Tag Archives: Grief and Loss

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.

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

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

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

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

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

Medical interventions

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

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

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

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

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

The invisibility factor

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

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

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

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

Facilitating the grieving process

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

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

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

What do counselors need to remember?

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

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

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

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

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

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

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

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

Challenging infertility stigma

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

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

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

Conclusion

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

 

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

 

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

Letters to the editor: ct@counseling.org

 

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

 

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

Relieving the heavy burden of survivor guilt

By Lindsey Phillips June 27, 2019

Patience Carter took a bullet in the leg during the 2016 mass shooting at Pulse nightclub in Orlando, Florida — the second deadliest mass shooting in the United States — and survived. In a poem she wrote while recovering, Carter captured the devastating effects of survivor guilt: “The guilt of feeling lucky to be alive is heavy. It’s like the weight of the ocean’s walls crushing, uncontrolled by levees.”

Some people are able to grasp and admit that they are suffering from survivor guilt. Others, however, don’t necessarily realize they are wrestling with it, or they struggle to acknowledge carrying a sense of guilt. Luna Medina-Wolf, president of Professionals United 4 Parkland, was part of the mental health response team after the 2018 shooting at Marjory Stoneman Douglas High School in Parkland, Florida. She says many of the teachers sought help for their trauma after the shooting and, through therapy, also found they were dealing with survivor guilt for not being able to protect all of their students or for living when a child died.

Thus, Medina-Wolf, a licensed mental health counselor and the owner of Helping Moon Counseling, advises other clinicians to pay close attention to subtle comments clients make that may indicate they are struggling with survivor guilt. Rather than directly stating “I shouldn’t have survived,” a client may say, “How is it that my friend died?” This question infers the thought “And I didn’t die,” explains Medina-Wolf, a member of the American Counseling Association. Counselors must sharpen their listening skills and not be afraid to ask questions and dig deeper, she adds.

“Even when people are admitting [their guilt], when the words are coming out, they’re not realizing what it is that they’re admitting,” says Melissa Glaser, an ACA member in private practice in Connecticut. “They don’t know as they’re saying it that this is survivor’s guilt and that they’re stuck in a place that they can’t navigate out of.”

Glaser, a community response and recovery leader, served as director of the Newtown Recovery and Resiliency Team following the mass shooting at Sandy Hook Elementary School in 2012. She says counselors can listen for telltale comments that clients are struggling with survivor guilt. For example:

  • “I can’t accept the help because someone else needs it more than me.”
  • “I keep thinking if only I had …”
  • “Other people were so much more courageous while I was just hiding under the desk.”
  • “I became frozen and immobilized, and I still feel like I’m in that place. I’m so angry at myself that I couldn’t move or do something more.”
  • “Why did my child come home while another [parent’s] didn’t?”

Glaser is a consultant, a public speaker on trauma and relevant clinical applications, and a licensed professional counselor (LPC) who specializes in trauma and posttraumatic stress disorder (PTSD). She says survivor guilt typically manifests when someone feels a sense of responsibility for a loss or traumatic experience or when someone is grappling with questions of why and how (e.g., Why did this happen? Why did I react that way? How can I enjoy life when others can’t?). This is especially true if they think they could have done something differently to prevent or change the outcome.

“It’s really important for clinicians to help individuals get to a place where they are able to understand that they’ll never have the answers [and] that they can’t stay rooted on the why. … You have to find a way to project those whys into or onto something else,” Glaser says. “Otherwise, it can consume you, and it can become such a part of your identity.”

Glaser often suggests that clients picture themselves throwing their why questions into the air and they don’t come back down. If clients value spirituality, they can imagine that God is going to deal with the questions for a while, she adds.

“Survivor guilt is complicated. … [A] lot of the time, people will not even seek counseling because … they feel they don’t deserve to feel better or they’re not worthy of getting relief,” Medina-Wolf says.

She had a client who was diagnosed with cancer at the same time a friend was diagnosed. When the client survived and the friend didn’t, the client said, “My friend was such a good person. I’m not a good person like her. She volunteered and was kind to everybody. I’m not kind to people. Why did she die?”

Shame is also often intertwined with survivor guilt, adds Courtney Armstrong, an ACA member with a private practice, Real World Therapy, in Tennessee. “When there’s an element of survivor’s guilt on top of [grief], they feel ashamed or guilty for having any joy … because that’s disrespectful to this other person,” she explains. For example, when a child dies, parents may not want to change the child’s room because they feel guilty about moving forward and seemingly “dismissing” their child.

Other clients have told Armstrong, “I can’t be happy if [my loved one] isn’t here. … I feel bad for enjoying my life when they’re not here.”

The ripples and waves of guilt

Survivor guilt can set in immediately, or it can make its presence known months or even years later. This past March, roughly one year after the Stoneman Douglas High School shooting in Parkland, two survivors — Sydney Aiello and Calvin Desir — took their own lives. Aiello’s family reported that she suffered from survivor guilt. A few days later, Jeremy Richman, who lost his daughter in the 2012 Sandy Hook shooting and who later served as one of the keynote speakers at an ACA Conference, also died by suicide.

Richman, along with his wife, had created a foundation to prevent violence and build compassion through brain health research. Up until his death, Richman was actively working with Parkland families. Glaser says Richman was the last person most people would have expected to take his own life, but she stresses the importance of being aware that everybody is in a different place. Counselors “have to be well-versed in [the] signs and symptoms [of PTSD and survivor guilt] and never hesitate to reach out, never hesitate to ask questions,” she adds.

John Super, coordinator of the Community Counseling and Research Center and a lecturer of counselor education at the University of Central Florida, has observed that a person’s proximity to the traumatic event may affect how quickly he or she feels survivor guilt. After the Pulse nightclub shooting, Super, along with two other colleagues, helped organize a grassroots collaborative plan to offer supportive counseling services to those affected.

Super compares trauma and the potential for experiencing resulting survivor guilt with throwing a pebble into a lake: “It ripples out. Those [who] are the closest feel it the quickest and the strongest, but that doesn’t mean that people on the outside don’t feel it.”

Working closely with media reporters after the Pulse shooting, Super witnessed how they also experienced a sense of guilt. “Generally, reporters tend to see themselves as hardened — ‘We’ve seen and heard the worst of life so, obviously, we can’t have any guilt or emotional response to this,’” Super says. “And they would be the ones who buried it the deepest.” Some reporters felt guilt almost instantly because they knew they were prying into people’s lives or pushing people to comment who weren’t ready. Super noticed the guilt appeared later for other reporters, such as when they were writing their stories, editing a video or doing a follow-up special.

According to Jeffrey A. Lieberman, who chairs Columbia University’s psychiatry department, adolescents are particularly susceptible to the after-effects of trauma, including survivor guilt, because they are already dealing with massive changes as they move toward adulthood.

One way that counselors can help survivors is to normalize the guilt they may be feeling after a loss or traumatic event. Glaser, author of Healing a Community: Lessons for Recovery After a Large-Scale Trauma and co-author of the chapter “Disaster Recovery in Newtown: The Intermediate Phase” in the fourth edition of ACA’s Disaster Mental Health Counseling: A Guide to Preparing and Responding, points out that part of the recovery process is simply understanding what is involved. After the Sandy Hook shooting, she noticed a sense of relief when she told clients about common physical and emotional responses to trauma. The clients would look at her and say, “Oh my God! That’s why I feel the way I do. That’s why I can’t do that [activity] anymore.”

During the first session, or when clients are otherwise ready to absorb information, Medina-Wolf will show them a “window of tolerance” infographic created by the National Institute for the Clinical Application of Behavioral Medicine (see nicabm.com/tag/window-of-tolerance/). The infographic helps clients understand that what they are experiencing is a normal reaction to a traumatic event.

A person’s window of tolerance is the ideal place for coping with stressors and triggers, Medina-Wolf explains. Hyperarousal (e.g., hypervigilance, anxiety, panic, fear, racing thoughts) sits at one end of the window of tolerance, whereas hypoarousal (e.g., feelings of numbness, emptiness) sits on the other. The infographic illustrates how a traumatic experience can narrow a person’s window of tolerance, causing the person to feel dysregulated. Although most people commonly associate trauma symptoms with hyperarousal, many of the symptoms of survivor guilt — such as feeling helpless, unmotivated, immobilized, numb or disconnected — are components of hypoarousal, Medina-Wolf adds.

Medina-Wolf says she has had clients cry upon viewing the window of tolerance infographic because they realize they are not going crazy. “A lot of what people need in the beginning is just that reassurance that what they’re going through is symptoms of trauma,” she says. 

In addition, recovery from survivor guilt and trauma isn’t a linear process. The guilt and grief of the loss comes in waves, not stages, says Armstrong, author of Rethinking Trauma Treatment: Attachment, Memory Reconsolidation and Resilience and Transforming Traumatic Grief. The reality is that people who are grieving typically move back and forth between loss-orientated waves, in which they feel emotionally and physically drained, and restorative waves, in which they become more task-oriented and don’t dwell on the pain, she explains. Counselors should reassure clients that experiencing grief and guilt in waves is a normal part of the recovery process, Armstrong says. Otherwise, clients who have been feeling better may wonder what is happening when they suddenly find themselves back in a loss-oriented wave.

Of course, as both Armstrong and Medina-Wolf point out, when clients start feeling better and moving through their grief, this can actually cause their survivor guilt to flare more intensely because they don’t think they should be “over it” this quickly or because they feel guilty about being happy again.

Medina-Wolf, who is certified in eye movement desensitization and reprocessing (EMDR), uses recent traumatic episode protocol (R-TEP) for early EMDR intervention with clients. If clients don’t have any underlying issues, this protocol often helps them feel better in as little as three to five sessions lasting 90 minutes apiece. This sometimes prompts them to ask, “How can I feel so good so quickly?” she says.

Of course, some clients may feel that they have their survivor guilt and grief under control, only to turn on the news and be faced with the reality of another traumatic event transpiring. This can throw survivors back into a sense of guilt, distrust and questioning why, Glaser says.

“It isn’t that [trauma] is going to be erased,” she says. “It isn’t that they are going to recover and never be triggered again or never have a day or moment where they’re feeling that extreme sadness, or they’re feeling dysregulated again, or they’re feeling things are foggy. They will experience times like that for the rest of their lives. Hopefully, it’s fewer and further between as they work through this.”

When you can’t talk away the guilt

Glaser is trained in cognitive behavior therapy (CBT), but when it comes to collective community trauma, she has found that CBT may not be the most effective approach — or not effective at all — until the client is grounded.

Medina-Wolf agrees: “Communal trauma requires specific brain-based therapeutic techniques to really be able to break some of the negative schemas that were created due to the trauma. Just doing talk therapy would really take a long time until you would be able to heal. … [A] lot of times, it doesn’t take care of it all. You just learn to cope with it, but the damage is done. And if you don’t make sure to really work on the underlying schemas, then [they] may stay with [you] for the rest of your life.”

With survivor guilt, clients experience a disconnect between what they feel and what they know, Medina-Wolf explains. They may realize on a cognitive level there was nothing they could have done to prevent someone’s death, but they still feel differently.

Medina-Wolf uses a metaphor to explain to clients how trauma shapes the way they see the world and themselves in it. If they were to put on red-tinted sunglasses, she tells them, then everything would seem reddish; once they removed the sunglasses, they would realize it was just the glasses making things appear red. Similarly, being in a state of hyperarousal or hypoarousal makes it difficult to think rationally and process one’s thoughts and emotions, which may alter a person’s perceptions, Medina-Wolf says. Thus, bottom-up approaches such as EMDR, neurofeedback and brainspotting, which allow emotions to be processed at an unconscious level, work better to treat survivor guilt and other trauma-related symptoms than does a top-down approach such as CBT, which assumes that changing thoughts will change behavior and feelings, she explains.

With EMDR, the client and counselor first identify the negative self-belief (e.g., “I could have done something more to save the person’s life”). The client then thinks about this distressing feeling while the counselor uses bilateral simulation such as eye movement, tappers or bilateral music. This technique allows clients to open a door between their conscious and subconscious minds so that they are able to figure out what happened and rewire the way they understand it, Medina-Wolf explains. By identifying the negative self-belief and reprocessing and desensitizing what happened, clients can come to terms with what occurred in a more rational way and are more in control of their emotions when they are triggered, she continues.

For example, Medina-Wolf used EMDR R-TEP with a Parkland student who felt guilty for not saving another student’s life. First, they identified the client’s negative self-belief (“I should have done something more to save the student”) and the positive self-belief she wanted to work toward (“I did the best I could”). Medina-Wolf used tappers to administer bilateral simulation, and after three sessions, the client was able to reach that goal. Her thought process was more rational, she believed she had done the best she could, and she no longer felt guilty for the person’s death.

Individuals who experience survivor guilt, complicated grief or extreme trauma reactions may not be able to organize their thoughts to tell counselors what they need, Glaser says. For that reason, she also recommends using mind-body techniques such as meditation and music therapy to regulate and ground clients. This helps them to process their story and recover the vocabulary to talk about their experience. In many instances, clinicians may need to take a layered approach — for example, doing CBT in conjunction with tapping, art therapy or brainspotting.

Glaser often reverts to something rhythmic to help ground clients. For example, she may have them tap the side of a chair or their leg in a rhythmic way or take them on a walk outside (if they feel safe doing that). This simple rhythmic work helps get clients through the initial acute stage so they can begin to hear the counselor and produce the language they need to tell the counselor what they are feeling, Glaser explains.

In session, Medina-Wolf uses aromatherapy, meditation, breathing techniques and a box filled with fidget toys, pencils and squishy toys that clients can grab and play with while they are processing the event. She also encourages clients to supplement therapy with activities such as running, swimming or cycling that encourage bilateral simulation. 

Reimagining guilt

The attachment system often confuses what is imagined and what is real after a traumatic loss or event, points out Armstrong, founder of the Institute for Trauma Informed Hypnotherapy. Thus, she finds the imaginal conversation technique helpful for calming clients’ attachment systems and rewriting the negative thoughts connected to guilt.

With this technique, Armstrong has clients close their eyes and imagine what the person who died would say to them now from a place of enlightened awareness. Would the person want them to be tormented? Would this person tell them they don’t deserve to be alive? Imagining these conversations often helps clients obtain resolution, she says.

Armstrong allows clients to take the lead on these conversations. If they struggle, however, she might say, “I’m imagining they understand that you feel regret and they appreciate how much you care, but they think that being stuck in this depression and guilt isn’t the solution. It isn’t the best way to honor them.”

Armstrong had one client whose mother died by suicide and blamed the client in the suicide note. Because the client had a complicated relationship with her mother, she had a hard time being able to think with a clear, stable mind about her mother. Armstrong told the client she could instead imagine the way she would have liked her mother to be. With clients who are spiritual, counselors can have them imagine a conversation with God and God telling them everything is OK and they are not responsible for what happened, she adds.

Armstrong also has clients write letters to the deceased about their feelings. Then she has clients write an imagined response from the deceased (using their nondominant hand so they are less likely to edit it with their intellectual mind).

Counselors may also need to help clients address another common symptom of survivor guilt: recurring nightmares. Armstrong finds imagery rescripting helpful here. The technique involves rewriting or changing the ending of the nightmare. Clients first describe the nightmare to Armstrong, and then she asks how they would want to change it.

Armstrong had a client whose son died by suicide. The mother felt guilty for not somehow preventing his death — which she feared had caused him to go to hell — and for cremating him when she wasn’t sure he would have wanted that. This guilt culminated in a nightmare in which her son was asking for help as he was being rolled into a furnace, but she was unable to move her body to help him.

Armstrong asked the client, “What do you wish you could do in the dream?” The client responded that she wanted to move and go to her son. Armstrong then asked her to close her eyes and imagine a new ending — one in which her feet could move, she possessed the superpower to leave her body and go to her son, or her son was able to walk to her. The mother closed her eyes and reimagined the nightmare: The son got off the gurney and met her halfway. Then he embraced her and said, “I love you, Mom. I’m sorry I didn’t get to say goodbye. I’m going to be OK.” This revision brought an end to the client’s nightmares.

Counselors should have clients imagine their dreams and the new endings as vividly as possible, Armstrong advises. It typically requires going over this new ending several times in session and having clients imagine it again before bed. “If you just talk about the ending without imagining it as best you can, it won’t work because your emotional brain needs that imaginal experience,” Armstrong explains. The emotional brain learns through experiences, not reasoning, she says, so counselors must have clients create an experience that will allow them to heal.

Turning pain into power

According to Glaser, survivor guilt is rooted in pain. She advises counselors to help clients realize that “guilt in any of its forms is not really productive” — either for clients, for those around them or for those who are gone.

Medina-Wolf says clients often acknowledge being angry, depressed or anxious, even when guilt is the underlying cause of their problems, because it is more difficult to admit feeling guilty. “They feel like if they say it out loud, then maybe they are guilty,” she observes. “The guilt is so deep and they’re so [ashamed] of it because they’re so confident … in that negative distortion that it’s literally killing them from the inside.”

It matters where that guilt is coming from, Medina-Wolf continues. Do they think they didn’t do enough? Do they feel they are a bad person who shouldn’t have survived? Counselors can help clients process exactly what they are experiencing and identify the underlying cause of the guilt, she says.

Often, the guilt is based on a fear of not knowing how to go back into a world they no longer trust, Glaser says. So, instead, they hold on to the guilt and the awful feeling of responsibility. “When we understand that, we can start to make some inroads,” she continues. “We can help the client know where it’s coming from.”

Armstrong points out that pain is also a way for some clients to maintain a bond with their loved one, especially if they experienced the death of a child or someone’s death by suicide. Clients may assume that living without the pain would suggest their loved one’s life wasn’t important, she explains.

She encourages clients to honor their loved ones by letting their importance stay alive in a positive way. Armstrong provides a personal example: Her husband enjoyed watching Atlanta Braves baseball games with his mother, so after she died, he and Armstrong continued to go to games to honor her.

One of Armstrong’s clients had a son who died of an overdose. The client’s happiest memory was of camping in the Grand Canyon with his son, but after his son’s death, the father’s sadness and guilt stripped him of his motivation to hike and camp. Armstrong asked the client to imagine whether his son would want his father to stop hiking to prove his love for him or whether he might prefer that his father do something that served as a positive reminder of their time together. After the father’s perspective was changed through this imagined conversation, he took a small step forward by going hiking. Eventually, the father and his wife planned a trip to the Grand Canyon in their son’s honor and spread some of his ashes there.

Armstrong also recommends using the making living stories technique, in which she invites clients to bring in photos or share stories about the deceased. However, she has found that if she asks clients to tell her a story about the person, their minds often go blank. So, instead, Armstrong will ask about the deceased loved one’s favorite music or food, about a trip the client took with the person, or even what annoyed the client about the person. These silly or trivial questions often end up producing the best stories, she says.

Armstrong also prefaces this technique with the phrase “when you are ready” to ensure that discussing the loved one won’t create additional pain for the client. Counselors can put the invitation out there, and when clients are ready, they can work together to find ways to remember the loved one, she says.

There are times when the attempt to turn pain into something positive can result in others feeling even more guilt. For example, the media often praises survivors or those who have perished in mass shootings for their bravery, such as in the case of Kendrick Castillo, a student who died trying to subdue an active shooter in his school in Colorado this past May. Glaser acknowledges the desire to honor those who perform heroic acts, but she also notes this action can create something of an expectation among adolescents that it is their responsibility to react bravely and save others during a school shooting. It can also exacerbate survivor guilt among those who followed safety protocols and hid behind their desks.

Armstrong is impressed when survivors take a horrible situation and become empowered, such as with the Parkland students’ gun violence advocacy work. However, she also acknowledges that survivors sometimes need to work on healing themselves first.

One of Armstrong’s clients had a daughter who died of a childhood cancer. Soon after her daughter died, the hospital and cancer community approached the mother about having a fun run in honor of her daughter and to raise money to battle the specific type of cancer. Her daughter’s death was too fresh though, and the mother ended up experiencing survivor guilt for not wanting to help create a fun run in her daughter’s honor.

To help the client, Armstrong had the mother imagine what her daughter would say about the situation. Armstrong knew a little bit about the daughter’s personality, so she mentioned the daughter would probably say that even she didn’t have time for a fun run because she was still learning to navigate the afterlife. This helped the client put her guilt into perspective and focus her energy on healing herself.

“You don’t have to be a hero,” Armstrong often reminds clients. “If you decide to do something later, then that’s awesome. But [honoring a person’s life] may just be in little simple ways — I’m just going to take more time to appreciate a sunny day, be kinder to people or not take things for granted.”

Compassion for self, not just others

Often, it’s easier to offer compassion to others rather than to oneself. This may be especially true for counselors. Super, an ACA member who presented “The Shared Trauma of School Shootings and Their Impact on Counseling and Education” at the ACA 2019 Conference in New Orleans, admits he wasn’t good at self-care during the recovery after the Pulse shooting. As one of the coordinators of the grassroots recovery effort in Orlando, Super spent the majority of his time at different counseling centers helping survivors and supervising counselors, and at the end of the day, he often had nothing left in him to tend to his own self-care.

Months later, as he was researching and presenting on his personal experience with this large-scale traumatic event, he realized how it had affected him. “Those thoughts [of ‘it could have been me’] start coming to you, that guilt of ‘this young person … just lost their life and I didn’t.’ I think that is probably a quiet voice that sat in the back of my mind through the entire process.”

Super also witnessed counselors who experienced guilt over not feeling prepared enough or not knowing enough about trauma and the LGBTQ+ community. Other counselors felt guilty that they didn’t help with the recovery efforts because life got in the way or because they simply weren’t ready and needed to take care of themselves first, he adds.

Super would pay close attention to how counselors were responding — for example, if they didn’t want to meet with clients or walked off by themselves — and check in with them. He and the other two organizers weren’t able to be in contact with all of the mental health providers offering assistance, so they also trained counselors to be aware of colleagues’ behavior and check in with them as needed.

People don’t often think about the need for counseling supervision during a collective trauma, Super points out. “But if you have counselors out there, you really need to have supervisors who are debriefing or helping process emotions for those who are providing services in the moment,” he says. He advises counselors and supervisors to make time for self-care. Talking about their feelings with another counselor, a supervisor or someone they trust will help counseling professionals recharge, and it will minimize the residual effects down the road, he notes.

Compassion also helps clients reframe their own guilt. Armstrong stresses the importance of providing psychological first aid — which includes making the person feel supported and safe — immediately after a traumatic experience. Armstrong has had sessions in which a client cried the entire time, and she felt guilty for not doing enough — only to discover that the client thought the session was extremely helpful. Outside of the counseling space, clients typically have to hold it together, she points out, so they often appreciate having a space where they can break down and not worry about others.

Armstrong also worked with a client who dealt with survivor guilt after the 2012 mass shooting in a movie theater in Aurora, Colorado. The client had been watching a movie next door and, on her way out, almost tripped over a woman who had been shot. She didn’t know how to help the woman, so she simply held her hand and called the woman’s mother. Discussing this with Armstrong, the client said, “All I could think to do for the gunshot victim in the parking lot was to sit there and hold her hand. I am in the health care field, and I felt completely incompetent.”

Armstrong reassured the client that she had done something valuable by offering the shooting victim compassion and psychological first aid, but the client still felt guilty for not doing more. While the client described the event again, Armstrong held her hand, which created an experience to demonstrate the power of compassion. When the client finished her story this time, she noted how the simple act of Armstrong holding her hand had helped her get through the story and made it seem less scary.

A few months later, the client ran into the woman she had helped after the shooting. The woman told her that the kindness of a stranger holding her hand was what replayed in her mind — not the horror of the event.

Armstrong acknowledges that counselors frequently worry about not doing enough, not knowing what to say to clients and not being able to rid them of all their pain. “At the end of the day,” she says, “it’s just us being able to sit with [clients] through all of the confusion and the heartache that heals them.”

For many survivors, the weight of survivor guilt is heavy. But counselors can operate as levees to prevent the weight of this guilt from crushing those who survive.

 

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Read more in an online companion piece to this article, “Doing the groundwork after a large-scale traumatic event

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

 

Letters to the editor: ct@counseling.org

 

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