Tag Archives: Grief and Loss

Untangling trauma and grief after loss

By Lindsey Phillips May 4, 2021

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

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

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

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

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

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

Identifying traumatic grief 

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

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

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

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

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

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

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

A new layer of loss

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

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

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

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

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

Grief is personal

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

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

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

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

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

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

Unspoken words 

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

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

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

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

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

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

Processing the trauma 

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

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

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

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

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

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

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

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

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

Creating new meanings 

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

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

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

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

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

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

Finding a way forward 

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

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

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

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

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

 

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

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

Gone but not missed: When grief is complex

By Bethany Bray January 27, 2021

The aphorism “do not speak ill of the dead” is attributed to the philosopher Chilon of Sparta. First written in Greek and later popularized in Latin, De mortuis nihil nisi bonum, the phrase perpetuates a social taboo against criticizing someone who has died.

Centuries after it was first uttered, clients in counseling may still hesitate to “speak ill” of someone in their life who has died. It’s natural, however, for human grief to involve a range of thoughts and feelings — not all of which will frame the deceased in a positive light. This is all the more true when the person who died had an abusive, rocky, strained, unsupportive, toxic or absent relationship with the client.

“Having conflicted feelings about the deceased happens more often than is discussed,” says Elizabeth Crunk, a licensed graduate professional counselor who specializes in helping clients with grief and loss at her private practice in Washington, D.C. “There’s a societal expectation that we don’t speak ill of the dead, and I think that sometimes can keep people even from seeking counseling.”

That hesitancy can be compounded when the client is worried about how a counselor might react to their situation. It isn’t uncommon for clients to assume that a practitioner will judge them negatively or expect them to forgive the deceased if they are struggling with mixed feelings about the person’s death, Crunk explains.

“It’s important [for counselors] to validate those coexisting feelings. It is possible to feel both sorrow and joy,” Crunk says. “Also, it’s important to validate [a client’s] feelings of numbness or not feeling sad. Assure them that they don’t necessarily need to conjure up sadness if that’s not genuinely what they feel.”

It’s complicated

The emotions that clients experience in response to the death of a person with whom they had an unhealthy relationship are certainly complicated. However, the term complicated grief is a specific psychological diagnosis (also called prolonged grief disorder) that involves lengthy, extended grief that often is accompanied by intense emotional pain and longing for the deceased, as well as maladaptive behaviors such as disbelief that the person actually died. (For more, see our 2014 article “The complicated mourner.”)

It is possible that clients who have lost someone for whom they have mixed feelings will experience complicated grief. However, Crunk says, the experience is perhaps more likely to fall under the definition of disenfranchised grief — a type of grief that is unsupported or unrecognized by society or culture.

Clients who don’t feel “sad” in the traditional sense about a death may believe that their experience is not socially acceptable. Such mixed feelings can be especially common when the death has a certain stigma attached to it, such as with deaths due to suicide or drug overdose, says Karin Murphy, a licensed professional counselor (LPC) who specializes in grief work at her Doylestown, Pennsylvania, private practice. Counselors who work in the addictions field or with clients whose loved ones battle addiction may hear clients disclose these types of feelings, she notes. Regardless of specialty, counselors may encounter clients using language that minimizes their loss (even when they feel the loss acutely) if they sense any stigma connected to the person’s death.

“It’s really important for counselors not to perpetuate that disenfranchisement. [A client’s grief] is supported, recognized and valid,” Murphy says.

The disenfranchised grief these clients experience “doesn’t allow room for them to express the range of what they’re feeling — especially relief,” adds Crunk, a member of the American Counseling Association and a courtesy assistant professor in the counseling department at George Washington University in Washington, D.C.

Such circumstances can spur conflict even within family networks, Crunk says. One or more family members may have had a good and loving relationship with the deceased, whereas other members of the family may not have. In these cases, family discussions about how, or whether, to memorialize and remember the deceased can be fraught with tension.

The death of a parent, spouse or other person who was abusive, neglectful or invalidating toward a client can result in a grief process that is difficult for others to understand or accept, says Mark Tichon, an LPC who is an associate professor and counseling program director at Lincoln Memorial University in Tennessee.

“The relief that can accompany the passing of an abuser is hard to discuss without seeming callous,” says Tichon, a member of ACA. “In these cases, strong contradictory feelings of longing for a [healthy] relationship and the burden of guilt at the sense of relief may result in a grieving process that is marginalized and not socially validated.”

Related emotions

Clients who seek counseling for a range of issues could be struggling with this type of unprocessed grief without being able to name it or disclose it themselves at intake. Counselor clinicians can listen and watch for a number of emotions that commonly dovetail with struggles over the loss of a person for whom the client had a complicated or unhealthy relationship.

In Murphy’s experience, shame, relief and guilt are most commonly expressed by these clients. Feeling a sense of relief that a person is gone often causes clients to question what that means about them.

“It’s feeling release, but [clients] have a very difficult time naming that. ‘What does that say about me if I’m relieved that this person has died?’ And with that relief comes shame,” Murphy says. Clients may struggle with, “What’s my part in this? What did I do to contribute to this sense of unfinished business? And the would haves, could haves, should haves that come from that.”

In addition, Crunk notes that these clients may express self-blame, anger, numbness or ambivalence over the loss. They may grapple with feeling unsettled or unresolved about certain aspects of their relationship with the deceased. They may feel grief centered not on the loss of the actual person but on the loss of a relationship that never was or of what might have been, Crunk adds.

Murphy urges counselors to remember that complicated feelings can also occur when clients experience nondeath losses, such as a change in someone who is no longer themselves because of dementia, addiction, chronic illness or other conditions. A conflicted relationship does not go away when the person begins to change because of illness, she points out. In fact, clients’ emotions may be exacerbated if they are pushed into a caregiving role.

“Understand that loss may not involve death. Life is really a series of losses, but a lot of times we don’t think about grieving, or giving ourselves permission to grieve, unless there’s been an actual death of a person,” says Murphy, who is certified in thanatology and has past experience as a hospice bereavement coordinator. “A lot of times, we have feelings about things, but we’re not really told or given space to understand that not only is it OK to feel that way, but we might expect to feel that way. That’s where the disconnect happens — feeling too much or too little. And that’s what brings [people] into counseling.”

In session, Crunk begins to explore the client’s feelings surrounding their loss with questions about the relationship the client had with the deceased. She asks the client to describe what life with the person was like. If there is any indication of conflicted feelings on the part of the client, she follows up with more gentle questioning.

“I ask them early on to talk about their relationship with the person [who died]. I try to open the door a little bit for them to share if there is some ambivalence. I don’t want to push that too hard but [simply] open the door. I want to assure them that they don’t have to speak positively all of the time,” Crunk says. “Even with deceased loved ones that we had a good relationship with, there are always aspects that we didn’t like, or things we didn’t agree with. I always try and leave room for that side of the coin.”

“Sometimes what comes up too is that we start our work and the client thinks that they had a pretty positive relationship [with the deceased], but as we begin to dig deeper into the story, other more complicated aspects arise,” adds Crunk, who co-authored a 2017 Journal of Counseling & Development article, “Complicated Grief: An Evolving Theoretical Landscape,” with Laurie A. Burke and E. H. Mike Robinson III.

This was the case with one of Crunk’s clients who grew up with a mother who was abusive. In counseling, the client needed help processing the death of her father. At first, the client identified her father as a protective figure, but as she worked through the loss in counseling, she began to voice feelings of disappointment that her father hadn’t done more to remove her from an abusive situation. At that point, Crunk recalls, their counseling work shifted to processing the client’s newly discovered feelings about her father.

Grief has many layers, but that is especially so for clients who have conflicted feelings, Tichon says. “One thing clients may need to do with a compassionate and humanistic counselor is grieve the loss of having an ideal parent, for which many clients hold hope as they grow older, or grieve the loss of hoped for reconciliation that will never come.”

Tichon once worked with a man who struggled acutely with the loss of what could have been. The client’s father, who had narcissistic personality traits, died “just as their relationship was starting to become more of an adult friendship where [the son] could exert healthy boundaries that allowed him to genuinely enjoy their time together,” Tichon says. The client’s father had died suddenly, so there was no chance to say goodbye or find closure.

“It took a long time for him to reconcile the conflicting emotions of sadness over the death of his father with the feeling of freedom from parental judgment and punitive emotions,” Tichon says. “One key goal of therapy was for this client to resolve feelings of guilt over the relief that his dad was no longer in his life. At the end of our time together, this client was able to say thoughtfully, ‘I still miss him, but I’m also relieved he’s out of my everyday life for good’ with a sense of peace.

“The tension between feelings of loss over what could have been a meaningful adult relationship, anger and resentment over emotional neglect during his childhood and adolescence, and guilt over feelings of relief that the relationship was finally over had resolved to … greater clarity and peace as he became more fully accepting of these intense and contradictory feelings.”

Unwrapping

Grief work should always be tailored to the specific needs of the client, but that becomes especially important with those who are navigating mixed emotions about the deceased. As a counselor who specializes in grief and loss, Crunk may have five clients who are experiencing the same type of loss — the death of a parent, for example. But as Crunk points out, each client will have different aspects of the loss that they struggle with and need to process.

To narrow the focus, Crunk encourages clients to identify what is “most troubling” to them about the loss. If the loss was traumatic or unexpected, that may be the aspect that is most troubling to them, she explains. But for other clients, it could be feelings of guilt or shame surrounding a person’s death.

One of Crunk’s clients was mourning the loss of her grandchild. The client had experienced a troubled upbringing herself, but as an adult, she had endeavored to create healthy and safe family dynamics for her own children and grandchildren. As their work in counseling progressed, it became clear that the client was grieving the loss of her identity as a loving grandparent as much as the death of her grandchild.

“I had assumed that losing her first grandchild was the worst of it. But when I asked her what was the most painful, she said, ‘I worked really hard to cultivate a healthy, stable life, and now I’ll never have that perfect life.’ She had lost that part of her narrative: She no longer had a ‘perfect’ life,” Crunk recalls. “It’s important [for counselors] to put personal assumptions aside. What you assume is the most troubling [aspect] may not be. Let the client dictate, and spend the most time on that.”

Helping clients give voice to the complicated feelings that accompany a loss is among the most important things that a counselor can do, says Tichon, who is scheduled to co-present a session, “Complicated Grief: Treatment Stories and Experiential Exercises,” at ACA’s Virtual Conference Experience in April. Tichon has past experience as a geriatric counselor and would sometimes hear clients express a range of feelings that they had held on to for years regarding a loss.

One client, a woman in her 80s, had lost her husband two decades prior but still harbored resentment because he had been emotionally punitive, controlling and physically abusive early in their marriage. In counseling, she needed to process both the loss of her husband and the pain he had caused her.

“She grew up in an era when people often did not discuss their marital problems outside of the home. At the beginning of addressing this topic in therapy, she had a lot of guilt and shame about ‘talking bad about him,’ as she had some religiosity about needing to honor her husband,” Tichon recalls.

As their counseling work progressed, the client grew in her ability to verbalize her feelings of hurt and sadness and, in turn, process the abuse her husband had perpetrated. Only then was she able to focus on some of the more positive feelings she had toward her husband, Tichon says. As a result, her depressive symptoms lessened, and her life narrative became much more positive.

“He had been dead for 20 years, but her unexpressed resentment had [been] pent up in her all those years. … She made a breakthrough in the process of grief when she was able to voice that although the physical abuse had ended when she was in her 30s, she held contempt and emotional distance [for her husband] through the end of the marriage. At 83 years old, she wound up owning her own part in a bad marriage, and in a faith-based, spiritual way, asked for forgiveness for not accepting his remorse and validating that, in some ways, he was a changed man [while] he was still alive,” Tichon says. “In short, grief needs to happen, and when we allow the depth of the process to work through in what is often long-term therapy, we deeply heal.”

Making meaning

Expressive therapies can be particularly useful in helping clients make meaning of losses that involve mixed feelings. Exercises such as writing a letter to the deceased can be especially helpful when clients feel that things were left unfinished or unhealed in the relationship. However, work should be client led, and interventions must be used only when appropriate.

“Writing a letter to the deceased person — highlighting the happy moments, the resentment, anger and sadness that the relationship caused, and unrealized dreams and hopes — and reading that letter using empty chair work can help integrate these emotions into the personality,” Tichon says. “I find that when using the empty chair technique, if I have the client mindfully visualize the person sitting there, down to remembering mannerisms and clothing of the object of their grief, it makes the experience particularly impactful. I would rule out this depth of visualization, however, if the deceased was particularly abusive. I would not engage the client in this level of visualization of the abuser, as the intervention is significantly deep. In cases like this, venting strong emotions and giving voice to unresolved anger and hurt is, in itself, very cathartic.”

Bernadette Joy Graham, an LPC who specializes in grief and loss at her Maumee, Ohio, private practice, uses a similar technique, prompting clients to use their imagination to create a space where they can visualize meeting the person who died and speak with them to find closure. This can be a real place, such as a room in their childhood home, or a setting that holds meaning for the client. Graham lost her mother when she was a teenager, and she uses this technique herself, imagining a front porch where she can sit down with, see and speak with her mother whenever she feels the need to.

Crunk also uses various correspondence exercises, including letter writing, journaling, the empty chair technique and other imagined dialogue techniques, with her clients. She says this work allows clients to say things they wish they had said while the person was still alive, apologize if they feel that is needed, work through complicated emotions and process unresolved conflict.

“The end goal is about revising their self-narrative and their narrative of the relationship with that person that brings a little more repair and helps things feel a little bit more integrated,” Crunk says. “I use a lot of attachment-informed meaning reconstruction techniques to help them create a coherent grief narrative.”

In sessions, she also looks for nonverbal cues that might indicate that a client needs to explore something further. If a client shows signs of agitation, for example, she’ll ask them to name what they’re feeling.

“If I see tears, I ask, ‘If these tears could talk to you, what would they be saying?’ If they say, ‘I feel a heaviness in my chest when I talk about this person,’ I might ask them to put a hand on their heart, and I might mirror that with my own hand,” Crunk says. “Then, I’ll ask them to describe that heaviness. Does it have a shape? Does it have an image? It’s all with an aim of them being able to tolerate that.”

Crunk is using telebehavioral health with her entire caseload during the coronavirus pandemic and acknowledges that picking up on nonverbal cues from clients can be more challenging. However, she believes that “it’s all the more important to show that I’m present, that I’m there with them, offering a place to cry or feel anger or relief, whatever it is.”

Some grief counseling techniques may need to be adjusted slightly when used with clients who did not have a good relationship with the deceased, Crunk notes. This is the case with empty chair, letter writing and other expressive techniques. The goal of these techniques is not to have clients reimagine their narratives regarding the person — for example, by pretending that the abuse never took place or that the person never lapsed into addictive behaviors. Rather, the goal is to help them reconstruct their narrative of their relationship with that person and, potentially, accommodate any new insights about the person who died or their relationship with that person into their current awareness or schemas. Sometimes, Crunk explains, when “conversing” with the person who died, the client stumbles upon a new insight about that person or their life that helps the client see their relationship with that person from a different perspective — one that can potentially help the client make more sense of their loss or bring them some calm.

These techniques are meant to offer clients a pathway “to revise the relationship in a way that they can carry it with them but that does not put pressure on the client to transform it into something that is unrealistic or fictional,” Crunk explains. “It helps the client imagine a world where there is an opportunity to receive an apology or hear words that they yearned to hear the person say.”

Clients sometimes express doubt about whether the deceased person loved them or struggle with things that went unsaid or undone while the person was alive, Murphy notes. She urges counselors to help clients find creative ways of expressing or completing what was “left undone.” For instance, counselors can leverage anything that a client enjoys as a hobby — writing poetry, painting, making collages — to help them communicate thoughts that are uncomfortable or to explore things that went unfinished between themselves and the deceased.

The simple act of writing down a thought, even if it gets tucked away in a desk drawer or journal, validates what the client is feeling and acknowledges that they are working through it, Murphy says. She sometimes recommends that clients read licensed mental health counselor Stephanie Jose’s book Progressing Through Grief: Guided Exercises to Understand Your Emotions and Recover From Loss, which features journal prompts throughout the text.

“Getting the thoughts and feelings out of your head and having a container for them is going to bring relief. It allows clients to process these feelings but also separate themselves from them and put them in a separate place than their mind,” Murphy says. “There is a common misconception: If I just give it enough time, I’m going to feel better. In reality, it’s time plus what you do that will help.”

In addition to encouraging expressive therapies, Murphy often suggests that clients seek out grief support groups so that they can connect with others going through similar experiences. Doing volunteer work can sometimes help clients address things that they feel they didn’t accomplish with the person who died, she adds. For example, they may not have been able to reconcile with an older relative before that person passed away, but they can forge connections with other older adults by volunteering at a nursing home or similar setting.

Similarly, counselors can help clients create new rituals to mark the passing of someone for whom they have mixed feelings. This can be done privately on their own, or with the practitioner in session. It can involve anything from making a donation to a cause that is important to the client or was important to the deceased, to eating at a restaurant that the client associates with good memories about the deceased.

Tichon agrees that expressive and creative therapies can be particularly helpful with clients who are “stuck” or need to process hurtful feelings regarding a loss. In one technique, Tichon has clients rip off a piece of paper for each emotion or painful memory that they express in session regarding the deceased.

“At the end of this exercise, the client is often in tears and staring at a shredded pile of paper, deeply in tune with the feelings of pain and brokenness. We then process how this piece of paper won’t look like what it did before we started, but we can use it to build something new. And in grief, things won’t be the same [either], but they can be good again,” Tichon says.

Tichon then directs clients to take their shreds of paper home and use them to create something that speaks to their hopes for the future. “This has been a particularly powerful experiential intervention, and clients have brought back art and murals that serve as metaphors for moving forward and building new meaning in life,” he says.

Leaning in

Counselors might find themselves experiencing the urge to comfort clients who are struggling with difficult emotions related to the death of someone who inflicted pain upon them, Crunk notes. While these clients need support, they also need to gradually work through the discomfort they feel regarding the loss.

“Grief, as painful as it is, it’s my belief that it needs to be felt. It can become complicated, but in general, for the vast majority of people, it’s not a disorder. [It’s] an emotion that needs to be felt and honored. I try and create a space for the person to emote and hold that grief [in a] container for them. I don’t want to press too hard, but I encourage them to lean in to it, to be able to expand their tolerance and sit with their grief,” Crunk says. “It’s a delicate balance because, as much as I want to provide comfort, if that’s all that I do, then nothing will change. … We want so badly to help [our clients] and provide support and comfort. It can feel counterintuitive in grief counseling, but sometimes the most helpful thing to do is to help them increase that capacity to feel their grief. As painful as it is, it’s a necessary part of healing.”

That delicate balance involves helping clients access and sit with their feelings of grief and find ways to take respite from their grief, pursue restoration or give themselves permission to feel positive emotions, Crunk adds.

Clients who are struggling with a painful, complicated loss sometimes ask how soon they will feel better or get through it. Making promises to these clients that everything will eventually be fine is not appropriate, Graham asserts. Although it is natural for counselors to want to “fix” these clients, practitioners must push back against that urge, she says.

“Be honest with the client and say, ‘This will never be easy, and you might never have [complete] closure,’” Graham advises. “I give them as much support as possible, but I never say, ‘It’s going to be OK.’ I say, ‘I don’t know how long this will take. Everyone’s different and everyone’s unique. There is commonality in grief, but no two experiences are the same.’”

Murphy acts as a gentle guide for clients as they lean in to their uncomfortable feelings related to grief. “I often tell clients, ‘We’re doing this in bite-size pieces … because it’s too big to do all at once.’ I hear this a lot from my clients: ‘It’s been three months, and no one wants to hear me talk about this [anymore]. Why aren’t I over it?’ A lot of [this] is realizing that grief has no timeline.”

Murphy says clients often need to give themselves the following permission: “I have every right to grieve this. It matters to me, and it’s going to take as long as it takes.”

Instilling self-compassion and focusing on self-talk can make an important difference for clients struggling with disenfranchised grief, she says. “Finding the self-compassion to sit with what you need to allows you to move past it,” Murphy says. “I often hear from clients, ‘If I let myself cry, I’m never going to stop.’ I [say to clients], ‘Let’s test that out. When was a time when you allowed yourself to feel something, and did that last forever?’ It’s a lesson that feelings come and go, but they’re not here to stay.”

Forgiveness and compassion

Clients who harbor feelings that go against cultural norms — such as feeling relief that a family member has died — need a safe space to voice those feelings. Tichon urges counselors to “wear their best Carl Rogers hat” when working with these clients and to remember the principle of unconditional positive regard.

“Allowing the client to experience the full range of conflicting emotions, and providing the depth of a supportive, nurturing and nonjudgmental environment — which the client often has not experienced — can allow deep healing to occur. … Clients may have feelings of longing and sadness, but also betrayal, anger and contempt. It is helpful to extend compassion and allow clients to explore and express the fullness of those conflicting emotions and grieve the loss of the ideal parent, spouse or significant attachment figure who they never had. [This can result] in validation of feelings [that are] contrary to cultural messages on grieving.”

Murphy also emphasizes the need for practitioner compassion with these clients. “Maybe they’ve never had anyone ask them how they’ve felt about the loss. That can go a long way, and it opens the door to get them to talk about it,” Murphy says. “Validation [of the client’s feelings] is the important first step.”

“A big concern [that clients voice] is ‘What’s wrong with me? Why am I feeling this, and why can’t I get over this?’ And the answer is because you’re human,” Murphy continues. “When we’re doing this type of work, the relationship — that therapeutic alliance — is the most important. We can talk about tools, but the most important thing is that the person is feeling heard and acknowledged. … What we [counselors] can bring is to be present during that pain and allow the space [to process it]. That’s what it’s all about: Just being validated is the most important thing, and then figuring out from there what tools are needed, because it’s so individualized.”

Graham says that “empathy goes a long way” with these clients and also stresses the need to keep the work client led. Prior to intake, she explains to clients that the assessment process will take the entire session and that she will be asking about subjects that may stir up difficult feelings. “Don’t assume that they know what assessment is and how it works,” Graham says. “They may not realize that they’re going to have to disclose past trauma, assault” or other painful issues.

A gentle approach on the part of the counselor can prevent clients’ anxiety from spiraling, Graham says, especially if they aren’t familiar with the therapy setting. This can mean the difference between a client returning to counseling or dropping out, she says. “I tell the client, ‘There will be a lot of serious questions that are going to take you back in time. If it gets too emotional, we can stop and take a break,’” says Graham, who previously worked at an inpatient rehabilitation center for clients with substance dependence. Graham also stays mindful during sessions and steers the conversation to lighter topics toward the end, while leaving time for questions from the client. If appropriate, she finishes with a joke to get the client laughing. “They are going to have to go home and function [after session],” Graham says, “[so] I try and close the wound back up a little.”

Another aspect of this work with which counselors must tread lightly is the issue of forgiving the deceased, Crunk says. This too must be client led. Forgiveness is sometimes an outcome of grief counseling, but it should never be imposed by a counselor, she stresses.

“I would never pressure a client or use that type of language unless they bring it up. If, through the work, they find more compassion or empathy toward the person, [that can be a positive outcome], but I just don’t feel that should come from me. It’s not a goal that I would impose on the work,” Crunk says. “There are ways that positive psychology can lead to growth and positive outcomes, but we also have to be careful how we use them. Clients can react, understandably, negatively if they feel their counselor is trying to get them to find beauty in their grief or goodness in their relationship. We have to be careful that it doesn’t feel forced [by] us.”

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Grief and doing your own work

Counselors are human, which means that they will experience personal losses throughout their career. Hearing clients talk about the different painful emotions related to the death of a loved one can be triggering for practitioners if they haven’t fully processed their own feelings regarding a loss in their life.

“It’s hard,” acknowledges Karin Murphy, a licensed professional counselor (LPC) with a practice in Doylestown, Pennsylvania. “Counselors have to do their own work [to process loss]. Oftentimes, counselors are not able to talk about it [a client’s grief or loss] because of their own history. It’s an important component of grief counseling: We have to do our own work so we’re able to let that come into the room.”

Ohio LPC Bernadette Joy Graham recently experienced the death of someone close to her, and she stepped away from her counseling practice for a brief time to mourn and process the loss.

“The counselor really has to have themselves rooted with all of their losses,” Graham says. “No matter how well-trained you are as a grief counselor, grief in your own life will be hard.”

As it relates to counselor grief, the 2014 ACA Code of Ethics cautions against practitioner impairment. Professional counselors are called to “monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired.” See more at counseling.org/knowledge-center/ethics, particularly standards C.2.g. and F.5.b.

 

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Action steps for more information

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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 and the COVID-19 pandemic

By Sophia Caudle December 21, 2020

The COVID-19 pandemic has triggered everyone around the world at the same time. The most common feelings people are reporting are fear, anxiety and loneliness, often with no clear pathway to feeling grounded again because of the uncertain nature of the pandemic’s timeline.

Unacknowledged grief is also being triggered for people during the pandemic. For example, a 22-year-old male client has been experiencing flare-ups with his obsessive-compulsive disorder, and his generalized anxiety and sex addiction have been triggered since the beginning of the pandemic. However, after guiding his therapeutic work into his deep, original grief, which he describes as not feeling connected or nurtured by his parents, he is now more effectively understanding and processing his grief, and his symptoms referenced above have drastically reduced. I have seen this pattern with many clients who experience reduced daily triggers after digging deep into their original grief work.

When grief is triggered (especially when we are unaware of our grief being triggered), it can create an intensity attached to the feeling we are currently identifying, because it traces back to our original grief. What I have termed “original grief” is the perceived awareness of our earliest emotional woundings, and when this gets tapped into, whatever we are currently dealing with seems exponentially more severe.

Original grief typically is formed during the first five years of life, when we are most vulnerable to being shaped by life’s circumstances. The foundational emotion attached to the pandemic is grief, and grief — if not acknowledged, felt and addressed — will continue to trigger more easily identifiable emotions such as fear, anxiety, depression, and whatever other feelings and reactions typically present for people in a crisis.

The COVID-19 pandemic is a perfect example of how understanding the different types of grief, especially original grief, can be helpful to us when we experience current daily triggers, because our deep grief awareness can better inform the tools we implement to ground ourselves.

Traditional grief

The most easily identifiable grief that the pandemic is creating for people is traditional grief. Traditional grief is the grief we feel when someone dies. For many of us, traditional grief is the only type of grief of which we are aware. Most of us are aware of acknowledging grief for ourselves or others only in the event of death and dying, and the biggest fear related to COVID-19 is the possibility of getting sick and that either we or a loved one will die.

According to the tracking website Worldometer, as of Dec. 13, more than 305,000 Americans had died from COVID-19, and there have been approximately 1.6 million deaths around the world. When we see the numbers of deaths related to COVID-19 around the globe, it is easy to become overwhelmed by fear and anxiety. It is also easy to think that if we or a loved one contracts COVID-19, death is inevitable.

Ambiguous grief

Another type of grief that is widely prevalent during the time of COVID-19 is what I term “ambiguous grief.” Ambiguous grief is the grief felt when a relationship ends or when we lose a loved one in our life who is still living. Ambiguous grief is also felt when we lose something important to us or when we have the awareness of something important that we never had. According to Pauline Boss, the principal theorist of the concept of ambiguous loss, the grief experienced during ambiguous grief can be ongoing because there is no closure as there is with traditional grief.

During the pandemic, ambiguous grief has certainly been ongoing for many of us. Most of us have lost relationships, lost in-person connections and lost our ability to move around our communities. Most people do not realize that the primary emotion being triggered in them is ambiguous grief, and typically, if we do not know what we are feeling and where it comes from, then we cannot effectively address it. People may believe that they are feeling anxious, scared or lonely when, in reality, their deep grief is being triggered and the felt awareness is anxiety and fear. Also, because there is no real sense of when the pandemic will be over and no sense of a projected closure date, ambiguous grief is constantly present and creating ongoing insecurities for many people.

The pandemic is triggering many types of ambiguous grief. The ambiguous grief I am seeing most often is the grief felt from the loss of daily interactions with others because of physical distancing. This has created a sense of feeling isolated and lonely for so many people. The interactions we are missing can involve either significant relationships or random interactions with people we do not know well at all. For instance, a simple conversation with the checkout person at the grocery store or a simple chat with a stranger in a park can serve as a type of spontaneous connection. For many of us, these interactions are no longer occurring or occurring much less frequently.

Live human interaction is sorely missed during this time, and our brains are noticing the loss of connection. As John Bowlby, the renowned attachment theorist, acknowledged, humans are hard-wired to connect, and the pandemic has removed person-to-person connection for many people. Some people who live alone or who are in other isolating living circumstances have not had a face-to-face conversation or felt a hug from another person in months, and this is tapping into their deepest sense of original grief aloneness.

For instance, my client “Charles” has not left his apartment in over eight months because of his fear of COVID-19 and his other health concerns. Charles lives alone and has not attended in-person Alcoholics Anonymous meetings since the pandemic began. Charles has also not experienced human touch in over eight months, and he describes feeling the effects of that unfortunate reality as “constant loneliness and depression.” Charles is experiencing deep grief around the loss of the ways he used to connect with others in a face-to-face manner.

Another type of ambiguous grief most of us are feeling is sadness around the loss of our “normal” way of living life. We used to be able to leave our homes and grocery shop, go to work, attend school, attend spiritual gatherings and socialize without thinking that our health could be in jeopardy. Now, these ways of living have either been stripped from us, or we must take extra safety precautions to do them at all. So many regular activities have been lost to us since the onset of the pandemic: marriage ceremonies, funerals, graduations, birthday parties, going away celebrations, sporting events, competitions of most kinds, and many types of intimacy.

Most of us took many of life’s daily activities for granted before the pandemic. Now, we are feeling ambiguous grief because much of what we used to do is not possible at this time. We are feeling a loss of our freedom to connect and move about in society.

Physical distancing during COVID-19 has forced us to set up intentional connections with others rather than relying on spontaneous connections if we want to feel emotionally healthy and maintain healthy relationships. Intentional connections during COVID-19 are exactly what they sound like — ways of meeting with others that we discuss and agree upon ahead of time. So, rather than communicating and deciding what fun activity we are going to do, we are actually planning with whom, as well as how, we want to connect in a safe manner.

COVID-19 has forced many people to make decisions about who they want in their inner circle of social connections. People who are being responsible and observing Centers for Disease Control and Prevention recommendations have chosen a short list of friends they can trust to socialize with during this time. Some relationships are blossoming, and some are deteriorating.

Living in isolation is difficult for many people, and not everyone can handle conscious connection for safety purposes. The removal of spontaneous interactions has required many of us to pivot and create new ways of connecting. Zoom, FaceTime, Skype and many other platforms have been used frequently during the pandemic in efforts to connect. Among those who have been able to transition into intentional connection during COVID-19, most are doing fine, but among those who are stuck in their original grief and not knowing how to create intentional connections, many are not doing well. In March, a commentary in QJM: An International Journal of Medicine predicted heightened isolation-related mental health impacts such as depression, anxiety and posttraumatic stress, which have already been identified during the pandemic in China. Furthermore, literature from Jiang Du and colleagues with the Drug Abuse Treatment Department at the Shanghai Mental Health Center suggests that those with substance use disorders and addictions are particularly sensitive to stress and have increased potential for maladaptive coping styles during periods of isolation related to the pandemic. Finally, according to research published by Brad Boserup, Mark McKenney and Adel Elkbuli in The American Journal of Emergency Medicine, relationship issues and domestic violence are trending upward globally following stay-at-home orders, quarantines and social isolation.

As noted, people in addiction recovery may be especially triggered during the pandemic because shelter-in-place regulations require disconnection, and addiction recovery is about learning how to connect. One of the main components of addiction recovery is learning how to have healthy relationships and connect deeply with others. When in-person therapy sessions, in-person group therapy, in-person 12-step meetings, etc., are removed from the recovery plan, it can be difficult for people to pivot and learn connection via teletherapy or video meetings, particularly when connecting was a challenge before the pandemic. Some people in recovery have transitioned nicely to video meetings, but for those who have not, recovery may be at a standstill, or they may be at greater risk of relapse.

Fortunately, some people in addiction recovery have used the extra time to do more recovery work and more self-care while acknowledging their grief, and this has provided an opportunity for further growth. Grief awareness and the use of recovery tools to intentionally connect are critical to sobriety and recovery. I facilitate two meetings on the global addiction recovery website In The Rooms. One meeting is for codependency, grief and relationships, and attendance at this meeting has doubled during the pandemic. I also created a coronavirus support meeting every Monday on In The Rooms, and for eight months, we have had more than 100 attendees participate. In fact, the entire website has doubled in membership since the pandemic began. People in recovery are trying to find various methods of connection because in-person meetings are not possible at this time.

Original grief

I believe the different types of grief created by the pandemic are also connecting back to people’s original grief and, therefore, increasing the intensity of emotions. As stated previously, I have identified original grief as the grief felt with the perceived awareness of our earliest emotional woundings. I believe that whenever we feel highly activated or charged, our original grief is being tapped into by whatever current trigger is occurring in the moment.

Jaak Panksepp’s research in his text Affective Neuroscience states that grief and social bonding are related together in the mammalian brain. A lack of social bonding, or a feeling of loneliness, is also what we feel when we feel grief. Grief is the experienced and felt loss of a lack of social bonding.

Essentially, all grief is connected not only in our brains, but also in our feelings and in our bodies. A current feeling related to grief, sadness or aloneness is going to track back to our original grief and make today’s feelings more intense or charged. In this way, original grief is being tapped into during the pandemic because at some point, we are feeling fear, anxiety, aloneness or loss. And because the trigger is safety-related and there is a possibility of sickness or death, the depth of the grief is beyond today’s situation; it actually connects back to the deepest and most disturbing grief we have ever experienced. Stated differently, our original grief is being tapped into daily due to the pandemic’s daily triggering of fear, loneliness and uncertainty.

A specific example of how daily triggers can connect back to one’s original grief is in the case of abandonment. During the pandemic, if one is feeling isolated and lonely, and if one’s original grief involves abandonment by parents or other primary attachment figures, then the current feeling of loneliness will connect back to early childhood abandonment, and that feeling will be more intense. This can also be the case if physical or emotional safety is a part of our original grief, because both are being triggered due to COVID-19.

As an example, one of my clients, “Colleen,” experienced abandonment by her father in her early teen years. Her experience was horrid and included lack of food and utilities. In addition, Colleen’s mother was so distraught after Colleen’s father left home that she abandoned Colleen emotionally. So, Colleen has always reported feeling deep aloneness.

During the pandemic, Colleen’s abandonment schema has been triggered again because of the constant isolation. Colleen feels like she has been abandoned and forgotten by the world. In her treatment, we are using this time to dive deep into her original grief, which she reports as, “I do not matter to anyone, not even my parents, who are supposed to love me.”

Treating Collen’s original grief is also soothing her current sadness about feeling alone and forgotten during the pandemic because both are connected in her social bonding neural pathway. Conversely, if we addressed only Colleen’s current feelings about COVID-19 and loneliness, we would not be addressing all that affects her because her original grief would continue to be tapped into. Thus, it would serve as an unknown trigger for her loneliness. In this way, knowing our original grief can be a very empowering process for identifying and treating not only our foundational aloneness, but also the current triggers that we experience as adults.

This unprecedented and difficult time in our world is certainly a trigger for most of us. If we can be aware of some of the deeper feelings underneath, like the various kinds of grief we are experiencing, then we can be more self-aware and take active steps to heal our ultimate trigger of original grief. The deep grief awareness of original grief can empower us to heal not only our foundational pain but also the current triggers introduced by the ongoing pandemic.

 

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Related reading, from Counseling Today columnist Cheryl Fisher: “Counseling Connoisseur: Death and bereavement during COVID-19

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Sophia Caudle is a licensed clinical mental health counselor with three private practices in North Carolina. She specializes in sex addiction, sex therapy, and ambiguous and original grief. She conceptualized ambiguous grief via her work with partners of sex addicts, as partners experience the grief regarding the loss of their partner after learning of the double life of sex addiction. Contact her at sophia@bullcitypsychotherapy.com for more information about ambiguous grief and original grief, or to schedule your High Speed Grief Breakthrough Intensive.

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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: Death and bereavement during COVID-19

By Cheryl Fisher June 2, 2020

“Grief does not change you, Hazel. It reveals you.”
― John Green, The Fault in Our Stars

Sarah pulls her black blouse over her head, trying not to smear her carefully painted makeup. The dark circles have settled beneath her puffy blue eyes, and she dabs another layer of cover up over top. She brushes her hair, overgrown with neglect, the color faded. The roots reveal her 52 years, and she covers them with a spray that is the deceptive color of her youth.

But none of this matters. Her father has died. Alone. Without family nearby. They will now gather to pay tribute to a man who was her everything. A man who taught her how to throw a softball and fish. A man who showed her what to expect in a partner by loving his wife wholly. Her mother grieves from afar. Phone calls, Facetime and Amazon packages bridge the miles–and the social distancing. No, no one will care that Sarah remains in the comfort of her jeans. Not really. No one will notice as she props herself on her couch with her laptop on a pillow and taps the “Start Meeting” button.

Rituals, memorials and funerals provide ways that those who survive a death have the opportunity to grieve. “We know that funerals date to at least 60,000 BC, and every culture and civilization has had funerals ever since,” says grief counselor and educator Alan Wolfelt, in the National Funeral Directors Association’s resource, 8 Talking Points for Funeral Directors, Crematory Staff, Cemeterians, and Other Death-Care Workers. “Funerals help us acknowledge the death, honor the person who died, and support one another. In other words, funerals help us mourn well and set us on a healthy path to healing.”

Wolfelt, who is the director of the Center for Loss and Life Transition in Fort Collins, Colorado, also advises finding ways to be with the body following death. Many funeral homes and crematoriums are finding ways to allow the immediate family to spend time with the deceased. One funeral home has created a particular time where family members can sit with the body one at a time. Another funeral home livestreams time when the family can be with the body.

The novel coronavirus that causes COVID-19 has changed the way we do many things in our daily lives. The need for social distancing has resulted in virtual meetings replacing physical gatherings. Zoom conferencing can be awkward, and online happy hour isn’t as satisfying as hanging out with friends at your neighborhood bar. But, the loss of one particular kind of in-person gathering has been completely devastating: shared mourning rituals. Grief is experienced in the support of community, often with hugs and handshakes. Now, some clergy and rabbis are making house calls, armed with sacred texts, masks and hand sanitizer. But it is not possible for extended groups of mourners to gather together. The final resting rituals that many communities of faith have observed for centuries are significantly altered. For example, during the Jewish mourning tradition of shiva, families, friends and the extended community offer comfort through condolence calls. These condolences are now taking place over the phone and via live streaming. Traditional Catholic funeral masses are now livestreamed with only immediate family present and upholding the six-foot rule. Absent is the physical contact so important in the grief process.

Even gatherings of immediate family and friends are restricted. According to Susan Coale, a clinical social worker and director of the Chesapeake Life Center in Pasadena, Maryland, even if people are able to gather following the death of a loved one, there is a 10-person limit–including the funeral director and any presiding religious figure, such as a priest, reverend, rabbi or imam.

“COVID-19 has complicated individual grief and community grief and loss,” Coale says. Not being able to participate in death and grief rituals can result in the experience of ambiguous loss, which can complicate the grief process leaving numerous loose ends, she explains.

According to family therapist and clinical psychologist Pauline Boss, who coined the phrase, ambiguous loss occurs when there is no closure or there are unanswered questions related to the death of a loved one. This can occur when people cannot be with the body or in community. Therefore, it is important to find ways to help families connect with loved ones. Coale says that some families are attempting to connect with loved ones through window visits or telephone calls at end of life.

People need community support in times of loss. Numerous technological resources have arisen to help fill the gap left by the inability to gather face-to-face. For example, grief support groups such as the Chesapeake Life Center’s Living with Loss are being offered online. The Life Center is affiliated with Hospice of the Chesapeake, but is available to anyone in the community who is grieving, whether or not they are using hospice services.

Thanatechnology sites such as Caring Bridge provide a virtual space to grieve in community. Yet, we must always be mindful of the disparities in both the availability of technology and understanding how to use it. Not everyone can—or wants—to replace in-person grieving with technology.

Coale has begun providing her clients with guided imageries that include detailed descriptions of physical touch. She has clients imagine the specific details of a hug experience. The warmth of arms wrapped around the person. The tickle of arm hair. The scent of the body. The brain responds to imagery in comparable ways as to a real experience and Coale is capitalizing on this phenomena in offering “hug imagery.”

Coping with loss during COVID-19

Grief can be an isolating experience and now, more than ever, it is important to have strategies to stay connected to family and friends. We can still be together while observing physical distance and small group limitations.

Connect

  • Check in with one another by calling, texting or through webcam or social media and don’t forget the virtual hug! This does not require an in-depth conversation. Just a reminder that you are thinking of the person and while they are isolated, they are not alone.
  • Drop off food or groceries while observing physical distancing. Send a care package or shop online to send items. Many restaurants offer curbside takeout and Amazon and Instacart will deliver groceries directly.

Observe virtual rituals

  • Offer or attend virtual group funerals, burials and memorials. It is important to honor the lives of our loved ones and to experience this in community. While we are limited in the number of people who can be gathered physically, we can use technology to host larger gatherings that include friends and extended family members. Photos and memories can be posted on virtual platforms and viewed by many to celebrate the life of the beloved member.
  • Plan an in-person memorial for when physical distancing guidelines are no longer in place. Sometimes the act of creating can be comforting even if the end result is delayed. Plan the memorial in great detail — to be hosted after travel and physical distancing restrictions are lifted.

Seek support and professional help  

  • Bereavement services are available. Many providers are offering their services by phone or webcam. You do not need to soldier this burden alone. There are virtual support groups, as well as individual counseling.
  • Check in with faith communities about online services and support. Faith communities are offering innovative alternatives to traditional worship.

This is a difficult time complicated by the inability to participate in traditional death and grief rituals and activities. Yet, we are a resilient people, capable of innovation as we craft creative ways to connect with one another during times of grief.

“As many challenges as the pandemic presents, it illuminates the hard stuff that causes us to grow…offering us as individuals and communities to do some work,” says Coale.

People are being intentional in how they connect. Some families are re-discovering family time. There are many things to be grateful for during this unprecedented time. People are complex, as well as resilient and we have the capacity to experience both grief and gratitude at the same time.

 

Further reading:

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

Counseling Connoisseur: Children and grief

Grief: Going beyond death and stages

Grieving everyday losses

 

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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.

Voice of Experience: It often comes down to grief

By Gregory K. Moffatt April 20, 2020

Somewhere along the way in our education as counselors, all of us studied great theoreticians such as Erikson, Piaget and Maslow. Their theories provide us with a general understanding of human behavior, and with that information we can develop clinical interventions. In my undergraduate days, I didn’t fully appreciate theory as much as I should have, but the further I traveled into my career as a counselor, the more I realized the importance of theory and how to use it.

But it isn’t just theory that is interesting to me. The insight behind the development of these theories is equally significant. How did these men and women come up with their theories to begin with? Have you ever looked at an invention and thought, “Wow, why didn’t someone think of that sooner?”

It is these potential blind spots that I have always tried to identify throughout the decades of my career. What am I failing to see? What might someone come up with in the future that would leave us wondering, “How did we miss that?”

And that is what brings me to the topic of grief. You’ve probably heard that “depression is really suppressed anger” or something very similar. We know there are often different emotions underlying the ones that we actually see in our clients. I’m convinced that grief is one of those underlying emotions in many cases.

When Elisabeth Kübler-Ross wrote her seminal work On Death and Dying in 1969, she was looking at grief only in the context of personal loss due to death. But later in life, she expanded her view to include other experiences of grief. Infertility, job loss, loss of health, and the death of a pet are among a host of other losses that one might grieve.

I’ve begun to believe that some of the dysfunction we see clinically is actually grief. When I was a very young man, my uncle once said to me that he grew up to “become everything I always hated.” What a sad thing to say. I didn’t realize it then, but I realize now that he was expressing grief to me — the loss of his dreams. He had hoped for one thing but achieved something quite different.

Addictions, affairs, anger and depression — to name a few things — may really be the client’s attempt to manage grief. A client struggling with fidelity in his marriage finally achieved an epiphany in therapy with me when he realized that his unfaithful behaviors had almost nothing to do with sex. Through extramarital relationships, he was seeking a fantasy — the thing he always hoped his marriage would be. In a way, he was in the bargaining stage of Kübler-Ross’ theory. “If I could just redo some choices in life, I would find happiness in a relationship with someone …”

Instead of grieving the loss of what he thought his marriage should have been, he tried to bargain his way through it. These bargains were illusions and, consequently, none of his extramarital relationships satisfied him. Once he was able to grieve the loss of the marriage he had hoped for, he was able to adjust his expectations and achieve a healthier relationship with his wife.

This doesn’t mean that we must settle for unhappiness. On the contrary! With resolution of grief comes peace of mind. Borrowing from yet another theory, perhaps this is akin to Rogers’ idea of the ideal self and the perceived self. No one suggests we stop dreaming of a better self, but there will always be a gap between these two “selves.” It is in the resolution of that disparity where strength of ego develops. Grieving the loss of the ideal can lead to healthier behavior.

In a sense, Erikson said as much regarding the final stages of psychosocial development — generativity versus stagnation and integrity versus despair. These two stages are successful, at least in part, when one has achieved a sense of accomplishment.

If a person can look back on life and find satisfaction with its direction, it provides a sense of “I did good” and allows one to sleep well at night. There is no grieving. On the other hand, looking back and ruing decisions and the direction of one’s life leads one to feel stuck and hopeless. This is grief — the loss of one’s expectations.

I suppose what I’m trying to communicate is that if we can see how grief might be driving our clients’ dysfunctions, then what we should be treating is grief rather than just depression, addiction or other symptoms of grief. We cannot change loss. Facing it and finding ways to cope are the keys to resolution.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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Recently published: See Gregory K. Moffatt’s article in the April issue of Counseling Today: “The need for standardization in suicide risk assessment

 

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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.