Tag Archives: Grief

The caregiving conundrum

By Tia Amdurer March 12, 2019

The branch of therapy that deals with anticipated loss due to death is a specialization that often gets overlooked. As a counselor who works with anticipatory grief and has five years’ experience in a hospice bereavement office, I have found that primary caregivers usually need guidance and support but don’t ask for it until they are completely overwhelmed. Counseling for end-of-life caregiving is very much an area in which good therapists can make the difference. 

Current Medicare standards for hospice do not cover the cost of a bereavement specialist for family members of a dying patient. Unless the family or caregiver seeks an outside therapist, chaplains and social workers affiliated with assisted living facilities or hospices become the de facto mental health experts, juggling family dynamics, anticipatory grief, medical regulations, spiritual concerns and the patient’s care plan.

Caregivers: The unsung heroes

Whether end-of-life care is being given in a home or a facility, caregivers can grow overwhelmed by the physical and emotional toll of their responsibilities. They may start showing signs of anticipatory grief, including mourning the loss of their role and relationship and fearing the future. This can be coupled with anger at the isolation and abandonment by others, bitterness at the exhaustion, frustration at the never-ending demands, shame for wishing caregiving were over already (which would mean the patient’s demise), helplessness at being unsure about what they should be doing and sadness at the way that time is running out.

In my book Take My Hand: The Caregiver’s Journey, Chris Renaud-Cogswell offered written reflections on her emotional overload with caregiving responsibilities: “I’m so jealous of all of you who enjoy your parents’ company and treasure the time you have with them. When do I get past the ‘I can’t believe this is my life,’ regretful, resentful stage? I have never used the F-word as much as I do since my mother moved in.”

Guilt seems to be the emotion that rises to the surface most often for caregivers. Even in the most “functional” homes, the intensity of caregiving can be enormous. For example, a spouse may not be capable of doing everything but still feels responsible for the care of his or her sick partner. Conversely, partners in good health may feel weighed down by the extreme change in their role and lifestyle. Adult children who are working or raising kids themselves can feel put upon to do more and angry that their time is so limited. Those caring for an elder may find old childhood resentments bubbling up. Relatives who might like to visit don’t know how to help. Asking for help triggers additional feelings of guilt and frustration among caregivers.

As grief counselors, we listen to recitations based on a lifetime of behaviors and try to help put boundaries in place. We validate and remind clients that they are doing the best they can under trying circumstances. Caregivers may struggle with the history of a poor relationship with the patient. These interpersonal dynamics are likely to continue being problematic. For many families, a storybook resolution or a full sense of forgiveness might be difficult to achieve.

One middle-aged man paid a daily visit to his dying father, who had a long history of being abusive and battling alcoholism. Despite the visits lasting for four or five hours, the man refused to interact with his father. Instead, he sat in a chair, played games on his phone and felt guilty. A daughter who had been constantly rejected by her narcissistic mother reacted by directing her frustration at staff for any minor infractions, fearing that her mother, who was dying, would deride her for her own lack of attention. In another case, an adult daughter wanted to scream at her mom for never asking for what she needed, acting out passive-aggressive patterns and playing the “martyr.” The daughter hated the nagging person she was becoming.

Caregiving can be a long journey, so, as counselors, we must explain the necessity of self-care for the caregiver. Even among caregivers who are fully engaged with their sick loved ones and content with their position, emotional exhaustion takes a toll. Whether dealing with a loved one’s personality changes or the loss of that person’s physical abilities or mental acuity, being on call as the “responsible adult” is draining. Caregiving can run the gamut of emotions and experiences, from boring to terrifying.

Self-care for caregivers includes asking for help, making schedules, sleeping, taking time alone, exercising, seeing friends, checking out support groups, praying, laughing, journaling, connecting through social media and, of course, learning to accept help. By presenting family members, friends, faith organizations or neighbors with specific ways to help, the caregiver is actually providing a service. Rather than viewing these “asks” as a burden to others, it can be reframed as an opportunity for others to do a good deed for the person who is dying.

A caregiver’s functions will depend on many variables. For instance, if the person who is dying is in a facility, the caregiver may be tasked with doing laundry, attending functions at the facility, visiting the sick loved one daily or weekly, finding coverage for meetings with facility staff to discuss behavior changes or concerns, driving the loved one to outside medical appointments, scheduling visits from friends and relatives, and maintaining a family home.

For at-home caregivers, responsibilities might include adjusting for safety precautions around the home. This might involve installing grab bars, removing throw rugs and acquiring nonslip mats, having a working fire extinguisher, checking that the water heater thermostat is set below 120 degrees Fahrenheit and preparing for durable medical equipment (such as commodes, hospital beds and oxygen tanks/cylinders). In addition, these caregivers typically shoulder the responsibility for being available to drive the person to appointments as necessary, finding coverage when away from the home and providing meals that are dietarily different.

Counselors should remind clients who have caregiver responsibilities that friends or relatives might be able to visit or engage in crafts or music with a sick loved one, thus allowing the caregiver some time off. To ward off burnout, caregivers need respite.

Thus we arrive at the conundrum of respite: “If I go away for a few days, what if my loved one dies? How will I live with the guilt?”

There are two scenarios at the end of life: One, the loved one dies when someone is with them and, two, he or she dies when no one is there. Caregivers often worry that their loved one might be alone when they die. Some hospices can provide 11th-hour care, during which volunteers can sit at bedside if the family wishes.

My experience in hospice has been that some patients follow a definitive trajectory in their decline, whereas others follow an indeterminate timeline, making a family’s desire to be bedside at the last breath fraught with uncertainty. Although many cultures encourage “vigiling” at the deathbed, there is an unknown: Does the patient want the family there? Some individuals need to be alone when they die and will release from this life only when the family or a specific person leaves. The speculation about why this happens is endless, but it may help alleviate family guilt to use the metaphor of a group coming to a bridge together, but because only the dying individual may cross that bridge, he or she will do it alone. 

Family dynamics

As counselors, we should encourage caregivers to see that a document such as Five Wishes (fivewishes.org) is completed while the elder is mentally competent. This document serves as a directive about how the patient wishes to be cared for at the end of life. It is a binding document like a living will. In considering end-of-life protocols, all adults should be encouraged to write down their wishes so that these are known in advance.

During a crisis or major upset in a family system, different personality traits come to the fore. Family members who aren’t the primary caregiver might assume many roles at the end of life: the Swooper, the Know-It-All, the Call-Me-If-You-Need-Me sibling, the I-Don’t-Know-Anything-About-Dying-Elders family member … All the family roles are intensified. Folks who have a personal need to make amends come crashing in. The Golden Child comes back for a weekend and questions everything that’s been done.

Renaud-Cogswell shared her experience in Take My Hand: “Mom was diagnosed with lymphoma a week and a half ago. The hospice team began coming to care for her at our house shortly thereafter. Brother wants to take mom to lunch. Incredulous, I tell him she is sick, she has lymphoma, and that he could bring lunch here. He brings lunch. He doesn’t, however, bring lunch for me. Not something I should be overly surprised by, but I am hurt nonetheless. Then brother asks Mom if she would like to move into his empty townhouse. (Alone.) Then he and his girlfriend begin telling her all the positives about moving in there. I say, ‘She’s sick. She needs 24-hour care.’ Brother says, ‘Since I kicked my renters out, I need the money.’

“Loudly enough for them to hear, but soft enough so that Mom doesn’t, I hiss, ‘She’s dying!’ Then what do you suppose this brother asks our mother? ‘Can I borrow $500?’ (Who asks their dying mother for money???) And do you know what? She gives it to him! This was yesterday. I ran from the minute my feet hit the floor in the morning till my head hit the pillow at midnight last night. I need to sit down and have a good cry, but today, I’m afraid, will be just as busy.”

There are additional complications that must be addressed when “helpers” come. For caregivers, it is a frustrating and delicate struggle between wanting support and allowing helpers to make mistakes while visiting. The strain of feeling that no one else can do the caregiving correctly is immense. Caregivers should establish safety rules that are nonnegotiable — for example, the parent cannot go out without oxygen, medications must be administered on time, hospice will be called if the elder falls.

Grief counselor David Maes created a template (see below) that can be used when conflict arises between family members. The template helps ensure that during a family meeting, the identified patient remains the center of attention. Family members respond to prompts written in the appropriate boxes. Other concerns are written outside the square in list format.

Start by asking the existential questions (the upper left-hand box): What is meaningful for the patient? Before the illness, what was the person’s worldview? How did he or she move through life? What was the essence of who they were? Next, move to the upper right-hand box, which deals with patient preferences. Ask what the person likes related to music, food, art, reading, nature, hobbies, etc.

The lower left-hand box deals with the illness: How is the diagnosis and prognosis affecting the loved one’s personality, behavior, likes and worldview? What gets in the way of who they are? Finally, list the resources: How is the family going to work together? What’s the plan of care? Who is responsible for what?

Counselors might need to remind family members that past relationship dynamics should have little bearing on the here-and-now focus of the discussion. The question to ask is, “Whose death is this anyway?”

Another protocol, from Susan Silk and Barry Goldman, is called Ring Theory (see tinyurl.com/RingTheory). In this exercise, the center circle is the patient, the subsequent circle is the primary caregiver and concentric circles can identify others who are less involved with daily care. The idea is that only comfort can go inward while the difficult emotions go outward. Family members and friends can offer unconditional love to each inner circle while finding their own support and a place to vent in extending circles. Each family member may find their own rings of support.

If end-of-life care is an area you are considering as a professional counselor, begin by learning about grief and bereavement. Alan Wolfelt’s comprehensive books are available through the Center for Loss & Life Transition (centerforloss.com). The Hospice Foundation of America also offers excellent webinars and books (hospicefoundation.org). There may be local support groups for caregivers in your area, and we should also be able to direct clients to resources such as the Alzheimer’s Association (alz.org) and AARP (aarp.org).

Competency in serving caregivers and families at the end of life involves a combination of approaches. We should be able to provide psychoeducation on dying and the needs of the dying. We should be competent listeners, validating and normalizing their experiences while encouraging life review and memory making. We can offer facilitation for family discussions. We can help our clients with boundaries, rituals and support groups. Finally, we can encourage the caregiver to engage in self-care, including therapy.

 

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Tia Amdurer is a licensed professional counselor and national certified counselor with a private practice, Heartfelt Healing Counseling, in Lakewood, Colorado, that specializes in grief, loss, life transitions and trauma. She is the author of Take My Hand: The Caregiver’s Journey, which was published last year (TakeMyHandJourney.com). Contact her at tiaamdurer@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.

Counseling Connoisseur: Children and grief

By Cheryl Fisher November 13, 2018

Nicolas was just under 3 years old when he attended his grandfather’s funeral. He wandered through the sea of adults, holding tight to his mommy and daddy’s hands as he made his way to the front of the line where his grandfather lay peacefully in the casket. His grandmother picked him up as he tried to climb into the casket. “Sleeping?” he asked his grandmother. “No, sweetheart. Your grandfather died.” Nicolas paused looking at the man in the box and back at his grandmother, “Sleeping?” he tried again. “No, he has died. He is not sleeping”, the grandmother replied softly. Nicolas looked around and attempted to contort his face — mimicking the adults around him. “They are sad, honey. When someone dies, we can feel sad,” his grandmother attempted to explain. Nicolas just watched, trying to imitate the adults around him as the man in the box continued to sleep.

 

According to William Worden, psychologist and grief expert, all children grieve regardless of age and stage of development. However, each stage provides a different understanding of death and loss. Grief can be experienced in a variety of ways. A child may experience a physical manifestation such as shock, or somatic ailments. They may feel anxious, angry, depressed or withdrawn. The children may act out behaviorally, resulting in biting or hitting. Additionally, there are critical periods where adverse experiences impact the neurological development of children in more critical ways. Having an understanding of how developmental stages affect the manifestation of grief can help counselors provide more effective support for children who have experienced a loss.

Infants and preschoolers: Infants and preschool age children experience life through their senses. Object permanence doesn’t become established until approximately 28 months. Therefore, children at this age may experience grief as the annihilation of existence: now you see me, now you don’t. Challenges resulting from loss at this age include a desire to connect to others but not knowing how, which may cause either clingy or standoffish behavior. A child may also exhibit a decrease in impulse control and tolerance, an increase in uninhibited behavior and poor emotional regulation, and possibly difficulty with toilet training. This is a critical period, neurologically. Neurons that fire together, wire together. Therefore, losses at this age have a higher chance of impacting children in significant ways.

School-age children: As children continue in their development, they are able to recognize attachment relationships, and they may experience loss as abandonment. School-age children may become preoccupied with death, which may become demonized during this stage, and children may experience anxiety related to the idea of mutilation. For example, children in this age group may talk of “blood and guts” and the Grim Reaper when referring to death. Children during this age are capable of conceptualizing loss as permanent and experience magical thinking. Grief may manifest as hyperactivity, emotional eating and/or somatic complaints. Children may withdraw or become argumentative and demanding. They may have difficulty concentrating and demonstrate a decrease in academic performance. Additionally, they may identify with the deceased by exhibiting similar behavior or experiencing symptoms of a loved one’s terminal illness. For example, Tony, an 8-year-old client came to me experiencing pain in his chest. A full pediatric work-up did not find a physiological etiology to his discomfort. However, in his intake, Tony stated that his grandfather had just died. When I asked his parents about Tony’s grandfather’s death, they indicated that he had died of lung cancer. Tony’s chest pain appeared to be a somatic manifestation connected to his grandfather, and after a few months in play therapy, Tony was able to work through his grief in a way that allowed him to find other ways to remember his grandfather.

Adolescents: Adolescents are capable of abstract thinking and struggle with the concepts of being versus non-being. While teens may feel immortal, they have increased awareness of the permanence of death. They may begin to think about death in terms of their own mortality. Teens may have experienced a variety of losses by now, and are better able to differentiate between types. The death of a distant elderly relative may feel different than the loss of a close friend.

Grief may manifest in a variety of ways including survivor’s guilt, a reduced sense of spontaneity, self-medicating (food, drugs, sex, etc.), social isolation and cyber mourning. Thanatechnology, or the use of media and technology to mourn, may be a way to seek comfort and connection through mourning sites, grief blogs and music playlists. However, it may also be a venue to glamorize loss in an unhealthy manner.

For example, I was working with a 16-year old girl who was devastated by the sudden death of her classmate by drug overdose. In addition to experiencing survivor’s guilt, she began engaging in high-risk behavior such as getting intoxicated at parties and offering sexual favors. This was a complicated situation as the client was not only grieving her classmate but also struggling with her own identity and self-worth. “Why should I live and she die?” We used an online memorial site to create a digital scrapbook of her friend’s favorite music, poems and pictures of special places they had gone together. I watched my client (and, with her permission, the memorial they had created) carefully. I started to get concerned as it remained a dark space for several months with little construction of hopeful meaning in sight. One day while the client was lamenting this loss, I asked, “Where would you have liked to go with your friend?” This led to a discussion about how the client and her friend had talked about hiking the Appalachian Trail when they graduated from high school. I grinned and said, “What a lovely tribute to your friendship to keep that promise.” By the next session, she had begun adding pictures and maps of the Appalachian Trail, marking the route she planned to take in a post-graduation trip to honor her friend.

 

Grief Work

It’s important to acknowledge that the deaths of family members or friends are not the only losses which can cause grief in children. For example, the death of a beloved pet, the divorce or separation of parents or a move to another school are all events that can evoke a significant sense of loss. It is vital to honor and understand these losses and ensure that children are allowed to express the accompanying grief.

Recognizing the varied symptoms of grief in children is essential as it may be masked in a variety of behaviors resulting in misdiagnosis and treatment. Even the most well-intentioned clinician or educator may misread and pathologize a child’s lack of concentration, fidgeting and restless behavior. This was the case for 5-year-old Andrew whose grandmother died suddenly from a heart attack. Andrew was very close to his grandmother, and even though his parents provided him with age-appropriate information around her death, Andrew began eliciting restless and inattentive behavior at school. Even though [his teacher was] aware of the death, notes were still sent home daily indicating that Andrew was disruptive in class. On the last day of the week, and the day before Andrew’s grandmother’s memorial service, the teacher’s note read, “Andrew is exhibiting signs of ADHD.” Andrew had not previously experienced difficulty in class. This is an example of a misdiagnosis. Andrew did not need medication or treatment for attention deficit hyperactive disorder (ADHD), but support during his grieving process.

After all, the goal of grief work, according to Worden, is to emotionally relocate the deceased loved one in a way that allows the child to move forward. In this way, children discover ways to remember the loved one in a healthy way. This involves helping children create connection to self, to others and to the sacred.

 

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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.

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

  • The upcoming ACA 2018 Conference & Expo in Atlanta includes an education session titled “Compassion and Self-compassion: Therapeutic Approaches to Heal From Grief and Loss” (Saturday, April 28, 7:30 a.m.). See the full conference program at counseling.org/conference.
  • For more on the mandate for counselors to practice competent, nonjudgmental care, refer to the 2014 ACA Code of Ethics at counseling.org/knowledge-center/ethics/code-of-ethics-resources. ACA members with specific questions can schedule a free ethics consultation by calling 800-347-6647 ext. 321 or emailing ethics@counseling.org.
  • Interested in networking with other ACA members on this and other related issues? ACA has interest networks that focus on women’s issues, grief and bereavement, sexual wellness and other topics. Find out more at counseling.org/aca-community/aca-groups/interest-networks.

 

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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.

 

Pain to purpose

By Kelly D. Farley May 5, 2017

Burying a child is not something that most people think about — until they must do it. I’ve done it twice, and I must say, I really do not know how I survived it. It has been more than 10 years, and I still do not truly comprehend the impact these events have had on my life.

It took me a while after the death of my children to realize that I needed help and that asking for help was not a sign of weakness. I reached a point where if I had any hope of surviving these losses, I needed to learn how to surrender. That meant I had to allow myself to be transparent and vulnerable — two words I was not comfortable with and did not truly understand.

Because of my lack of familiarity with transparency and vulnerability, the first step for me was acknowledging that I couldn’t do it by myself. I needed help. I had always prided myself on “handing things” on my own.

I will never know the damage I caused myself by not surrendering and asking for help soon after the deaths of my children. I still remember the pep talks I would give myself: “Keep pushing. You’ll get through this.”

But I didn’t, not by myself or by “handling things” my way. The tried-and-true approach to life that I had been taught and was convinced worked “if you only fought hard enough” no longer worked for me.

After 18 months of fighting, I finally threw in the towel and decided to seek help. It was the first time in my life I had considered going to a counselor, and it was only after a friend recommended it to me. I had no idea how a counselor could even help me, but I was finally willing to give it a try. I was desperate for the pain to subside, so I decided to stop fighting and surrender to the process of healing.

I learned many things through the process of working with a counselor. For one thing, I learned that I was dealing with more than just grief and depression. I was also dealing with posttraumatic stress disorder. I also learned that life is about more than just me and my needs. I started to see things from a different perspective and through a new lens. As I started to heal, I realized I had the ability to help others who had lost a child and were following in my footsteps.

I decided to make helping others through the death of a child one of my life missions. It gave me a purpose to pull others along in the aftermath of burying a child. I felt like I knew the way out, and it was my responsibility to go back and help other men find their way out as well.

I decided to do this by writing a book called Grieving Dads: To the Brink and Back. I also decided I would be an advocate and fight for other grieving families when I could. One of the first opportunities I had to do this was in 2011 when I met fellow grieving dad Barry Kluger. After several conversations, we realized there was something wrong with the three to five days of bereavement leave granted to most employees after losing a child. We both agreed that parents who bury a child need more time to comprehend what has happened to them and to their child. These parents’ lives are forever changed, and they need adequate time to start the very difficult path of surviving the loss of a child.

From these conversations, the idea for the Sarah Grace-Farley-Kluger Act (also known as the Parental Bereavement Act of 2017) was conceived. This legislation proposes a change to the Family Medical Leave Act of 1993 and would allow bereaved parents to take up to 12 weeks of unpaid time off after the death of their child without fear of losing their job.

Those of us who have lost a child understand that 12 weeks will not erase the pain that accompanies this loss. But we do believe that it allows bereaved parents the time to start the grieving process and seek the help they need to survive this nightmare.

Our mission is driven by our desire to provide compassion to others in their most vulnerable moments. We understand that we cannot do this on our own. We need help to get this commonsense legislation passed. We invite you to join us in our mission by contacting your representatives and senators and encouraging them to support this legislation. Together as one voice, we will get this done.

 

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To support the need for a Parental Bereavement Leave Act as a way of extending coverage and existing benefits allowed by the Family Medical Leave Act, visit FarleyKluger.com.

 

See the full text of the bill:

House bill: H.R.1560: congress.gov/bill/115th-congress/house-bill/1560/related-bills

Senate bill S.528: congress.gov/bill/115th-congress/senate-bill/528

 

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Kelly D. Farley is the author of Grieving Dads: To the Brink and Back. Visit grievingdads.com to learn more.

 

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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.