy. The struggle for privacy is nothing new: The tension between privacy and personal expression has existed between teens and parents for decades. In It’s Complicated: The Social Lives of Networked Teens, danah boyd*, principal researcher at Microsoft Research notes that social media introduced a new dimension to this age-old power struggle. Instead of worrying about what teens wear outside, parents are concerned about what pictures teens are posting about what they wear outside.

[*boyd prefers to spell her name with lowercase letters.]

“Although teens grapple with managing their identity and navigating youth-centric communities while simultaneously maintaining spaces for intimacy, they do so under the spotlight of a media ecosystem designed to publicize every teen fad, moral panic, and new hyped technology,” writes boyd.

Yet, online spaces allow for exploration of feelings and thoughts, examination of death anxiety, and expression of grief and loss. For example, a 14 year- old client crafted an entire mix of music and prose around the complicated emotions she experienced related to the death of her estranged father who had abused her as a little girl. Using an alias, she posted the eulogy online and watched as strangers connected with her, validating her feelings and experience.

Expression and Influence of Identity Formation

The internet provides creative space for expressing grief and honoring loved ones. Sites such as KIDSAID.com, offer children the opportunity to connect, interact and creatively express their grief. In addition to expressive sites and online memorial services such as Legacy, Remembered.com and Your Tribute provide an unfettered opportunity to honor loss, especially for those who are marginalized or disenfranchised. The use of letters, photos and sound provide rich and detailed memorials that allow users to express their grief, absorb their loss and ultimately move forward.

Sense of Community

Blogs provide a venue to capture experiences and to cultivate topic-based virtual communities. Boyd suggests that these constructed networks serve as a public place to interact with real and imagined communities, thus satisfying a desire to be part of a broader world.

Instant Alerts

Online communication is often in real time. Twitter, Snapchat and a variety of other digital sites offer instant notifications and ongoing engagement. Technology allows users to gather multiple streams of almost instantaneous information from afar. For example, recently I was at a social gathering where a young woman, glued to her phone, was continuously texting. At one point I interjected, “Is everything alright?” She looked up and shook her head. “No, I have a friend who was just in a car accident and the medics are transporting her to shock trauma. Her parents are on their way to the hospital — but no one thinks she’s going to make it.”

The accident occurred in another state, yet this young woman was experiencing the event minute by minute via her phone messaging.

There are numerous attractive features to thanatechnology. Information is persistent and endures. There is a sense of immortality and legacy when a person’s comments, photos and work is posted in cyberspace. It is visible to infinite numbers of individuals. It is spreadable, and with one repost or share, hundreds more are invited into our experience. It is searchable. Just yesterday someone emailed me after reading my article on pet loss and grief. She had been Googling information about pet loss and my article popped up. I was able to provide her with additional support resources.

While there are many helpful aspects of using technology for grief support, there are some serious causes for pause. Are the online interactions healthy? Who is actually participating in the network communities? Are youth oversharing personal information while in a vulnerable state? How pervasive are social divisions and are they perpetuated in the participating forums?

Clinicians, parents and educators must be digitally literate and provide opportunities for genuine face to face connection while acknowledging the cyberworld of teens. Using technology during this very vulnerable time can provide tremendous support and healing, but it may pose risks. Counselors have the responsibility to help youth develop the skills to navigate technology in a way that creates a safe environment for their grief experience and promotes bereavement support.

 

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy: and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

 

 

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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.

When post-abortion emotions need unpacking

By Bethany Bray April 3, 2018

Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon, has made it a habit to avoid using “must” phrases with clients. “It sends a message to the client about what they’ve experienced,” says Beckett, who specializes in grief counseling. “I don’t ever want to say, ‘Oh, you must feel so guilty,’ or ‘You must feel so isolated,’ because that may not be the case at all.”

A case in point: when clients reveal in counseling that they have had an abortion at some point in their past. Some clients consider that experience to be just another piece of their life story, free of any negative associations. For others, the experience can evoke a range of issues, from spiritual and familial turmoil to attachment difficulties and feelings of loss. When dealing with such a highly charged topic, counselors must be prepared to put their own personal views aside to support clients who fall into either camp — and those who present a range of emotions in between.

Research cited by an American Psychological Association task force found that the majority of women who elect to have an abortion will not experience mental health difficulties afterward (see apa.org/pi/women/programs/abortion/). In February 2017, JAMA Psychiatry published a study titled “Women’s mental health and well-being 5 years after receiving or being denied an abortion.” The study observed 956 women over the course of five years, including 231 who initially were turned away from abortion facilities. Among the authors’ conclusions: “In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women’s access to abortion on the basis that abortion harms women’s mental health.”

Even though most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or encounter other negative emotions caused by external factors such as culture or family. For certain clients, a past abortion experience, whether it took place one month ago or decades ago, can be at the root of a range of issues — low self-esteem, relationship problems, disenfranchised grief — that surface during counseling sessions.

Beckett notes that most of the women she works with aren’t questioning their decision to have an abortion but rather “struggling to process it and place it in the narrative of their own lives in a way that feels comfortable.”

“As a practitioner, you should know about [abortion] and understand that within the population you’re seeing, it’s probably in their story,” says Jennie Brightup, a licensed clinical marriage and family therapist in private practice outside of Wichita, Kansas. “You need to be prepared to know how to work with it.”

Counselors should approach the revelation of an abortion just like any other experience or issue that clients may have in their histories, Brightup says. “Have an open mind. Allow it to be something that can be a problem for your client. See that it could be an issue … [and] have some knowledge about how to treat it.”

‘You think you’re alone’

The Guttmacher Institute, a reproductive health research organization, estimates that in 2014 (the most recent data available), 926,200 abortions were performed among women between the ages of 15 and 44 in the United States. This comes out to a rate of 14.6 abortions per 1,000 women.

The institute notes that this marks America’s lowest abortion rate since the process was legalized nationwide by the Roe v. Wade Supreme Court decision in 1973. The U.S. abortion rate has seen a steady decline after peaking in 1980 and 1981 at close to 30 abortions per 1,000 women. Using the 2014 data, the Guttmacher Institute extrapolates that 5 percent of U.S. women will have an abortion by age 20; 19 percent will have an abortion by age 30; and 24 percent will have an abortion by age 45.

Abortion is more common than many people, including mental health practitioners, think, says Trudy Johnson, a licensed marriage and family therapist who presented on “Choice Processing and Resolution: Bringing Abortion After-Care Into the 21st Century at ACA’s 2012 Conference & Expo in San Francisco. Johnson, who had an abortion in college, says that for many people, processing the abortion experience is “a slow burn. It doesn’t affect you until later on. [Many] women have had an abortion, but you think you’re alone. You don’t feel you get to grieve it. … It’s a gut-level thing, a tender place. Many have never told a soul,” says Johnson, who specializes in trauma resolution, including abortion-related issues.

Connecting issues

For clients who have yet to process and place a past abortion into their self-narrative, it can feel like a sadness that they can’t quite pinpoint or define. “It’s kind of like a phantom pain. It’s there, but you don’t know why,” Johnson says.

Clients with a variety of presenting issues may have unprocessed emotions surrounding a past abortion that could be compounding their struggles, Johnson says. These issues can include:

  • Depression and anxiety
  • Complicated grief
  • Anger
  • Shame and guilt (especially shame that is undefined or has no apparent cause)
  • Self-loathing and self-esteem issues
  • Relationship issues (including destructive relationships)
  • Destructive behaviors (including substance abuse)

For certain clients, their unprocessed emotions can feel like a weight they have carried and buried deep within themselves for a long time without sharing it with anyone, Johnson says.

Johnson recalls one client who initially came for couples counseling with her husband but eventually started seeing Johnson for individual counseling. During a session, Johnson recognized that the woman was becoming upset, so she handed her a blanket and pillow for comfort. The client put the blanket over her head, obscuring her face, and disclosed that she had had an abortion 18 years prior. Her family had shamed her for the decision, and her feelings of shame were still so overwhelming that putting the blanket over her head was the only way she could bring herself to talk about the experience, Johnson recounts.

“You just can’t imagine the shame that [some of] these clients carry,” says Johnson, a private practitioner who splits her time between Arizona and Tennessee. “They just have to talk about it. We, as professionals, can be that safe place.”

Clients who have had abortions sometimes question whether they have the right to grieve because there was a choice involved to terminate their pregnancies, says Beckett, who is an adjunct faculty member in the doctoral counseling program at Oregon State University. The concept of the experience of disenfranchised grief — those who are not supported in their grief because it is not culturally recognized or validated — applies in these instances, Beckett says. In fact, the disenfranchisement can be both external (a loss not recognized by the client’s culture) and internal (a loss that the client, individually, does not recognize).

“People do not have the same kind of support and validation [to grieve a loss] when they’re disenfranchised, and that is a huge part of abortion grief,” Beckett says. “The emotional aftermath is so impacted by spiritual, political and ethical values and beliefs. That will really color how they process it and how much they’re able to reach out and get support. This all needs to go into our assessment of a client. What was their experience, but also how are they talking to themselves about it? All of that should inform how we offer support.”

Broaching the subject

Practitioners might want to consider asking clients (female and male) about pregnancy loss, including abortion, on intake forms. Brightup asks clients about past pregnancy loss in a genogram exercise she does in the first few sessions of counseling. If the client mentions an abortion, she simply makes a note and keeps going. It is not a topic she feels a need to jump on immediately, she says, and she doesn’t want to risk retraumatizing clients or prompting them to talk about it if they are not ready. Some clients may not mention an abortion on an intake form or genogram because they don’t consider it a loss or associate it with trauma, Brightup says. Others have buried the issue so deep that they don’t think about it or feel that it is worth mentioning, she adds.

“When you’re hearing their story, you can find places to check in and ask questions. Most of the time, I allow them to come around and tell me. It’s a core secret. If you feel [judgmental] to them, they’ll never tell you and they’ll run [stop coming to therapy],” says Brightup, a certified eye movement desensitization and reprocessing (EMDR) therapist.

Practitioner language is also important, Beckett notes. “For some people, asking [if they have an abortion in their past] is giving them permission to talk about it. And the way we ask about it may give them clues about whether or not it is safe to talk to us about it,” she says. “For example, there’s a difference between, ‘Is this something you have experience with?’ and ‘Well, you haven’t had an abortion, have you?’”

Even the word “abortion” can provoke an intense reaction for some clients, Johnson says. In some cases, she will use the phrase “pregnancy termination” or even “the A word” with clients who feel triggered and begin to close themselves off.

“You might need to say it differently,” Johnson advises. “Abortion immediately turns it into a political, socially charged [issue]. Changing the terminology helps it to be safer.”

The key is to foster a safe, trusted bond so that clients will feel free to bring the topic up themselves when they are ready, Johnson says. “The most important thing is building a relationship of safety,” she emphasizes.

Different points on a path

Clients who disclose having an abortion in their past may vary widely on how they feel about the procedure and how much they have processed those feelings.

“There are clients who will come in and do not report having any mental health issues related to their abortion experience. Understand that they’re out there. But the other side is out there too,” Brightup says. Practitioners must be prepared to work with clients who express either sentiment — or a range of feelings in between.

Counselors should watch their clients’ body language and other cues, especially in cases in which a client is emphatic or even defensive when talking about an abortion. It is wise to unpack the client’s experience and associated feelings over time, Brightup says.

If counselors disagree with a client’s assertions concerning how she feels about the procedure, “you can lose the client because they won’t come back [to therapy],” she says. “Agree with their narrative. In little pieces, once they trust you, you can come back to the story and probe a little, ask a few questions as gently and carefully as you can.”

Some clients will have fit the abortion into their self-narrative and moved on, whereas others won’t be as far along in the journey. Still others will have worked through their feelings surrounding the procedure in a healthy way previously but may find themselves struggling with it again as they move into another life stage such as pregnancy or motherhood, Beckett says.

This was the case for one of Beckett’s clients who sought counseling because she was struggling with powerful emotions that had resurfaced. The client had undergone an abortion when she was 17. Later in her life, she had a daughter, and that daughter was now turning 17 herself. Even though her daughter wasn’t facing any type of decision regarding pregnancy or abortion, her age triggered feelings in the client that needed more therapeutic attention.

The client’s abortion had been illegal at the time where she lived, so she had felt compelled to keep it a secret, Beckett explains. The client realized her daughter was now the age she had been when she had an abortion. “The mother saw, for the first time, how young she [had been] and how desperately she had needed love and support at the time, and she didn’t get it,” Beckett says. The realization was “exquisitely painful” for the client, but at the same time, it brought “a new level of compassion for her 17-year-old self,” Beckett recounts.

“She took a great deal of comfort in knowing that if her daughter were to get pregnant, it would be an entirely different experience. Her daughter would have the support of her family and better care,” Beckett says.

The hard work of unpacking

Just as clients will differ in the work they have done — or haven’t done — to process the emotions surrounding an abortion, the support and interventions they might need from a counselor will also vary.

“People grieve very differently, and we need to be ready to support people however they are doing it,” Beckett says. “Some people are going to want to take action or give back somehow. Others will respond to more creative processes or ritual creation. Others will want a quiet, safe place to process.”

Normalizing a client’s experience can be a much-needed first step. Beckett says that talking about how common abortion is, and the fact that many people feel a need to process their feelings afterward, can bring relief to clients. Practitioners can also help clients reframe their thoughts to realize that feelings of relief after the procedure are common, as is a fear of judgment and a sense of isolation that can accompany that fear.

“Figure out what this particular client’s experience is and then, if appropriate, offer normalization of that,” Beckett says. “Support them to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

In Brightup’s experience, post-abortion work with clients often falls into four quadrants:

  • Reconciling how clients feel about themselves
  • Engaging in grief work around how clients perceive and feel about the loss (if they do indeed view it as a loss)
  • Working through clients’ spiritual issues or any inner tensions related to “rules” that were broken
  • Working on clients’ relationships and how they relate to people: Are there areas that need healing?

From there, practitioners should tailor their approaches to meet each client’s individual needs and pacing, Brightup says. She often uses sand tray therapy as a tool to help clients talk about post-abortion loss and find closure. Journaling, writing letters or poems, creating art and engaging in other creative outlets can also be helpful, she says. Certain clients may respond to creating some kind of physical memorial or taking time out of a counseling session to do a remembrance with just the two of you, Brightup adds.

Beckett agrees that counselors should collaborate with clients to find a ritual or activity that works for them. Although many clients will make progress through talk therapy or by connecting in group work to those who have had similar experiences, others will feel a need to take some kind of action, Beckett says. Creating memorials and rituals, writing letters or participating in other creative interventions can help these clients to process their emotions and experiences.

For one of Beckett’s clients, healing involved creating a special ritual on what would have been her child’s due date. Each year, the client would be intentional about spending time with a child — whether a niece or a nephew or the child of a friend — who was the same age that her child would have been.

“She came in pretty soon after her abortion, and she knew she needed help to process it,” Beckett says. “She wasn’t questioning the decision, but she was having trouble [with the fact] that her life would move forward but the life of the baby she had not had wouldn’t move forward. She wrote a letter to that baby expressing her caring and regret and explaining why she felt she couldn’t bring him or her into the world. Every year on her due date, she would find a way to connect with a child she knew that would be that age. She would spend time with that child and make it a good day for them.”

Whereas this intervention helped this particular client to find peace, “for other clients, the thought of that would seem hellish,” Beckett stresses. “There’s no prescription for this. It’s a process of figuring out what is still remaining and needs to be released. Talk with the
client to find creative ways to be able to do that.”

Counselors can help clients navigate areas in which they feel emotionally stuck, Beckett explains. For example, one of her clients was struggling even though she had worked through many of the emotions she had experienced after an abortion. The client had three children, and when she became pregnant with a fourth, she and her partner made the decision to terminate the pregnancy.

“There was one part that she couldn’t get OK with: ‘I see myself as someone who takes care of others,’” Beckett says. “That’s where we focused: How did she define ‘taking care’? How did this decision threaten her self-concept? We dove into that area and she eventually realized that terminating the pregnancy was taking care of her fourth child. That was the best way to take care of that child, instead of bringing the child into an already-overwhelmed system that wouldn’t have been able to provide what the child needed.”

Johnson finds narrative therapy a useful approach when focusing on post-abortion issues with clients. Giving them the freedom to tell the story of their abortion — how old they were, how it happened, who came with them that day — can be powerful, she says. Sometimes clients won’t remember the details about their abortion because they’ve blocked them out, Johnson says, but as they open up and talk about the experience in therapy, they often start to recall things.

“This has been in their head for years. When they finally start talking about it, they go on and on because that’s [often] what they need,” Johnson says. “You can see the layers coming off as they’re processing it verbally, the whole story. … Letting them talk about the details and tell their story is a starting point.”

When relevant, Johnson also helps clients identify all the points of grief connected to the abortion beyond the loss of a pregnancy. For example, clients might have experienced a breakup with their romantic partners or the breakdown of a relationship with their parents or other family members either leading up to or after the abortion. Giving clients permission to grieve and accept the loss of these things is an important step, Johnson says.

There are “so many layers to this. The main thing [for counselors] is being a safe place. The impact of a hidden abortion could really be affecting the outcome of your therapy if it’s not addressed. Be aware that there could be this issue under all of the other stuff [the presenting issues],” Johnson says.

“Treat this as a disenfranchised and complicated grief situation, and take out all the political mess and pros and cons,” she continues. “The client has already made a choice. Let’s forget about that and just work on the grief. They’re not the same person that they were when they made the choice. They’re a different person now, so they need to have permission to revisit that time in their life and be free of it. The therapist is kind of a vessel of freedom for that, and it’s a wonderful place. … You’re helping them overcome the bondage, pain and grief that’s been with them for so long.”

Putting personal feelings aside

Abortion remains one of the most politically and socially polarizing issues in modern-day America. Despite this — or, in some cases, because of this — certain clients are going to need to work through issues related to abortion in the counseling office. A practitioner’s role is to be a support through it all, regardless of his or her own personal views on the topic.

Brightup urges counselors to rely on their training, which includes setting personal opinions aside and being what the client needs.

Creating a neutral and welcoming space for clients to talk about such a sensitive topic is paramount, Johnson agrees. “If you don’t have any experience working in this area, you can do more damage without meaning to,” she says. “Or, for some people, there’s a hidden implication that if you help a client through feelings related to an abortion, you’re condoning abortion.” That is simply not true, she stresses.

Beckett agrees. “Clients need a safe and nonjudgmental space to share [about their abortion experience], and that’s hard for some counselors based on their own belief system. It’s not going to be easy for all counselors — that affirmation of [the client’s] right to grieve. [But] a client needs support to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

 

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Disclosing an innermost secret

As clients process post-abortion emotions, they may struggle with the decision to tell others, including a current or former partner. What should a counselor’s role be in that process? Read more in our online-exclusive article: wp.me/p2BxKN-54z

 

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Related resources

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editorct@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.

 

Grief: Going beyond death and stages

By Laurie Meyers October 27, 2016

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.

 

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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.

 

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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. (counseling.org/bookstore)

Podcasts (counseling.org/continuing-education/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 (counseling.org/continuing-education/vistas)

  • “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 (counseling.org/knowledge-center/practice-briefs)

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

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@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.