Tag Archives: Grief and Loss

Grief and the COVID-19 pandemic

By Sophia Caudle December 21, 2020

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

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

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

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

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

Traditional grief

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

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

Ambiguous grief

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

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

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

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

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

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

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

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

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

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

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

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

Original grief

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

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

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

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

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

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

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

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

 

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

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

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

Counseling Connoisseur: Death and bereavement during COVID-19

By Cheryl Fisher June 2, 2020

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

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

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

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

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

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

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

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

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

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

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

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

Coping with loss during COVID-19

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

Connect

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

Observe virtual rituals

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

Seek support and professional help  

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

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

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

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

 

Further reading:

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

Counseling Connoisseur: Children and grief

Grief: Going beyond death and stages

Grieving everyday losses

 

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Cheryl Fisher

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

 

 

 

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

Voice of Experience: It often comes down to grief

By Gregory K. Moffatt April 20, 2020

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

 

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

Helping clients grow from loss

By Sherry Cormier February 4, 2020

Loss is a universal experience and an underpinning of many therapeutic issues. The client who has just lost a job, the parents whose son is addicted to opioids, the client whose long-term relationship unraveled, and the client who received a devastating health diagnosis all have loss in common.

As a professional counselor and bereavement trauma specialist, I am sensitized to the ways that loss informs clients’ worldviews and emotional struggles. And as a grief survivor, I am aware of the unique ways in which loss can serve as a catalyst for growth. An African proverb captures this sentiment when it says, “Smooth seas do not make for skillful sailors.” But this raises questions: Is growth possible for everyone, and how do counselors help clients grow after a traumatic loss?

Posttraumatic growth: What is it?

Posttraumatic growth (PTG) is an approach that informs our practice as professional counselors. Richard Tedeschi and Lawrence Calhoun, who pioneered much of the research and theory on PTG, define it as positive change that follows the struggle after some kind of traumatic event. PTG represents change that occurs after a life crisis rather than during it. It usually involves longer-term change that occurs over an extended period of months to years as individuals cope with crisis by developing ways of thinking, feeling and behaving that are different from what they relied on prior to the life-changing event.

PTG is not the same as personal development or maturity. It may be thought of as something that occurs somewhat spontaneously as the result of trying to cope with a challenging life experience of seismic impact. Evidence of PTG does not imply that the loss or traumatic event was somehow desired.

Approximately 10% of loss survivors stay mired in grief, guilt and despair for an extended period of time following their loss. Clients who experience these emotions, coupled with an intense yearning for who or what was lost, might be suffering from complicated grief, which requires a particular kind of professional treatment (see complicatedgrief.columbia.edu). The majority of loss survivors do not get stuck in acute grief, however, and report some measure of growth during recovery from loss. For many of these survivors, growth may coexist with distress.

Research summary: What do we know?

In 1996, Tedeschi and Calhoun’s research resulted in the Posttraumatic Growth Inventory, a 21-item self-report measure that yielded five empirically derived markers of PTG:

1) Improved relationships with others

2) Greater appreciation for life

3) New possibilities for one’s life

4) Greater awareness of personal strengths

5) Changes in spirituality

These five markers of growth have been reported by a variety of survivors, including prisoners of war, veterans with posttraumatic stress disorder, people diagnosed with cancer or other life-threatening illnesses, people who became paralyzed from accidents, and those who have lost spouses or life partners. Although much of the research has been conducted with people living in the United States, other studies have explored PTG with individuals in other countries.

Among current findings on PTG, Tedeschi and his co-authors cited the following in their 2018 book Posttraumatic Growth: Theory, Research, and Applications:

  • About 30% to 60% of survivors report some experience of PTG following a difficult life event.
  • PTG is both a process and an outcome.
  • PTG is generally a stable phenomenon over time.
  • PTG is more evident in those individuals who score higher on measures of extraversion and openness to experience and is also related to optimism.
  • There are both universal aspects and culturally specific characteristics of PTG.

Critics of PTG point out that self-reported or perceived growth is not necessarily the same as actual growth. Some of the conflicting findings on PTG seem to be the result of differences in how growth is defined and measured across studies.

Growth-promoting practices with loss survivors

There has been less research about specific interventions and techniques that might facilitate PTG in survivors, although a predominant feature of a growth-oriented therapeutic approach involves working with client stories or narratives. The following practical strategies can be used to help facilitate growth with loss survivors.

Create a safe therapeutic environment. Traumatic loss erodes a sense of security and thrusts survivors into the middle of unfamiliar circumstances. Social support is crucial, yet many people in survivors’ social networks may be uncomfortable with grief or may offer well-intentioned comments that feel offensive to the survivor. Counselors’ first task is to provide a safe container that is comforting and companionable for loss survivors. Creating a therapeutic environment in which we listen closely and hold up a mirror to reflect these clients’ experiences will help loss survivors feel known.

Use self-care practices. Traumatic loss may disrupt the rhythm of survivors’ connections. One way to help loss survivors reestablish bonds with others is to encourage them to grow a new relationship with themselves. We can help clients do this by recommending effective self-care practices such as movement and exercise, adequate sleep, and the intake of nourishing food. In the 2012 book The Emotional Life of Your Brain, Richard Davidson points out that a lack of consistent self-care practices sabotages our ability to regulate our bodies and emotions. Mindfulness and self-compassion are additional self-care practices that can be used by loss survivors who feel emotionally flooded with anger, guilt or anxiety. Teaching self-compassion and mindful meditation to these clients can help them reestablish a connection with themselves and, ultimately, with others. These tools also enhance clients’ equilibrium, making further work toward growth possible.

Explore client narratives. An important part of therapy with loss survivors involves exploring their narratives or stories. PTG occurs most often with clients who create an adaptive narrative in which they are able to see themselves as survivors rather than victims. The following items play integral roles in exploring client narratives.

Timelines: Initially, clients can construct a timeline of their lives with significant events marked at various ages. Timelines provide critical clues about pre- and post-loss stressors as well as the loss event itself. Clients who have been subjected to many pre-loss stressors often have more difficulty discovering growth. Using strength-oriented queries when asking clients to review their timelines is useful. For example, “Juanita, I noticed you had a miscarriage when you were 20. How did you cope with that? What tools did you find that helped you through that loss?”

Clues of growth: Many clients are so affixed to the trauma of the event that it’s hard for them to detect anything positive about their story. Counselors can be most helpful by noting clues of growth and healing in clients.

For example, James, an African American in his mid-20s, is discouraged because he has been through multiple losses. The house he once lived in with his grandmother was recently obliterated by a tornado, and now she is in the hospital with multiple injuries. In addition, the business he started just folded. In recounting his narrative, James mentions that a local church has offered to help rebuild the home, and a nearby car dealership just offered him a job. He says having others reach out to him with offers of assistance feels so unfamiliar that it’s starting to change his opinions about the world and other people. Although he doesn’t identify this as an indicator of growth, his counselor does by pointing out ways in which James’ views of himself, other people and the world are shifting in a new direction.

Cultural context: Exploring client narratives within a cultural context is also crucial. Some clients may present narratives of cultural losses rather than individual losses in instances in which they have faced significant discrimination based on their race, ethnicity, gender, age, ability status or sexual orientation. It is important for counselors to be aware of the ways that clients’ cultural affiliations affect their lives and their views of traumatic loss and healing.

For example, James reveals that he has been working odd jobs since he was 14 to support himself and his grandmother, whose only source of income is a small Social Security check. James confides that this elevated level of financial stress and the recent losses he has experienced make him feel more vulnerable as a black man living in a predominantly white rural community.

Journaling: Counselors can also facilitate client narratives by encouraging the use of journaling as an adjunctive therapeutic intervention. Therapeutic journaling is a tool developed by James Pennebaker, who says that writing about traumatic events reduces stress and strengthens immune cells. Consistent journaling is most effective, but 15 to 30 minutes of journaling several days a week can be more productive than daily journaling, which may produce more rumination than growth, according to Pennebaker. When working with survivors of loss, counselors typically instruct these clients to write about their deepest thoughts and feelings regarding their loss.

Case example: Sharon

Sharon is a 62-year-old woman whose live-in partner of 40 years died of a sudden heart attack. Sharon resides in rural Appalachia, where she had lived with her now-deceased partner for many years. She has no children, and her one brother lives hundreds of miles away. Sharon stopped working in a dental office seven years ago to help take of her partner, who had uncontrolled diabetes. She has no real friends and reports that she has rarely been out of the house in the past seven years. She says that she has no neighborhood acquaintances or memberships in any social groups.

In the first several counseling sessions, Sharon sobs and indicates that she has no idea how she will go on after losing her partner. She has limited income but no real expenses other than rent and utilities. She insists that she does not want to return to work and has sufficient income to meet her monthly obligations. She presents herself as something of a loner and describes herself as isolated.

Sharon came to the community counseling center at the urging of her brother, but she is unsure that grief counseling can be helpful to her. Short of bringing her partner back to life, she doesn’t know how talking and crying about her loss will accomplish anything. She is not having trouble sleeping but feels compelled to get out of the house during the day. She drives around randomly and visits local discount stores just to have someplace to go.

Sharon becomes more interested in counseling when a grief support group is offered, and she attends several sessions. She returns to individual counseling in a much more animated state and is even able to laugh. Having made several friends in the grief support group, Sharon reports that the group has helped her feel less alone. She is able to construct a grief timeline in counseling and is amenable to doing occasional journaling when she has bursts of grief. Over time, she pursues recommendations for joining a local gym and a book club at the public library.

Four months into individual counseling, Sharon becomes interested in volunteering at a local animal shelter and starts doing so on a weekly basis. Several months later, she feels like a different person. She says she is ready to stop coming to individual counseling sessions but will continue attending the grief support group.

Not all grief survivors experience the kind of growth that Sharon experienced — or so quickly. Even though she continued to miss her partner terribly, her life as a caregiver for the past seven years had precluded her from developing much life satisfaction for herself. Her ability to make friends and develop social connections and her volunteering activities with the animal shelter gave her a great deal of self-efficacy and provided positive ways to deal with the absence of her partner.

Some people will not cope with loss as effectively as Sharon did. Those who experience losses associated with violence or who have coexisting diagnoses such as depression, anxiety or substance disorders are more likely to go through an extended recovery period for healing. In addition, many grief survivors feel guilty for experiencing any kind of satisfaction, as if it amounts to some kind of betrayal of the person who is no longer here.

At the same time, it is not uncommon for grief survivors to reevaluate and shift their priorities in life, in part because their life circumstances have changed. For example, Emilee lost her spouse Roberto, who was a retired military officer and active in veterans’ affairs. Roberto had spent his retirement years traveling internationally in support of this cause. Emilee had rarely accompanied him because of her fears of terrorism and plane crashes. After Roberto’s death, however, Emilee decided to engage with the same veterans’ foundation that Roberto had been active in and found herself traveling all over the globe. Emilee wanted to preserve her spouse’s legacy and share her own gifts with a larger number of people. Loss survivors such as Emilee and Sharon who find ways to give back or volunteer are more likely to report narratives of growth.

Being attuned to growth

Potential for growth exists when clients uncover meaning from their loss and construct narratives that fit into their worldview and sense of self. Skilled counselors can serve as guides to help survivors make sense of what has happened. No survivor should ever be pushed to grow, but having a counselor attuned to growth may be the missing piece that helps clients become more resilient in the face of traumatic loss.

In my own experience as a grief survivor following a series of personally devastating losses, awareness of my growth sneaked up on me. It was as if a dimmer switch got turned up again as my outlook and mood shifted in a positive direction. I include this because being attuned to indices of growth may be one of the best ways that we can help clients recognize growth possibilities and emerge from the darkness of a traumatic loss to find light again. As Jon Kabat-Zinn, founder of mindfulness-based stress reduction, has said, “You can’t stop the waves, but you can learn to surf.”

 

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Sherry Cormier is a licensed therapist, certified bereavement trauma specialist, and former faculty member at the University of Tennessee and West Virginia University, as well as being a public speaker, trainer and consultant. She is the author of Counseling Strategies and Interventions for Professional Helpers (ninth edition), senior author of Interviewing and Change Strategies for Helpers (eighth edition), and co-producer (with Cynthia J. Osborn) of more than 100 training videos for Cengage. Her newest book is Sweet Sorrow: Finding Enduring Wholeness After Loss and Grief. Contact her through her website, sherrycormierauthor.com.

 

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

 

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

Supporting survivors of suicide loss

By Dana M. Cea October 29, 2019

Each year, more than 40,000 people die from suicide in the United States, making suicide the 10th-leading cause of death in our nation. Worldwide, more than 800,000 people are lost to suicide annually. These are devastatingly high numbers. But an even larger number encompasses the people who have been impacted by a loved one’s death from suicide. They are known as survivors of suicide loss.

In 1973, psychologist and suicidologist Edwin S. Shneidman — who founded the American Association of Suicidology (AAS) — estimated that for every suicide death, there were six survivors affected. Thirty-eight years later, research by psychologist Alan L. Berman — at that time the executive director of AAS — determined there were anywhere from five to 80 or more survivors of suicide loss for each suicide death. That year, 2011, was the same year my dad died from suicide.

The response to my dad’s death made Berman’s research findings seem like a significant underestimation. Hundreds of people showed up for my dad’s funeral and contacted our family after his death. A 2018 article published by the American Association of Suicidology found the number of people impacted by one suicide death to be around 135 people. Thus, approximately 6 million people in the United States are affected by suicide loss each year.

 

Survivor day

After I found out my dad had died from suicide, I called my previous college therapist. Even though I had not seen her in more than a year, she called me back. She listened, she validated, she empathized — all of the things you hope a therapist would do. She also told me about a day specifically to support survivors of suicide loss: International Survivors of Suicide Day (Survivor Day for short). In 1999, Sen. Harry Reid, who had lost his father to suicide, introduced a resolution to create an annual day for survivors of suicide loss to come together for healing and support. Congress designated the Saturday before Thanksgiving as Survivor Day.

The American Foundation for Suicide Prevention (AFSP) supports hundreds of Survivor Day events around the world. Each year, AFSP creates a documentary of the stories of suicide loss survivors that is shown at Survivor Day events. Both the documentaries and the events focus on healing, surviving and thriving. Survivor Day events offer survivors of suicide loss a safe space to “find connection, understanding and hope through their shared experience.” Past documentaries can be viewed on AFSP’s website.

Since 2012, I have assisted in hosting a local Survivor Day each year. This year, I am hosting the event in Greenville, North Carolina, at East Carolina University’s Navigate Counseling Clinic, part of the Department of Addictions and Rehabilitation Studies, where I am pursuing my doctorate. At past events, I have witnessed survivors talking about their loved one’s death from suicide for the first time — sometimes years or decades after their loss. I have heard survivors share their experiences of shame, guilt, anger and grief. I have also heard stories about funny, kind, caring, smart, artistic and achieving loved ones who have been lost to suicide. I have experienced connections that may not have been found anywhere else.

 

Support groups

In 2011, Survivor Day fell on the same day as my dad’s funeral, and in a sense, we held our own impromptu Survivor Day event. Without the actual designation or documentary, hundreds of people came together as survivors of the suicide loss of my dad. After I went back to Tennessee, where I was living at the time, I began individual therapy with a local provider. I remember feeling that she did not “get it”  — the “it” being all that comes with the loss of a loved one to suicide. However, she gave me information about the Tennessee Suicide Prevention Network, which was hosting a support group for survivors of suicide loss in my area. That support group is where I found others who did get it.

The support group members did not blame each other for their loved one’s death. They did not make comments such as “I hope God forgives your dad”; “You should have known this was going to happen”; “Your dad is in a better place now”; “I do not know how I could keep living if I were you”; “Why didn’t you stop him?”; “That was so selfish of him to do that to you”; or any of the other insensitive remarks that survivors of suicide loss so often hear.

Some of the group members had people in their lives who no longer talked to them or who actively avoided them. Yet the support group members continued to show up for each other. When group members tried to talk with other people about their pain or how their loved one had died, the conversations often shut down immediately. Yet the support group members encouraged one another to share and express their emotions.

Losing someone to suicide is very different from losing someone to another cause of death. And sometimes, finding someone who understands your loss requires finding someone who has also lost someone to suicide.

 

Postvention

Postvention is the work done to support survivors of suicide loss. In my master’s counseling program, we learned some about suicide prevention, yet suicide postvention was hardly mentioned. Although suicide prevention and intervention training can be inadequate in some counseling programs, suicide postvention training is often nonexistent. So, how can we as mental health professionals help clients who have lost a loved one to suicide?

First, we can be trained to provide services specifically tailored for survivors of suicide loss. AFSP’s website has a list of clinicians trained in suicide bereavement. These clinicians have been through a daylong training workshop that includes information about what being a survivor of suicide loss means, the impact the loss has on survivors’ mental health and well-being, and common themes survivors may experience in their bereavement. Clinicians also learn clinical techniques that can help survivors work through their bereavement and piece their lives back together. AFSP provides training for professionals interested in becoming suicide bereavement clinicians.

AFSP also provides training for clinicians who want to lead or facilitate support groups for survivors of suicide loss. There are two different versions of the training: one for facilitating adult support groups and another for child and teen groups. Each program lasts two days and includes lectures, interactive discussions, and role-playing.

Clinicians who are not interested in leading a group can still give clients a list of AFSP-curated support groups for survivors of suicide loss.

Hosting a Survivor Day in your area is another powerful way of helping suicide survivors, some of whom may be more comfortable with a one-day event rather than regularly attending a support group. The Out of the Darkness Community Walk is another one-day event. These walks, which take place in numerous locations nationwide, are not specifically for survivors of suicide loss. Their purpose is to raise awareness — and funds — to help prevent suicide. These walks are also where many survivors of suicide loss find support for the first time. Each walk is sponsored by a local chapter of AFSP, and being connected to those chapters can give clinicians access to resources to help themselves and clients.

 

Other resources

When I called to set up therapy after my dad died from suicide, I was told the wait was several weeks. During that time, I leaned on the support of family, friends and co-workers. I wish I had known about some of the resources available to recent survivors of suicide loss.

Healing Conversations is an AFSP program that connects recent survivors of suicide loss to volunteers who are also survivors and have been through a training and vetting process. Healing Conversations, formerly known as the Survivor Outreach Program, offers that connection to people without the pressure of therapy, groups or events. Survivors simply submit a form through the AFSP website, and a coordinator connects the survivor and a volunteer for an in-person visit, phone call, or video call.

AFSP’s I’ve Lost Someone page contains a variety of helpful tools, including practical information for immediately after a loss, resources to help loss survivors find support, and self-care recommendations. Schools, colleges and workplace managers can also access postvention toolkits. Survivors can use the page to identify ways to honor loved ones lost to suicide through digital and physical memory quilts, memorial funds, and Out of the Darkness walks.

AFSP is not the only organization that provides helpful resources and information. The Suicide Prevention Resource Center (SPRC) offers a variety of suicide prevention resources, training programs and toolkits, including “Suicide Prevention Competencies for Faith Leaders.” SPRC’s website also has sections devoted to postvention and supporting survivors of suicide loss.

The Tragedy Assistance Program for Survivors (TAPS) offers “compassionate care to all those grieving the loss of a loved one who died while serving in our Armed Forces or as a result of his or her service.”

The U.S. Department of Veterans Affairs (VA) has suicide prevention coordinators at each VA medical center nationwide. They can help active-duty members and veterans get counseling and needed services. The suicide prevention coordinators are also incredible resources for families, loved ones and communities.

 

Talking about suicide

The phrase “commit suicide” can be one of the worst things that a survivor of suicide loss hears. Where did this phrase come from? For hundreds of years, attempting or dying from suicide was an actual crime in Britain. Punishments may have included denial of a funeral, burial alone without a marker, desecration of the body, and confiscation of the person’s property. States such as Maryland and Virginia, despite having developed their own laws, continue to recognize this law. The phrase “commit suicide” reinforces the suggestion of suicide as a crime.

Two other phrases that come across as icky, for lack of a more scientific term, are “completed suicide” and “successful suicide,” as if death were the preferred outcome of an attempt. Advocates for suicide prevention and postvention encourage the use of “died by suicide.” While I see this as a much-preferred phrase, I take the phrase one step further and use “died from suicide.” I have never heard anyone say someone “died by” a heart attack, an accident, cancer, or any other disease. People commonly say that someone “died from” whatever the cause of death was. Therefore, I prefer “died from suicide.”

Other advocates prefer to say that someone “died from a mental illness” rather than from suicide. Although I can see the intention behind this phrasing, the reality is that not everyone who dies from suicide has a mental health condition. In 2018, the Centers for Disease Control (CDC), after examining suicide statistics in 27 states from 1999-2016, released a report showing that more than 50% of people who died from suicide did not have a diagnosed mental health condition at the time of their death. Reading and quoting these statistics can make the conversation confusing, and the bottom line is that there are tens of thousands of people dying from suicide each year who do not have a mental illness.

Regardless of your current or future involvement in supporting survivors, I ask one thing of each of you reading this: Please be aware of how you talk or joke about suicide. Both AFSP and SPRC have guidelines for talking about suicide: Speaking Out About Suicide and Suicide Reporting Recommendations.

 

Suicide’s impact on counselors

As mental health professionals, we are not immune to being impacted by losses from suicide. While I am not going to delve into our legal responsibilities, I will touch on our ethical responsibilities. If we lose someone to suicide, we may be affected by our grief more than we realize, and this can take a personal toll and negatively affect our work with clients. I encourage us as mental health professionals to take care of ourselves, to seek support, and to take off as much time as needed so that we can live up to the ethical responsibilities we have to provide competent care.

I also implore mental health professionals to bracket their values that may be harmful when discussing death from suicide with clients. If someone comes to me and says that they will not attempt suicide because that would be a sin, I will use that as a protective factor with the person. However, I would not tell someone that attempting or dying from suicide is a sin. The reality is that many religions and places of worship no longer view suicide as a sin and have come to realize the part that mental health and life situations play in deaths from suicide.

If you do decide to offer services specifically to survivors of suicide loss, or if some of your clients are or become survivors of suicide loss, please consider seeking training, consultation and supervision. Survivors of suicide loss are at higher risk of having thoughts of suicide due to their exposure to suicide compounded with their grief. Grief journeys can be difficult enough without the additional layers that come with a suicide loss. Gaining additional expertise in counseling survivors of suicide loss through training, consultation and supervision can make all the difference in the care you provide to clients.

 

Conclusion

As we continue to raise awareness and work to prevent suicide, we can expand our efforts to assist those who have been affected by suicide. Please join me in supporting survivors of suicide loss by being aware of and using available resources, encouraging postvention efforts, talking about suicide safely, and taking care of ourselves so that we can continue to provide effective mental health services.

 

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Dana M. Cea, pronouns she/her or they/them, is a volunteer for the National Alliance on Mental Illness and the American Foundation for Suicide Prevention, a mental health professional, a survivor of suicide loss, and a current doctoral student at East Carolina University. She focuses her research on mental health and suicide, the LGBTQ+ community, youth, and autism spectrum disorder. Dana lives with mental health disorders, her spouse, and their three dogs. Contact her at danamcea.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.