Tag Archives: Grief

The Counseling Connoisseur: Pet loss: Lessons in grief

By Cheryl Fisher April 11, 2017

 

“Until one has loved an animal, a part of one’s soul remains unawakened.” — Anatole France

 

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On Jan. 22, following a three-week whirlwind diagnosis and decline, my husband and I said goodbye to our 6.5-year-old goldendoodle, Lily. Her disease had rendered this Frisbee-catching superstar unable to stand or walk. She needed to be carried outdoors to “get busy,” and she no longer had the stamina to stay awake for extended periods of time.

The author, Cheryl Fisher, with her dogs Max and Lily.

We spent the entire last weekend with Lily in the emergency room as she struggled against various gastrointestinal issues and, finally, internal bleeding. Her vet and neurologist felt that the disease had progressed and her prognosis was bleak. It was then that we made the most difficult decision we have ever made — to let her go. We took time lying with her, holding her, reminiscing … and stayed with her until her last heartbeat.

On the first day without our Lily, I kept tripping over my grief as I called out to see if she needed to go outside or wanted to lie by the window and watch “her birds.” Max, our 9-year-old goldendoodle, moped around the house, trying to sniff Lily out without success. He looked at me as if begging, “Bring her back, OK?” I canceled my clients for the day. I couldn’t imagine sitting with their pain as my pain continued streaming from my eyes.

I found myself returning to the little Catholic girl inside of me and lighting a candle next to a picture of our Lily that I had placed on the fireplace mantle. I wrote, announcing our loss to all 210 close friends on social media. I started a scrapbook and printed pictures long held captive in my iPhone. I cried continuously, as if the floodgates had been lifted and years and layers of grief came pouring out. All the losses in my life appeared to be resurrected with Lily’s death. My heart ached and my stomach hurt.

My attempts to prep for my classes that week proved futile. I just couldn’t concentrate. I kept reading the same sentence over and over again. Mostly I was just tired. Tired from three weeks of relentless caregiving, painstakingly attempting to keep the horrific disease at bay — the disease that stripped my beautiful bird-watching, tail-wagging, never-had-a-bad-day rescue pup of her mobility, energy and dignity. In the end those soulful eyes would beg me to end her suffering, and in keeping the promise I had made to her, I mercifully did, holding her till the end.

 

Tips for coping with the loss of a pet

Experiencing the death of a pet can be painful and devastating. Our pets are often our most vulnerable family members, relying on us completely for their care. This includes end-of-life care, which may involve making very difficult decisions about treatment and finally letting go. This adds complexity to grief because we may struggle with questions surrounding the decision to stop treatment and euthanize: Did I do enough? When is it time to let go?

1) Grief comes in waves. Initially the waves may be intense and relentless, pummeling us to the ground. We may feel that we will never breath (or stop crying) again. But with time and some work, the waves gradually recede, allowing us to stand and take tentative strides toward a “new normal.” Still, the waves will come and go, often crashing near a special day or at a moment when our dear fur-family member comes to mind.

2) Grief is brain work. Grief affects our neurology. It makes it difficult to concentrate. We forget things. We are easily irritated. We definitely are not on our A game. We may even feel like we are in a dream (or nightmare). Neurologically, we have taken a hit and require time to recover. Don’t worry. The grief fog will lift eventually. In the meantime, be gentle and kind with yourself.

3) Grief is an ever-changing chameleon. Elisabeth Kübler-Ross identified stages of grief related to dying that can also be applied to our experiences of grief and loss. These stages are no longer thought to happen in a linear manner. Rather, they are common experiences that can occur moment to moment as the result of grief.

Anger: Initially, I felt anger at the sudden deterioration of Lily. She had been running and playing catch just days before her back legs began to buckle under her body. Following an MRI and spinal taps, she was placed on a steroid treatment that quickly led to weight loss and gastric-intestinal discomfort. I was angry at the doctor. I was angry at the disease. I was angry at God.

Guilt: Although I knew I had responded quickly to Lily’s symptoms, I was plagued with self-doubt around the decision to use steroid treatment. Should we have gotten a second opinion? Should we have taken her to a holistic veterinarian? Ultimately, I ruminated over our decision to stop all care and put her to sleep. Was there more that we could have done? It was profoundly clear that the disease had progressed and Lily’s quality of life had suffered drastically, but I still experienced pangs of guilt.

Denial: The first few days were the most grueling. Walking in a daze, I still held some hope that this was all just a nightmare, and as I tripped over Lily’s misplaced toy, I would awaken to find both of our dogs curled at the foot of the bed.

Sadness: It is immensely sad to lose a love one — even a curly headed, wet-nosed, tail-wagging one. I am free with my tears in general, so I just let the emotions stream down my cheeks. Sadness, like grief, looks different for each individual. I am an emotional griever. I emote. My husband is an instrumental griever. He does research on the internet to seek answers. He walks our dog, schedules doggie play dates and arranges activities to help our other dog, Max, with his grief.

Acceptance: Ultimately, the hope is that there will be a sense of peace and understanding at some point and time. This may be experienced in fleeting moments rather than in an arrival at a destination, however.

4) Grief is individual. For me, Lily’s death overshadowed any other event occurring in the world. My Lily had died. Nothing else mattered to me. I crafted my coping strategy selfishly without concern for the feelings or needs of anyone else, including my husband, who had experienced the same loss.

It quickly became apparent that my grieving was more expressive and ritualistic. I made a scrapbook, displayed sympathy cards on the mantle with Lily’s urn, wrote blogs and lit candles in memory of our little rescue. My husband’s grief was more privately experienced, with an occasional shared story and shed tear. It was important not to trip over each other’s grief experience.

5) Grief grows out of a relationship. Some people (and even some therapists) may dismiss the death of a pet as a lesser loss. However, as with any relationship, it is important to understand the meaning ascribed to this relationship. Often a pet serves as a companion who provides unconditional love and affection. Many clients have told me stories of the richness and depth that surrounded their interactions with their pets. For me, Lily was the piece that completed our family puzzle.

 

Conclusion

The death of a pet can be such a huge loss. These fur-family members may serve as faithful friends and playmates, enriching our lives with their magnificent and comical personalities. It is important to honor their story as it intertwines with our own narrative.

I still tear up every time I hear Eva Cassidy’s version of “Somewhere Over the Rainbow.” I imagine my curly white bundle of pure love bounding across a green field to greet me … just around the Rainbow Bridge.

 

 

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland, and a visiting full-time faculty member in the Pastoral Counseling Department at Loyola University Maryland. Her current research examines sexuality and spirituality in young women with advanced breast cancer. She is working on a book titled Homegrown Psychotherapy: Scientifically Based Organic Practicesthat speaks to nature-based wisdom. Contact her 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.

 

Walking with clients through their final days

By Laurie Meyers October 31, 2016

During the time that Kerin Groves spent by her dying client’s hospital bed, she could tell that he felt conflicted. “I sensed he kept hanging on because his adult children were unable to cope with him dying,” she recalls. “The son kept urging him to fight and get better, even though the patient was in his 90s and ready to go.”

When the man’s children left his room for the day, he visibly relaxed. Groves, a licensed professional counselor (LPC), gently pointed out the difference in his tension level.

“[I] let him know it was OK to go whenever he was ready, and I assured him that I would be there to help his son get through it,” Groves says. “He looked right at me, held my gaze for a time and then closed his eyes for the last time. Given permission and support, he was able to go in peace.”

Groves, an American Counseling Association member who has worked with older adults in retirement communities, assisted living, nursing homes and home care settings, is among a select number of counselors who routinely help individuals and their families cope with the process of dying.

Acceptance and denial

Receiving a terminal diagnosis, or having a loved one receive it, is almost too much to comprehend initially, says Mary Jones, an LPC who spent 20 years counseling patients and their families in an oncology center. “People go into shock, and there is an inability to wrap their minds around what they are hearing,” she says.

Loved ones who are in the room when the terminal diagnosis is given often go through a secondary trauma — shock at what they are hearing and concern for their loved one’s feelings, Jones says. In fact, she adds, these loved ones may initially experience more anxiety than the person receiving the diagnosis.

branding-images_final-daysJones counseled patients with varying prognoses, including those who would go on to live long lives after treatment, but in her role, she often saw people at the very end, when they had been told they had only months or weeks to live. “Once they know that treatment isn’t working and there are no more options, it seems like people hit a fork in the road emotionally,” she says.

One path certain patients chose was accepting their impending deaths but also determining to answer a weighty question: What do I do next? In her role as a counselor, Jones would talk to these clients about their legacies — what they wanted to say to or leave behind for their loved ones.

One of her clients was a father with a young son. He made a video that talked about the things he wanted his son to know but wouldn’t be there in person to tell him. The video included subjects such as what the son should know about middle school, about girls and about sex.

The other fork in the path that Jones commonly witnessed was complete denial of the terminal diagnosis. She heard patients make statements such as “This isn’t happening” or “I’m not going to die.”

As a counselor, her role was to try to guide these patients toward acceptance. She acknowledges that the task was difficult. “It so goes against our belief and training and experience [as counselors] to have to say to someone, ‘But your end is near,’” she says.

Jones would sit with these patients and encourage them to talk about their feelings regardless of what they were: fear, anger, sadness, disbelief, etc. After validating what they were feeling, she would circle back around to acceptance and the importance of deciding what they wanted to do or say before they died.

Groves, currently a private practitioner in Denton, Texas, often used existential and person-centered therapy when working with individuals in denial about their impending death. “Person-centered therapy gives the patient the lead in directing the conversation in the way they feel it needs to go, at their own pace,” she says. “We talk about denial openly and how it helps or serves a purpose, as well as how it might work against them. Helping a client make a cost-benefit analysis regarding denial is empowering and respectful of [his or her] needs.”

Of course, it isn’t uncommon for family members to be dealing with denial too. Jones, who would also provide family therapy in her role, says this can create tension between family members and the person who is dying, just when that person needs more support than ever.

Seeking support

Emotional support from family members is important, but the principal source of support for many clients is their husband, wife or partner. If discord is already present in the couple’s relationship, these problems will only be exacerbated by the stress of serious or terminal illness, says ACA member Nicole Stargell, who has used emotionally focused therapy (EFT) with couples facing breast cancer diagnoses. EFT operates on the premise that to feel “attached” (safe and secure) in a relationship, couples must be able to manage and share their emotions, she explains.

When certain people experience conflict or distress, they withdraw — sometimes physically — and don’t want to talk about the problem or issue, Stargell says. Other people are “pursuers,” she continues, and their desire is to talk about what is wrong. Pursuers will actively seek responses from their partners.

Anytime that either partner displays withdrawing or pursuing behaviors, implicit assumptions are being made, says Stargell, an assistant professor of counseling and the field placement and testing coordinator at the University of North Carolina at Pembroke. For instance, partners who withdraw often do so because they perceive themselves not to be strong enough to cope or view themselves as being deficient in some other way. When pursuers try to talk to withdrawers about what is wrong, this just reinforces the withdrawers’ feelings of deficiency, Stargell explains. Meanwhile, pursuers are thinking that withdrawers don’t regard them as being important enough to try to talk things through with them. As a result, both partners end up feeling alone and unsupported, which isn’t good for either individual’s mental or physical health, she says.

Using EFT, Stargell would identify the cycle of misunderstanding that plays out repeatedly between the couple but make it clear that neither partner is to blame. Next she would help the couple start to reframe their interactions by asking them to talk about a conflict and actually say out loud what they were thinking in response to their partner’s behavior.

Stargell would then help the couple see that their reactions had more to do with self-blame than with the other person’s actions. In other words, there was no implicit message attached. She would also have the couple role-play, taking turns presenting a problem and practicing reacting differently to what the other person said or did.

Stargell also works with couples to identify triggers or recurring situations that tend to set off the negative cycles. For instance, in the week following chemotherapy, the partner who is a withdrawer and is undergoing treatment might retreat emotionally, in part because he or she is sick and feels like a failure for not being able to perform his or her normal role, such as being the one who washes the dishes. Because the withdrawing partner is sick, the pursuer doesn’t want to push for interaction. However, Stargell says, it’s not uncommon for the pursuer to feel some anger or resentment about the things the partner with cancer — or the couple together — can no longer do. The withdrawer can typically sense the underlying tension, which makes him or her withdraw even more. Together, Stargell and the couple would talk about what the couple could do differently the next time the withdrawing partner has chemotherapy.

Approaching the end 

There are many ways that counselors can support and assist clients who know that they are dying. “I have helped clients find meaning in their personal [histories] and accept suffering during the dying process by engaging in life review and reminiscence, with both laughter and tears, allowing them to say what they haven’t been allowed to, reconciling unfinished business from the past [and] helping them connect with and share their true feelings with their loved ones,” Groves says. But sometimes, the most significant role is “just sitting with them in silence as a companion,” she adds.

Groves has also helped clients facing death to work through their fears and concerns. These have included issues such as feeling guilt about being ready to die when family members beg them to keep fighting; fear of more pain or agony; weariness from long medical treatments; spiritual doubts or fears; and anger over family conflicts erupting or being exacerbated during the medical crisis.

Jones would sometimes take on a sort of facilitator role with these patients, making sure they received what they wanted or needed in their final weeks or days of life. But counselors can also advocate for patients in other ways, Jones says. Especially toward the end, patients with terminal illnesses can experience a significant amount of pain but may not want to take yet another medication. She recommends that counselors working with this population educate themselves about alternative methods of pain relief and relaxation techniques.

As the end approaches, some individuals find it easier to accept that they are going to die, whereas loved ones often have the opposite reaction, Groves notes. “Curiously, people who are near death may be more calm … because they have accepted their prognosis, while their loved ones struggle with denial and avoidance because they are not ready to let them go,” she says. “When a person dies, the opportunity to make peace with them is over, so at least when the person is still hanging on, the belief or hope that it can be reconciled is still there. They may fear letting that person die with unfinished business still between them but struggle to vocalize those unsaid things because they don’t feel it’s appropriate or acceptable.”

Groves says counselors can also play an important role in preparing family members for what to expect in the dying process. “If hospice is involved, their nursing staff may make an extra effort to help counselors explain to the family what is happening biologically, the signs of impending death and other medical information,” she says. “A counselor can also be of help with active listening, reflecting feelings, normalizing emotional responses, addressing spiritual and existential concerns, and [exuding] warmth. Many people do not know what to do or say, so they do or say nothing at all, leaving the family members stranded in their grief. Counselors are equipped to sit with people in pain and be present with them.”

Groves also believes that being present when a loved one dies can be very healing for family members. “It’s very hard to witness a death and, frankly, most people fear and avoid that experience,” she says. “They are typically afraid they will be overwhelmed with their feelings and be unable to cope. But if one is willing and able to tolerate the discomfort, with the support of the counselor, being with a dying person in their final moments allows one to genuinely embrace the natural process of death and confront its reality, which is important for healthy grieving.”

 

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Related reading: See Counseling Today‘s November cover story, “Grief: Going beyond death and stages

 

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

Letters to the editorct@counseling.org

 

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

 

 

Grief: Going beyond death and stages

By Laurie Meyers October 27, 2016

For many years, mental health practitioners labored under the assumption that grief was a relatively short-lived process that people navigated in an orderly and predictable fashion until they reached “closure” — the point at which the bereaved would move on and put the person they had been grieving in the past. Despite the continued prominence of Elisabeth Kübler-Ross’ “five stages” in the public lexicon, experts now know that grief does not move smoothly and predictably through a series of predetermined stages. In reality, it is a process that follows a different course for each individual.

Furthermore, the experiencing of grief isn’t exclusive to the loss of a loved one through death. As American Counseling Association member Kenneth Doka explains, grief is a reaction to the branding-images_griefloss of anyone or anything an individual is attached to deeply. Although society expects people to grieve the death of a family member, people also mourn events such as the passing of a pet, a divorce or the loss of a job, Doka says.

Licensed mental health counselor Beverly Mustaine, a private practitioner and an associate professor of counseling at Argosy University in Sarasota, Florida, has taught graduate-level courses in loss and grief for 20 years. She notes that she has helped clients cope with grief connected to experiences as varied as moving, losing contact with a friend, retiring and aging.

“Counselors are going to be working with grief and loss really in some regard with every client they see,” asserts Elizabeth Horn, an assistant professor of counseling at Idaho State University’s Meridian Health Science Center.

Doka, Mustaine and Horn agree that counselors who do not work regularly with issues of loss may need to rethink their concepts of grief.

“There’s so much outdated information about how we conceptualize grief and loss,” Horn says. “We’ve gone beyond the idea of ‘stages.’ We really see grief as a unique process for each individual.”

Regardless of the nature of the loss, Horn says she approaches grief work with the same goal in mind: to help clients experience and express their grief in a way that is natural for them.

It’s personal

“People react to loss in all kinds of ways,” says Doka, who has written numerous books on grief and loss, including his latest, Grief Is a Journey: Finding Your Path Through Loss, published earlier this year. Clients grieving a loss may feel sadness, yearning, guilt, anger or loneliness, but some may also feel a certain sense of relief or emancipation, particularly if they had a problematic relationship with the deceased, he explains. Whatever clients are experiencing, it is important for counselors to provide a safe place and to validate their losses, Doka says.

“We [counselors] have to communicate that we’re safe — that other people may not want to hear about this [loss] anymore, but we do,” says Mustaine, a member of ACA.

She likes to use Rogerian methods when helping clients process their grief. “I’m reflecting feelings, repeating, setting up a ‘holding’ environment where it’s OK to say the unsayable or mention the unmentionable, like ‘I hated my father, I’m glad he’s dead,’” she says. In addition to talk therapy, Mustaine often uses nonverbal tools such as sand trays or music to help clients evoke and express their emotions.

Horn, whose research focuses on grief and loss, says it is important for counselors to recognize that people have different coping styles when it comes to processing losses. Some people process loss affectively, which means they tend to express their grief verbally; others are more likely to process the loss cognitively, which means they rely more on thinking than feelings to work through their grief and tend to give expression to their grief through physical activity. In general, men are more likely to use cognitive coping styles and women affective coping styles, Horn says, but she cautions that this is not always the case.

Horn also warns that counselors shouldn’t label either coping style as the “right” way or the “wrong” way to process loss. “Within our field, we frequently have an affective or an emotional bias,” she says. “We are trained to elicit emotion and focus on emotion, and that’s great for people who grieve that way. But sometimes if we have someone who grieves in a more cognitive way, we might say that they are in denial … but that’s how they’re dealing.” She also notes that most people aren’t exclusively affective or cognitive while experiencing grief; instead, they use a mix of both coping styles.

That is one of the reasons that Horn is a proponent of helping clients design rituals, whether they involve holding a memorial ceremony or simply lighting candles in a counselor’s office, that will be meaningful and beneficial to them in processing their grief. Rituals can offer opportunities for both cognitive and affective grieving, she explains. For example, someone who copes cognitively might take charge of making all the practical arrangements, whereas someone with a more affective style might arrange for speakers or even speak himself or herself at the ceremony, Horn says.

The importance of rituals

“The ritual aspect is really important,” Horn explains further, “because frequently we have funerals, and for some folks that’s great for providing an outlet for mourning a loved one. On the other hand, it often happens so soon after [a person’s] death that there’s not a chance to really make it meaningful.”

Rituals can provide a very personal and ongoing way for family and friends to remember the deceased in a meaningful way. Horn shares a ritual that she describes as her favorite.

The son of one of Horn’s friends had died from an overdose. Although his family and friends remembered him with fondness, they felt it was important to also honor his ornery personality, so they developed a ritual based on an actual incident. At one point, the son had been asked to get his younger siblings some food from McDonald’s, but he didn’t want to. The task left him so agitated that when he returned home, he threw a cheeseburger at the wall in a fit of pique. So every year, a group of his family members and friends pick a date to get together, buy cheeseburgers from McDonald’s and throw them against the wall.

Doka tells the story of a good friend who died from amyotrophic lateral sclerosis (ALS). Before the ALS rendered him incapable of physical activity, Doka’s friend — who described himself as “an engineer by vocation but a bluegrass musician by avocation” — played with a band at various outdoors venues, which made the performances dependent on the weather. As a nod to this reality, the band always opened its sets with a song titled “Singing in the Sunshine.” When Doka’s friend was diagnosed with ALS, the band started opening instead with “Singing in the Rain” and telling the audience about their missing band mate. When he died, the band played the song at his memorial service.

Doka believes that when a child or teenager dies, it is important to get his or her friends and classmates involved in the memorial service. For instance, Doka, a Lutheran minister, presided over the funeral of a 13-year-old girl, and her family asked her friends and classmates to help design the service. The friends suggested having her school choir sing at her service. “It let the kids feel involved and was also very powerful for the family,” Doka says.

Children’s friends and classmates are the people who really know them best, says Judy Green, whose work as a private practitioner and school counselor in the Jacksonville, North Carolina, area has focused on grief and loss. She encourages children and adolescents to reach out to the families of friends or classmates who have died to share their memories. In her experience, Green says, families often find this helpful in mourning their child’s death. Both Green and Doka say it can also help the child’s friends and classmates better deal with the death.

Horn says it is important for counselors to talk to their clients about their cultural backgrounds and discuss any rituals that they might find helpful in grieving the loss of a loved one. Some rituals can even affect how clients verbalize their grief, she says. For instance, in certain Native American cultures, a person who has died is believed to be on the “spirit road,” which is an essential journey. Speaking a person’s name after death will take the deceased off the road, Horn notes.

Horn emphasizes that whatever a client’s background, grief is still very individual, so rituals should take whatever form is comfortable for the client. “We are all so very unique in the way that we interact with our culture, ethnicity and personal traditions,” she concludes.

Adjusting to the new normal

Rituals can also help grieving clients move on to what counselors call the “new normal,” a world in which the person, relationship or other object of loss is no longer with them, yet they continue to make a place in their lives for that connection. Counselors can assist clients in coming up with rituals that recognize the progression but also honor the relationship to the loss, Doka says.

As Doka explains, these might include a ritual of continuity, such as lighting a candle on the person’s birthday; a ritual of transition, such as a ceremony for a widow removing her wedding ring; a ritual of reconciliation, in which the client says, “I’m sorry” or “I forgive you”; or a ritual of affirmation, in which the bereaved says, “Thank you.”

“Creating a memory box with mementos from the loved one or creating a figure out of molding clay can be helpful to capture the grief and shift the sadness,” says Barbara Sheehan-Zeidler, a licensed professional counselor in Littleton, Colorado, whose practice specializes in grief and loss. “Sometimes clients write letters, poetry, songs, or draw pictures to their loved ones that they either save or we burn or shred together. Sometimes clients write letters to their future selves as an attempt of encouragement that the future will be different and they will be all right. I have also helped create a ritual, usually around the anniversary of the death, using candles, burning items, shredding old papers or burying artifacts like a time capsule.”

Sheehan-Zeidler encourages clients who desire a longer-lasting remembrance to volunteer or join a group that is connected to their loved one or to create an annual event in honor of the person.

Says Green, “When people realize that their relationship with the deceased did not end when the death occurred, but that the relationship will always be part of them, they will be well on their way to healing from the loss.” At the same time, Green urges counselors to let their clients know that grief isn’t linear. Months or even years after the loss originally happened, they might wake up and hear a song on the radio that reminds them of their loved one. And that experience might trigger a brief wave of grief, she says.

Green says many people do most of their active grieving within the first six to eight months of the loss. But she adds that grief cannot fully be processed until the client has lived at least a year without the loved one and gone through events such as birthdays, anniversaries and any holidays that were significant in their relationship.

Complicated grief

Complicated grief occurs when people become so debilitated by grief that they are unable to return to their daily activities, even after an extended period of time. The symptoms are similar to those of “uncomplicated” grief, but more intense and debilitating, and longer lasting, Green says.

“There is no specific time frame for grief to end,” she adds. “Everyone is different, so our reactions to loss will be unique to every individual. As a general rule, however, people usually work through their grief and can get back to their life tasks within six months of the loss.”

A variety of factors can contribute to the presence of complicated grief, Green says. These include the death of a child, the perception that the death was avoidable, an unhealthy or dependent attachment to the deceased, death following a prolonged illness, a client’s prior history of loss and a lack of social support.

Clients who are experiencing mental health issues at the time of the loss — or have experienced them in the past — are also at greater risk of being confronted with complicated grief, Doka says.

“Each of these factors can result in interrupting [the ability] or prolonging the grieving person’s inability to cope with the death,” Green says.

“Complicated grief can be likened to a wound that will not heal,” she continues. “In addition to emotional problems, a person who is experiencing complicated grief becomes at risk for health-related issues such as lack of adequate sleep, severe depression, suicidal ideation or behavior, substance abuse, suppressed immune system and stress that can lead to heart attacks or strokes.”

As for treating complicated grief in clients? “I have found that group counseling is one of the most healing methods for people suffering from complicated grief,” Green says. “Being able to share with others who have suffered a similar loss lets people know that they are not alone. By sharing a similar loss, people come to realize that there is hope for them even though they might be experiencing deep despair. By sharing experiences with others who have suffered similar losses, people learn that in allowing themselves to experience the pain of their loss, eventually the pain lessens as they learn to adjust to life without the deceased and begin to invest in their future without the loved one present.”

“This does not mean that they lose the connection with their deceased loved one,” Green explains. “Rather, they learn that their emotional connection with the deceased will go on forever; they learn how to embrace that and move on.”

An important consideration is that these groups be made up of people who have experienced the same kinds of losses, Green emphasizes. For example, a group for those who have lost a child, a group for those struggling with the aftermath of a loved one’s completed suicide and a group for those who have lost someone to a sudden and unexpected death.

Green finds group counseling so helpful for these clients that she often recommends they stay or rejoin another group once they have processed, or are well on their way to processing, their grief. “Their experiences can help others and they continue to heal further [themselves],” she says. “In fact, I have had many people ask to rejoin a new group or take training to lead the groups because they have found how therapeutic this modality is.”

She acknowledges that these groups aren’t offered as widely as they need to be. “However, my suggestion is that counselors build a network wherever they are so they know where grieving people might attend such groups,” she says. “First, I [would] begin with hospitals. Many run groups for the families of cancer victims, cancer patients themselves and parents who have lost babies through miscarriage or stillbirth, for example. Another great resource is local funeral homes. Many have a social worker or trained person on the staff who runs such groups, [which are] usually open to anyone, not just those who have used the services of that particular funeral home.”

In addition, cognitive behavior therapy (CBT) can be very beneficial for those who are struggling with complicated grief, Green says. It helps them “think about their situations from different points of view, thus altering how they feel and behave when thinking about the deceased,” she explains. “The structure provided using CBT techniques can help grieving individuals deal with their loss and provide a means to measure how much progress is being made each week.”

Green assigns her clients homework, such as journaling about feelings and memories connected to their loved one or developing lists (e.g., five things the client misses about the deceased). “These activities help clients focus on their relationship with the deceased rather than on the loss itself,” she says. “For example, having them make a list of things they enjoyed sharing with the deceased or writing a goodbye letter to the deceased, which is then shared with the counselor, is both cathartic and healing. This also helps clients begin the process of experiencing the pain of the loss that might otherwise remain unattended to. Stuffing down one’s thoughts and feelings is detrimental, so these activities help gently to bring the thoughts and feelings to the surface where they can be dealt with.”

Counselors should also help grieving clients work through any unfinished business, Green says, such as not having been able to say goodbye to the deceased or feeling guilty about something related to the deceased.

Doka has clients write letters to the deceased or engage in role-play to have conversations with the deceased. He gives the example of a boy who had carried guilt over the death of his father. When the boy and his family visited his father as he lay dying in the hospital, the father would always ask the boy for a hug before he left. The final time that the family visited, the boy didn’t want to give his father a goodbye hug before leaving because he had already hugged him earlier in the visit.

During a counseling session, Doka had the boy role-play with him and apologize to his father. He then asked the boy to move to the “father’s chair” to better imagine what his father might say to him. Doka says that as soon as the boy inhabited his father’s chair, he could imagine his father saying, “That’s what you’ve been worried about, sport?”

The boy realized his father would have been surprised that the incident was such a source of guilt to his son. What happened would not have stood out as a source of hurt for the father or been something that he held against his son.

Sheehan-Zeidler uses a similar method, asking clients to imagine what they would say or want to hear if they could talk to their deceased loved ones. But certain types of death, such as suicides, horrific accidents, murders or even sudden and unexpected losses, can be traumatizing to clients. In such cases, Sheehan-Zeidler has found that the use of eye movement desensitization and reprocessing can be helpful.

All losses can be complicated

A loved one’s death is not the only type of loss that can result in complicated grief. Mustaine once counseled a woman who had been divorced for five years yet still fully expected her ex-husband to return, even though he had remarried and had children with his second wife.

In cases such as these, clients may not even have begun to grieve because they have not identified (or cannot identify) the loss and associated feelings that it engenders. Mustaine doesn’t dive into grief work right away with clients who are experiencing complicated grief. Instead, she focuses on establishing the therapeutic bond and giving the client time to accept the counseling office as a safe space. Later, she asks these clients — such as the woman who couldn’t accept her divorce — how they feel about their loss and starts to tease out any underlying feelings. For instance, “I hear you saying that you have not experienced any anger over your divorce, but a lot of people would feel angry.”

Mustaine waits to see if the client takes her statement as a cue to express anger. If the client doesn’t, Mustaine will circle back and say something such as, “You really don’t feel anger?”

In these instances, it is not uncommon for clients to respond that they don’t feel anything because they are numb, Mustaine says. So she sometimes asks them to imagine what they might feel if they weren’t numb. She then explores the reasons behind their inability to truly express their emotions. “What were you taught about having feelings?” Mustaine asks. “Maybe that it’s not OK to express your feelings?”

“You give them permission to have their defenses,” Mustaine continues, “but broach the idea of emotion: ‘What’s so scary about thinking about even having a feeling?’”

Some clients grew up in environments in which it wasn’t safe to express emotions, Mustaine says, such as having a father who would say, “You don’t have anything to cry about. I’ll give you something to cry about!” In such cases, Mustaine says there might be a need to switch from grief work to traditional psychotherapy.

 

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All of the sources Counseling Today spoke to for this article cautioned that in order for counselors to avoid their own complications, they should engage in their own grief work before working with clients on grief and loss issues.

 

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Additional resources

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

Books, etc. (counseling.org/bookstore)

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

  • “When Grief Becomes Complicated” with Antonietta Corvasce
  • “Remembering Lives: Conversations With the Dying and Bereaved” with John Winslade and Lorraine Hedtke

VISTAS Online articles (counseling.org/continuing-education/vistas)

  • “A Shift in the Conceptual Understanding of Grief: Using Meaning-Oriented Therapies With Bereaved Clients” by Jodi M. Flesner
  • “Current Trends in Grief Counseling” by Elizabeth A. Doughty, Adriana Wissel and Cyndia Glorfield
  • “Frequency and Importance of Grief Counselor Activities” by Darlene Daneker
  • “The Anniversary of the Death of a Loved One” by Rebecca M. Dedmond, Annie K. Smith and Sania Frei-Harper
  • “Understanding Grief and Loss in Children” by Jody J. Fiorini and Jodi A. Mullen

Practice Briefs (counseling.org/knowledge-center/practice-briefs)

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

 

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

Letters to the editorct@counseling.org

 

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

Empty crib, broken heart

By Bethany Bray September 22, 2015

This past summer, Facebook CEO Mark Zuckerberg and his wife, pediatrician Priscilla Chan, announced that they are expecting a baby. This celebrity baby news grabbed headlines for a different reason than most, however. The couple’s announcement included a candid acknowledgment that they had been trying to have a baby for several years and had suffered three miscarriages along the way.

“It’s a lonely experience,” Zuckerberg wrote in a July Facebook post. “Most people don’t discuss miscarriages because you worry your problems will distance you or reflect upon you — as if you’re defective or did something to cause this. So you struggle on your own. … We hope that sharing our Empty-crib-broken-heartexperience will give more people the same hope we felt and will help more people feel comfortable sharing their stories as well.”

Zuckerberg and Chan’s post resonated with millions of people (witness the post’s 1.7 million “likes,” nearly 112,000 comments and 49,000-plus shares as of the end of August) and helped raise the curtain on some painful yet common issues that are rarely talked about openly.

Although many people who face miscarriage and infertility feel alone or isolated, statistics show the circumstances are much more common than people may think. Miscarriage, defined as the loss of a pregnancy before 20 weeks, occurs in 15 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists. The U.S. Centers for Disease Control and Prevention reports that about 12 percent of women ages 15 to 44 have “difficulty getting pregnant or carrying a pregnancy to term,” while an estimated 7.4 million women in that same age bracket have used fertility services.

“Trying to make sense of it all is really, really challenging. The depth of the pain and the challenges you go through are hard to put into words,” says Kristin Douglas, a licensed professional clinical counselor and American Counseling Association member in Kentucky who has personal experience with infertility and multiple miscarriage losses. “You don’t ‘get over’ these kinds of losses. You work through them, but you don’t get over them.”

Mourning what might have been

A person or couple can’t help but think about the future, even if cautiously, after a fertility treatment or positive pregnancy test. Considerations from possible baby names to how the mother might be “showing” by a certain month naturally spring to mind.

“When that is taken away” — either through miscarriage or an unsuccessful fertility treatment — “you’re not grieving the past, you’re grieving what was going to be. You’re grieving the future,” says Valorie Thomas, a licensed marriage and family therapist and licensed mental health counselor in Florida. “With pregnancy loss and infertility, each time it doesn’t happen, you’re grieving … for all the ways you were thinking it was going to be. Helping the client to see that can be eye-opening — acknowledging that it’s real, it’s a loss [and] it’s gut-wrenchingly painful.”

Thomas knows this pain firsthand. She has been pregnant 10 times, but only one — her sixth pregnancy, a now 16-year-old son — was carried full term. Thomas and her husband also have a 7-year-old daughter whom they adopted.

Unlike when other family members, friends or acquaintances die, miscarriage and infertility can leave clients without memories to grieve. Often, people don’t even realize that they have the right to grieve, says Thomas, an ACA member who has a small private practice and is an adjunct professor at Rollins College in Winter Park, Florida. It’s the type of loss “that’s hard to understand,” she says. “You [typically] think of a loss as something that was already here, and you’re grieving it [no longer being here].”

With fertility treatment, she says, “You get the call from the doctors saying, ‘The pregnancy test was negative, we’ll see you next month,’ and they hang up,” leaving the individual or couple reeling with a flood of emotions, from anger and frustration to sadness and embarrassment.

Clients who are struggling with infertility or grieving a miscarriage can present with a range of issues in a counselor’s office. Depression, anxiety and intense stress are very common, Douglas says, as are feelings of guilt, anger, disappointment, frustration and fear. It is also possible for these clients to wrestle with trauma symptoms associated with their loss, she says.

It is not uncommon for couples or individuals to have experienced both infertility and miscarriage. Miscarriage, or “the inability to carry a pregnancy to term,” may be part of the infertility experience, Thomas says. But even when there is no overlap, couples who experience a miscarriage may share some of the same emotional responses as those who are having difficulty conceiving, she says, including a sense of helplessness, desperation and loss of control.

Because miscarriage and infertility can be taboo subjects, clients may not realize that they can — and should — acknowledge a pregnancy loss. For example, Thomas says, perhaps a client feels “down” every autumn but doesn’t know why. It could be that she experienced a miscarriage years or even decades ago during the fall that she never processed.

Professional counselors can provide help and support in a variety of ways to those who have experienced infertility or miscarriage. This might include helping clients work through the pain and stress of disappointment, self-doubt and even family or cultural expectations. It might also encompass encouraging these clients to practice self-care and teaching them coping mechanisms to help them get through the bad days.

Above all, counselors must familiarize themselves with infertility and reproductive issues if they are going to be sensitive and effective helpers for these clients, says Ebru Buluc-Halper, a mental health counseling graduate student at Pace University who runs a support group for couples and individuals going through infertility.

“If [a counselor] doesn’t know what they’re talking about, it’s a huge turnoff,” says Buluc-Halper, an ACA member who led a poster session on multicultural considerations in infertility counseling at ACA’s 2015 Conference & Expo in Orlando, Florida. She has friends “who were very frustrated by [a therapist’s] lack of knowledge and were turned off from therapy because they wanted to be understood. It doesn’t happen to everyone, but it does happen.”

“People want to be heard and want someone to talk to,” says Buluc-Halper, who has personal experience with miscarriage and fertility treatment. “They are deeply in need of empathy and understanding, which they’re not getting from the people around them, sometimes even from their partners.”

Counselors who don’t understand miscarriage and infertility — at the very least possessing a basic knowledge of the processes, terminology and biological factors surrounding these issues — risk reinjuring and alienating clients, agrees Douglas, an assistant professor of counselor education and coordinator of the counseling clinic at Murray State University in Kentucky. People who disclose their miscarriage or infertility struggles are often subject to the well-meaning but hurtful comments and assumptions of others, she says. Among the statements that are common: “If you just relax and de-stress, you’ll get pregnant”; “Just give it time, it will happen”; “At least you weren’t that far along to get attached”; “Maybe you should just adopt”; and “Maybe it’s not in your cards.” Comments such as these are often completely untrue and very upsetting to the receiver, says Douglas, who wrote her doctoral dissertation on miscarriage at the University of Wyoming.

“The last thing a person wants is to talk to a counselor who is going to say some insensitive and hurtful things in response to what that person experienced,” Douglas says. “There is a fear of what a counselor might say. Are they going to say the insensitive things that everyone else says? Things that are so hurtful or that minimize the loss?”

Handle with care

One of the most important things counselors can keep in mind is that no two clients’ experiences are the same, says Courtney Armstrong, an ACA member with a private practice in Chattanooga, Tennessee. Each client will attach a different meaning to what she or he is going through.

“Everyone’s experience with infertility is different. You can’t just make assumptions,” says Armstrong, a licensed professional counselor who accepts client referrals from a fertility clinic in her area. “You have to respect that it’s a process for people to come to terms with their infertility. It’s not something you can help them reason their way out of. You have to treat each person individually because every person is going to respond in a different way.”

Counseling and therapy must also be individualized in cases of miscarriage. Douglas says she finds it much easier to talk about her first miscarriage, which involved triplets, than her second, which was a single baby. “People would never compare the death of a sibling or a parent to that of an uncle or other relative,” Douglas says, “but somehow, [people] just lump all the miscarriages together. Each failed fertility treatment is not the same either.”

There is no one-size-fits-all way to address a client’s infertility or miscarriage in counseling, agrees Thomas. “It’s important that the counselor be aware [of] spirituality and traditions and culture. Your clients are bringing all of that to you,” she says. “You can’t just [use] a cookie-cutter approach.”

Thomas terms miscarriage a “silent sorrow,” saying that the loss typically goes unacknowledged by society. Too often, she says, the message that women who have experienced miscarriage receive is: “Get over it. You’ll be fine. Don’t worry about it.”

“But depending on your spiritual beliefs, depending on what that meant to you at the time, what it signified, what does family mean to you, what does creating a family [mean to you], how bad you wanted it — all those things play into your reaction,” Thomas says.

Paying careful attention to the language the client uses can provide counselors clues about how the person is processing the loss, she says. For example, does the client say, “I was 10 weeks pregnant, and I lost the baby,” or does she use another word? If the client or couple isn’t ready to use the word “baby,” the counselor shouldn’t refer to the pregnancy that way either, Thomas advises.

After going through pregnancy loss and several rounds of in vitro fertilization, Armstrong and her husband made the choice to be child free. Making that conscious decision was empowering, she says. “The choice piece is the really important part — deciding if this is the best and right thing for me,” she explains.

Likewise, Armstrong says, in counseling it can be empowering for clients to find meaning and realize they still have the ability to make choices in an unwanted situation. Wanting to be a parent and wanting to be pregnant are two different things, and helping clients to uncouple those two concepts in their mind can be helpful, she says.

“If they’re going to explore infertility treatment, adoption or other options, is this about having a child or having a child that’s biologically connected to you? The most important thing is that they feel they have the freedom to make a choice,” she says.

Thomas’ experience with infertility caused her to rethink the assumptions she’d held growing up in a Catholic family with nine brothers and sisters. “In my family, it was just assumed we’d all have large families,” she says. “When that didn’t happen for me, I had to revisit [that] and ask myself if I’d be OK if that didn’t happen. Then I came to grips [with the realization] that you can create family in different ways. It was OK that I had other parts of myself to be a whole person. I realized that it may be different for me.”

How to help

Heartbreak can accompany miscarriage and infertility. But so can hope and healing. Here are a few ways counselors can help clients who are processing these experiences.

Storytelling and narrative therapy: Two of the most important things counselors can provide to these clients are a listening ear and empathy. “It’s just so important to listen to their story, really listen to their story,” Thomas says. “Every one of them is so different. Each one has a different journey. Listen compassionately and really be present.”

Douglas recommends inviting clients, but not pressuring them, to talk about their loss experiences, such as where they were and how they felt when they learned they were pregnant, what it was like to be pregnant, what happened during their miscarriage and what feelings they had when they learned their pregnancy was over.

“Just like with other types of trauma, you want to be sensitive to not retraumatize clients by having them share their story over and over again,” she says. “But at the same time, if clients feel it would be healing to share their story, invite them to share it and process it as many times as they feel they need to. It can be healing to remember, to talk it through, to process these things with other people, especially if clients did not feel their loss was acknowledged or if they did not have the opportunity to share their story in full with anyone.”

This hit home for Douglas as she wrote the narrative of her first miscarriage for her doctoral dissertation. It was the first time she had written out the entire story, start to finish, she says. Afterward, she read the four-page narrative aloud to her own counselor in a therapy session. “It was such a powerful moment. I just sobbed and sobbed as I read it,” Douglas says. “It was then that I realized I had shared my story with lots of different people but never the whole thing beginning to end — only parts. That was huge for me. I had a further glimpse into the power of story, the power of vulnerability, the power of giving voice to nebulous experiences and the power of validation. Sharing my story beginning to end was emotional but very healing.”

The empty chair approach: This Gestalt technique can be helpful for processing “unfinished business” — something all too common for those who have had a miscarriage, according to Douglas. Counselors might ask clients to speak to an empty chair as if their child who was miscarried were sitting there. Or use the empty chair to have clients speak to whomever they need to — perhaps a co-worker who made an insensitive comment or a doctor who came across as callous, sterile or impersonal. The empty chair can also provide a means for clients to speak to their deity, even venting frustration or another emotion.

“This can be a way to give the client a voice or provide a degree of closure,” Douglas says. “It not only helps clients work through complex feelings as they process lost hopes, dreams and frustrations, but also helps them have an important, needed voice.”

Journaling and letter writing: Writing a letter can provide clients an outlet to tell their miscarried baby that they miss and love the child. Similarly, clients can write themselves a letter from the baby, Thomas says.

“At some point when they’re ready, have the client write a letter from the baby to the parents. They can say, ‘I’m still here. I love you.’ That’s very healing, but it shouldn’t be done right away,” Thomas warns. “It takes time. [The parents] have to be ready for that.”

Creating a journal can also help clients process a pregnancy loss by encouraging them to explore the loss and what it meant to them, Thomas says. Each experience will be different, whether it is the client’s first miscarriage or third, whether the client already has children at home, whether it was an unplanned pregnancy and so on.

Expressive arts and other creative therapies: Douglas displayed copies of some of the pastel chalk drawings she created as part of her own way of coping with her miscarriage loss when she co-presented a session at the ACA Conference in Charlotte, North Carolina, in 2009.

She advises counselors to pay attention to their clients’ creative interests and incorporate those interests into the therapeutic process, if appropriate. For example, if the client likes to garden, planting a tree in honor of a child who was miscarried might be healing for the client. If the client has a flair for design, perhaps she could design a bracelet with charms that represent the pregnancy. Douglas finds that expressive arts or other creative therapies not only help clients work through challenges associated with their loss, but also assist in making the intangible tangible.

Douglas had one client who enjoyed scrapbooking. Creating scrapbook pages became her version of a journal and helped her find meaning in the miscarriage she had suffered. Scrapbooks or other creative projects can include ultrasound images, hospital bracelets, photos of baby gifts that were received or a narrative written by the client about what it felt like to find out she was pregnant.

“One of the challenges of miscarriage is the intangibility,” Douglas says. “When you have such few items, those ‘artifacts’ such as an ultrasound photo become very important in validating your experience and your loss. You cling to those things.”

Mind-body and wellness approaches: Thomas says mind-body approaches such as yoga, relaxation techniques, meditation, deep breathing, guided imagery and repeated prayer can be helpful to clients who have experienced miscarriage or infertility. In one case, Thomas used guided imagery with a client before her fertility treatment, instructing her to envision that her grandfather, who had passed away, would be with her to support her throughout the procedure.

In addition, encouraging clients to pursue a wellness lifestyle, including eating healthy food, exercising regularly and getting enough sleep, can be helpful, both because of the health benefits provided and because it gives clients a new area of focus. Spending time on healthy cooking, for example, can divert a client’s energy and focus away from frustrated or anxious thoughts. Assure clients that they are working to be “in the best place they can be to ride this roller coaster,” Thomas says. The thought becomes: “I am doing the best I can to make my body healthy so I have a chance of conceiving.”

Encouraging clients in the practice of self-nurturance, such as taking 30 minutes each day to do something they really enjoy, can also help refocus their energy away from the stress of fertility treatments. Thomas instructs clients to think of 10 things that they enjoy doing and that make them happy. Then she asks clients, “How many of these things are you doing? You’re allowed to enjoy things during this time. Look for ways to enjoy yourself.”

Developing signals: Sometimes social situations can be overwhelming for individuals who are going through infertility or who have experienced a miscarriage. Buluc-Halper and Douglas both suggest that counselors have these clients develop a signal to let their partners or trusted friends know when they need to change the subject or take a break during social gatherings.

But clients also need to be realistic about what they can and cannot handle, Buluc-Halper says. “Going through this experience is a good time in your life to put yourself first,” she says. “[When] you’re expected to show up at a dinner or a baby shower and you emotionally, truly, cannot handle it, it’s OK to put yourself first and say, ‘It’s not a good day for me.’ Put yourself in touch with what you’re feeling. You’re in such a fragile state. There are days when you wake up and you know that you can’t go, and others when you are strong enough.”

Externalize the problem: Buluc-Halper suggests that counselors help clients remove the word infertile from their vocabulary. Infertility is not their identity, she explains. “We don’t say, ‘I’m cancer.’ We say, ‘I have cancer,’” she says. “Infertility doesn’t define them. It’s just part of their journey. Finding a way to externalize that does make it easier to go to the dinner, the family gathering, the baby shower, [knowing] this is just part of my journey. Everybody will go through something in their lives, and this [infertility] is one of the things that we just happen to be going through. … Everybody will find some sort of resolution, whatever that may be. As in every experience, there will be a resolution. It might not be the resolution you envision, but you will find some kind of closure.”

The trusted friend: When clients are hesitant to tell family and friends about what they are going through, Buluc-Halper suggests that they pick one person, such as their mother or a favorite sister or cousin, to confide in. Ideally that person should be able to serve as a buffer when awkward or painful subjects or questions are raised at family or social gatherings. In Douglas’ case, she had a trusted friend who would intercept baby shower invitations for her, knowing she wasn’t ready to face such a baby-focused event.

A cultural perspective: A client’s cultural background can play a huge role in how that person views and deals with miscarriage or infertility. At the same time, counselors should never assume that individual clients will experience these issues within the cultural norms of their respective backgrounds, Buluc-Halper says. Doing a cultural genogram with clients can help counselors get a better idea of the role that cultural background plays in a person’s life, she says.

Thomas agrees, noting that she asks clients about their spirituality and family of origin at intake.

“The very, very important part for all counselors to remember when working with infertility clients from a cultural perspective is to be very aware of their own cultural biases,” Buluc-Halper says. “Be cognizant not to distort the couple’s experience based on how you assume that culture perceives infertility in terms of its ideologies, in terms of its experiences or in terms of the resolution. … They might not be experiencing infertility the same way you might expect them to based on their cultural background.”

Taking a break: For clients who are going through fertility treatments, each stage brings a series of decisions and procedures that can be exhausting, Armstrong says. Counselors can offer their clients reassurance that if they decide to take a break from treatments, it doesn’t mean they are giving up,Empty-crib-broken-heart-small she says. “Maybe take a month off, regroup and then go on to the next stage [of fertility treatment]. Tell them, ‘You’re not giving up. You’re just backing off for a minute to get some perspective and come back,’” Armstrong says.

Internet forums: Numerous websites and online forums are available for people going through infertility and reproductive issues. Although these sites provide helpful information and a way to connect with and find support from other people facing similar issues, the sites can also cause clients to spend more time focusing on issues that cause them anxiety, stress or sadness.

In Armstrong’s case, she stopped visiting online forums while she was undergoing in vitro fertilization because they were provoking her anxiety. Although such forums can offer support in many situations, Armstrong found they could also act as a platform to swap “horror stories” or misinformation. “Some people find them very helpful, while others find it makes them feel worse,” she says. “It helps them know that they’re not alone, but there can also be a risk because it can make them more worried.”

If online forums don’t appear to be serving clients’ best interests, counselors can suggest that they take a break and attend in-person support groups instead. Support groups, whether online or in person, can play an integral role in breaking through the isolation that often accompanies experiences of miscarriage and infertility, Buluc-Halper adds.

Grief: Douglas theorizes that women grieve miscarriage loss developmentally. “This is a life that would have been,” she explains, “and you will most likely grieve in different ways and different stages for what that child would have been like [as it aged]” — such as when the child would have started walking and talking or when the child would have started kindergarten. Missed milestones may be extra emotional as time passes. As a result, grief may resurface over and over again, but in different ways, complicating the healing process, Douglas says.

Anniversaries: In cases of miscarriage, multiple dates can be painful, such as the day the couple found out they were expecting, the baby’s due date, the date they lost the pregnancy and so on. Counselors might suggest that clients engage in extra self-care on those anniversaries or commemorate the dates with rituals such as playing a meaningful song, lighting a candle or sending up a helium balloon with a letter inside to their miscarried child, Douglas says.

Control: One of the most difficult aspects of dealing with infertility or miscarriage for clients is accepting that what has happened or is happening is largely out of their control. “A lot of people blame themselves and think, ‘I’m not doing enough or could be doing things differently,’” Armstrong says.

In cases of infertility, some clients will do things to try to take control of the situation, such as cutting gluten out of their diets or taking their temperature daily. Counselors need to be sensitive to the fact that these clients may have devoted a lot of time and energy to finding different methods that might increase their chances of conception, Armstrong says. If the methods are giving them more confidence or security about their situation, that can be good, Armstrong says, but if the methods are only serving to make clients blame themselves further, that can be harmful. “Be mindful and aware of helping clients find what makes sense and what may not be influencing whether or not they get pregnant,” she says.

In cases of miscarriage, Armstrong says she most often points to biology with clients. The human body is designed to abort a pregnancy that could be harmful, she says. “I really try and bring it back [to the fact] that we don’t understand all the reasons why [women miscarry], but it’s purely biological,” she says.

Offering hope: Individuals receive very straightforward — and sometimes upsetting — information from medical doctors about their infertility, including the slim percentage they may have of getting pregnant or the complications that could happen as a result, Thomas says.

On the other side of that coin, a counselor’s focus on the positive can provide clients an antidote to discouragement, she says. “Hope is such a big factor. … Put [clients] back in charge of their life,” she advises. “Offer hope that there are some coping strategies [available and that the client is] a normal person responding to the struggles of creating a family. [Tell them], ‘You need to give yourself permission to be angry and cry. … Keep the faith. If you want a family, it will happen. It may just not be the way you envisioned.’”

Couples: It takes two

Spouses or significant others will naturally deal with miscarriage or infertility in different ways and process things at different rates. In fact, it is common for a counselor to see relationship partners who are in two very different states emotionally, Armstrong says. One partner may have already accepted what has happened, while the other is still in a bargaining stage, thinking, “Surely there is something we can do” to change the situation, Armstrong says.

Counselors can help by educating couples that the grief that accompanies a miscarriage or infertility will come in waves and that each partner is likely to be at a different point along the grief spectrum. Once couples understand that it is natural to feel differently about what they are experiencing, they often express a sense of solace, Armstrong says.

“They’re relieved [because] they don’t see themselves in conflict, just at different stages in the process. Then they can understand and be more patient with each other,” she says. “Help them understand that they’re in different stages and how to communicate and best support each other” wherever they are in the process.

Differences in spirituality level or religious background can threaten to divide a couple during a miscarriage, notes Thomas. For example, one partner may consider a miscarried baby to have a soul, while the other does not.

“Spirituality can be very healing or create a lot of conflict if they’re coming from different perspectives,” Thomas says. “One may feel it’s ridiculous to grieve, while the other feels it’s necessary. Work with them to be respectful of each [other’s perspective].”

It can be helpful for counselors to suggest that a female client bring her partner to medical and therapy appointments when possible, Buluc-Halper says. It is important that the client learn to rely on her partner for support throughout the entire process, not just during times of extreme anxiety, she points out.

“Partners don’t always understand how all-consuming this [infertility] experience is,” Buluc-Halper says. “You’re the one that is doing blood work, and your arm is purple from all the injections. It’s not to diminish the male experience of this, but they don’t always understand why the female can’t really detach herself from the issue.”

As important as empathy is for counselors, it is equally important to teach that skill to couples, Thomas says. She often has couples hold hands as they tell each other what the miscarriage journey has been like for them. The counselor is there to assure both partners that whatever they are feeling is valid, real and quite possibly intense, Thomas says.

“Give them a safe place to explore what this has been like for them — sometimes for the first time,” Thomas says. “What does that loss mean to them? [They are] really seeing each other describe what happened and how they’re feeling right now. Because they grieve differently, it’s important to validate their experience and [explain] that it may trigger some previous losses and intensity that might scare them.”

“With infertility, they can get stuck and not want to move on if they’ve had a pregnancy loss and not really grieved it,” she says. “They need to slow down and experience what they need to experience before they go on to the next step.”

Breaking the silence

By inviting conversations about miscarriage and infertility, counselors can play an important role in removing the stigma and isolation that surround these issues. Douglas cites the example of breast cancer, a once-taboo subject that is now openly talked about and advocated for with well-publicized campaigns and fundraisers.

“Invite the conversation and break the silence,” Douglas says. “Help give women and men permission to grieve miscarriage losses and give voice to those losses. Give them a safe, nonjudgmental place to share their stories. Invite those stories. Take time to listen to those stories over and over again, as many times as people need.”

 

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For more information

  • Valorie Thomas will be presenting two sessions on these topics at the 2016 ACA Conference & Expo in Montréal. Thomas’ sessions are titled “Creating Rituals for Couples Experiencing Early Pregnancy Loss” and “A Mind/Body Approach for Struggling With Infertility.” See counseling.org/conference for session and registration information.
  • Oct. 15 is Pregnancy and Infant Loss Remembrance Day. Visit october15th.com for information and events, such as remembrance walks, listed by state.
  • The National Infertility Association (resolve.org) offers a wealth of information and resources, including online support communities and a hotline, 1-866-NOTALONE.
  • The American Pregnancy Association has resources on infertility and pregnancy loss at its website: americanpregnancy.org
  • An ACA Practice Brief titled “Counseling People Experiencing Infertility,” by Donna M. Gibson and Jennifer M. Gerlach, is available to ACA members on counseling.org. (Practice Briefs are listed at the Center for Counseling Practice, Policy and Research page, which is under the “Knowledge Center” tab on the homepage.)

 

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Bibliotherapy resources for clients and practitioners

  • Jaffe, Janet and Diamond, Martha (2011). Reproductive Trauma: Psychotherapy with Infertility and Pregnancy Loss Clients
  • Kohn, I. and Moffit, P. L. (2000). A silent sorrow: Pregnancy loss: Guidance and support for you and your family. New York: Routledge. Doubleday Dell Publishing Group, Inc.
  • Kushner, H. (1981). When bad things happen to good people. New York: Avon Books.
  • Domar, A. D. and Kelly, A. L. (2004). Conquering infertility: Dr. Alice Domar’s mind/body guide to enhancing fertility and coping with infertility. New York: Penguin Books.
  • Jones, C. F. (2009). Hopeful heart, Peaceful mind: Managing Fertility. Fraser Davis Press.

 

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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 editor: ct@counseling.org

The complicated mourner

By Helen Nieves July 29, 2014

The first time I met Cynthia (not her real name) was in my office. She was in her late 20s and came to me because of a fear of driving. Initially, I believed her case would require cognitive behavioral work, and having received advanced training in rational emotive behavior therapy, I Hand-&-Candle_brandingbegan formulating an outline of how to handle the case in my head. I thought it would be an interesting case in which to apply the techniques that I usually use with clients who come in with some form of anxiety-related problems.

During intake, I inquired about deaths or other losses Cynthia might have experienced. I usually do this when meeting with new clients to gather information and better assess them. Cynthia told me her sister had died. There was a fresh sadness to Cynthia’s mood and affect when she talked about her sister, which made me think the loss was recent. Her sister was two years older than Cynthia and had lived in another state. Before Cynthia had moved, she and her sister were very close, going shopping together, taking road trips and sharing secrets. After Cynthia moved, they still spoke on the phone with each other every day. Cynthia’s sister was her best friend.

As I inquired further, Cynthia told me her sister had died five years ago in a car crash. Her sister was coming home from a party when a drunken driver ran through an intersection and hit her car, turning it over. The driver fled the scene but later was apprehended. Cynthia told me repeatedly that her sister’s car caught on fire, burning her to death. No one knew whether her sister was unconscious when the fire consumed her or conscious and unable to escape the horrible death.

Cynthia didn’t find out about her sister’s death until the following day, after she tried calling her sister, just like she did every other normal day. The call went straight to her sister’s voice mail. Cynthia left numerous messages and waited for her sister to return them. Finally, a couple of hours later, her mother received a call from the hospital where her sister had been taken. The upsetting news was revealed. Cynthia reported to me that she could not believe the news and continued trying to call her sister to leave messages. She told me her family chose not to bury her sister because her body had decomposed from the fire.

As Cynthia continued telling me about her sister’s death, she reported feeling a wave of loneliness every day because she could no longer talk to her sister on the phone. At times, Cynthia even believed that her sister was still alive and continued trying to call her. Cynthia and her mother agreed that nothing should be removed from the room her sister grew up in. Cynthia also reported feeling guilty that she and her family did not hold a funeral for her sister. She acknowledged feeling angry that her sister had died and furious at the drunken driver who had killed her.

At this point, my initial thoughts concerning offering cognitive behavioral treatment for Cynthia’s presenting symptom — her fear of driving — were replaced by my belief that she was in much greater need of grief work. Given the way Cynthia described her feelings and talked about her sister and her death, I realized this was not a case of normal grieving. Rather, Cynthia was experiencing symptoms of complicated grief.

What is complicated grief?

To understand what complicated grief is, it is first important to understand “normal” grief and the tasks a grieving person should address to adapt to the loss. J. William Worden is a pioneer in the hospice movement in the United States. He is a founding member of the Association for Death Education and Counseling and has written on topics related to terminal illness, cancer care and bereavement. In the fourth edition of his book Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (2009), he indicates the four tasks a grieving person should address:

1) Accept the loss.

2) Process the pain of grief.

3) Adjust without the deceased.

4) Live effectively in the world by finding a place for the deceased in your emotional life.

In the first task — accept the loss — the mourner should face the reality that the death happened and that the person is not coming back. Some people refuse to believe that the death happened, causing them to live in denial and get stuck in this first task. In the second task — process the pain of grief — people in mourning need to acknowledge and work through their pain. If they fail to do this, they will carry the pain with them throughout their lives, and the pain can manifest into physical symptoms.

In the third task, three areas of adjusting without the deceased need to be addressed: external, internal and spiritual. External adjustment usually develops approximately three to four months after the loss. It involves coming to terms with being alone and assuming responsibility for the different roles previously played by the deceased. This could mean the person takes on the role of being the breadwinner, accountant, gardener, mother, father and so on. With internal adjustment, it is important for the person to adjust to his or her own sense of self. In other words, how has the death affected the person’s self-efficacy? For the mourner, it is important to ask (and answer), “Who am I now?” Spiritual adjustment simply means addressing the adjustments one has made to the world in the absence of the deceased. It involves searching for meaning within these life changes both to make sense of them and to regain a sense of control of life.

The last task is to live effectively in the world by finding a place for the deceased in your emotional life. This means the person in mourning should find ways to remember the deceased without allowing it to get in the way of continuing his or her life.

Complicated mourning has been given many different names, including unresolved grief, chronic grief and delayed grief. Whatever name you choose, complicated grief is, as described by Worden, when a “person is overwhelmed, resorts to maladaptive behavior or remains interminably in the state of grief without progression of the mourning process toward completion.” In other words, something is impeding the mourning process, and a good adaptation to the loss is negatively affected.

The table below shows the diagnostic criteria for complicated grief as proposed by Katherine Shear, Naomi Simon, Melanie Wall and colleagues in a study published in February 2011 in the journal Depression and Anxiety. The table shows the distress that Cynthia was experiencing at the start of her treatment. The diagnostic criteria are strong enough to produce continuing separation distress. In other words, the symptoms presented are associated with impairment, similar to other psychiatric diagnoses. Cynthia was experiencing impairment in her social and occupational life. She remained in a state of grief, with a healthy, normal progression through the mourning process being impeded.

 

p55 chart

[CLICK ON TABLE TO SEE IN FULL SIZE.]
Table adapted from “Complicated grief and related bereavement issues for DSM-5” in “Depression and Anxiety,” February 2011.

It was clear to me, having completed advanced training in grief counseling and based on the information Cynthia provided in session, that she was experiencing complicated grief. Complicated grief encompasses difficulties in acknowledging the death on a social, emotional or cognitive level. During our initial therapy session, Cynthia and I explored the lack of resolution to her loss and its relationship to her fear of driving. I explained to her the four tasks of grieving and how she had not processed through the grief work.

For instance, in task one, the mourner must face the reality that the death occurred and that the deceased will not come back. There were instances when Cynthia could not emotionally accept her sister’s death. She continued to call her sister, believing that her sister would return her call. For Cynthia, the loss of her sister was debilitating and didn’t improve over time. Her emotions were so painful, long-lasting and severe that she had trouble accepting the loss and resuming her life. She refused to acknowledge the loss in order not to grieve. Denial kept her from admitting the loss.

In task two, the person needs to acknowledge and work through the pain of the loss. Cynthia did not acknowledge her sister’s death and thus did not process the associated pain. This resulted in her pain manifesting into anxiety and fear of driving. She reported in our sessions that her fear of driving started about a year after the death of her sister. Cynthia’s heightened symptoms of trembling, choking, dizziness and fear of dying prevented her from continuing to drive.

In task three, Cynthia had a hard time adjusting without her deceased sister. As mentioned previously, her sister had been her best friend, and they had done almost everything together. Cynthia continued trying to call her sister despite knowing her sister had died because the thought of being alone terrified her. The death caused disruption in Cynthia’s social functioning. She refrained from engaging in activities by herself. In addition, she often avoided going out and interacting with peers because being around friends no longer meant anything to her. She made radical changes to her lifestyle following her sister’s death, including excluding her friends and avoiding many of her former activities. Likewise, Cynthia couldn’t function optimally at work and couldn’t trust anyone in the same way she had trusted her sister. She felt lonely and empty and believed that life without her sister was difficult.

Internally, Cynthia did not know who she was anymore. She felt she had lost part of herself when her sister died. Although she denied suicidal ideation, she mentioned that she wanted to be with her sister and missed her terribly. Cynthia said she did not consider suicide because she kept wishing for her sister to be alive rather than experiencing death herself to see her sister again.

Spiritually, Cynthia could not regain control of her life. Prior to her sister’s death, Cynthia had her life in order. She had many friends, socialized, held a great-paying job and wasn’t afraid to drive. After her sister’s death, she lost that sense of control and could no longer find meaning in the things she once enjoyed.

Task four was difficult for Cynthia to process. She could not find an appropriate place in her emotional life for her sister’s death without it interfering with her ability to live her life effectively.

Interventions used with Cynthia

In this case with Cynthia, I had to use different techniques to help her process through normal grief. I first introduced her to normal grief and complicated grief. I described the model of adaptive coping, the building of a satisfying life and her adjustment to the loss. We also discussed her personal life goals, which were to drive again without fearing she would die, to rebuild her social networks and to be successful in her career like she had been before her sister’s accident. We worked on each of the four tasks of grieving until we both felt she was ready to proceed to the next task.

In the beginning of our treatment, I invited Cynthia to have a supportive person attend the therapy session with her. Cynthia chose her mother, with whom she stated she had a close relationship. The reason I did this was to restore Cynthia’s connection with others, because with complicated grief, individuals often lose that sense of connection. In addition, attending one of our sessions allowed Cynthia’s mother to better understand what Cynthia was going through and helped her to provide support throughout Cynthia’s treatment. I provided her mother with an overview of complicated grief and its treatment.

A couple of sessions later, I asked Cynthia to visualize when she became aware of her sister’s death and to recount the story into a tape recorder. I had her tell the story repeatedly and then listen to tapes of the recitation. This was done to introduce her to imaginal revisiting. It was also a way for her to process the death on an emotional level and integrate her emotions with the reality that her sister has died. I then debriefed with her, having her describe what she felt as she told the story of her sister’s death. I also instructed her to listen to the tape every day between sessions.

Other elements that I used throughout the treatment included a grief monitoring diary. I use this diary with clients whose social and occupational functioning is compromised due to the death. I instructed Cynthia to monitor her grief intensity throughout the day (0 = no grief, while 10 = the most intense grief) and the associated situations. We discussed the diary in sessions, exploring both her positive and negative emotions. Discussing her grief levels helped to bring the treatment into her daily life. When exploring her grief levels, Cynthia often confused her feelings of grief with her feeling of anxiety. I helped her to discriminate between her emotions and to work with them differently. We worked on resolving her feelings of guilt, anger and anxiety.

At the start of our treatment, Cynthia mentioned she felt depressed. She had feelings of hopelessness that she would never recover and regain control of her life. This made it difficult for her to come to terms with the loss of her sister and find fulfillment in her own life. In addition to using imaginal exposure and the grief monitoring diary, I asked Cynthia to think about her personal goals and activities to help reawaken her joy and meaning in life. This was a form of restoration work in which I told her to reward herself with pleasant activities each time that she found an assignment distressing but was willing to try it anyway. The purpose was to help her move toward a goal so she could begin visualizing a satisfying life without her sister.

I also felt it would be helpful for Cynthia to talk about pleasant memories and positive characteristics of her sister. I invited her to bring photographs and other mementos to the sessions. I encouraged her to share those happy memories and to hold imaginary conversations with her sister under my guidance. I often use this empty chair technique in my sessions with clients who are experiencing some form of trauma or grief. This experience proved meaningful for Cynthia and helped her gain the closure she needed.

Final thoughts

If I hadn’t inquired about possible losses and deaths during intake, I wouldn’t have known that Cynthia experienced a loss. I would have continued to treat her fear of driving without getting to the core of the problem. Cynthia wouldn’t have processed her grief in a healthy way, and she would have continued living her life with sadness, isolation and anxiety.

Instead, because we focused on the real issue, Cynthia made progress by the end of treatment, no longer meeting the criteria for complicated grief. Although she occasionally experienced moments of sadness, they were neither debilitating nor prolonged. She had stopped feeling guilty and angry and no longer avoided looking at pictures of her sister. She started driving again without the fear that she might die and forged closer relationships with her friends.

Termination with me was an easy process for Cynthia. She expressed gratitude and, although some of the exercises had been hard for her, she was able to acknowledge that they helped her to reduce the pain she had experienced for so many years. She mentioned that she was doing much better and no longer needed counseling services.

Grief is a condition that we all will experience. As counselors, our job is to diagnose and treat mental and emotional disorders. However, some of these disorders may be intertwined with grief. I believe it is important for counselors to pay close attention to what our clients are discussing in session as well as what their presenting symptoms are because there may be other complications that remain unspoken unless we ask. I also think counselors must make it a priority to educate themselves in grief counseling in order to give proper treatment to our clients.

 

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Helen Nieves is a licensed mental health counselor and certified attention deficit consultant specialist who works in her private practice and at an outpatient mental health clinic in New York. She is on the advisory board at the American Institute of Health Care Professionals. Contact her at hnieves.lmhc@gmail.com or visit counselingadhd.com.

 

Letters to the editor: ct@counseling.org