Tag Archives: Grief and Loss

Perspectives on grief and loss

Compiled by Jonathan Rollins October 26, 2021

If you go to the books page on Amazon and enter the word “grief” in the search box, you’ll receive a message saying there are “over 60,000 results” available.

To winnow the choices, you might decide to view only those titles released over the past 90 days. This narrows it down to “over 10,000 results for ‘grief.’’’

Titles published in the past 30 days? “Over 5,000 results for ‘grief.’”

Finally, if you click on books “Coming Soon,” you receive a somewhat manageable “541 results for ‘grief’” (at least that was the case as September drew to a close).

This prodigious output would seem to support the statement that grief is a universal and yet very individualized experience — one that continues to captivate and challenge us as humans. The ever-increasing numbers of books, journal articles and other reports on grief and loss also hint that our thinking about this experience continues to evolve.

Counseling Today recently invited several American Counseling Association members with in-depth knowledge in the area of grief and loss to share their insights on specific aspects of grief that they believe to be largely overlooked or misunderstood.

****

Maintaining continuing bonds with the deceased

By Kenneth J. Doka

In recent years, there have been significant challenges and changes to the understanding of grief. These changes include such aspects as:

Extending the understanding of grief from reaction to a death of a family member to a more inclusive understanding of loss
Acknowledging that there are no universal stages in grief and recognizing the very personal pathways that individuals take when experiencing loss
Recognizing the multiple and multifaceted reactions that people have toward loss (rather than seeing grief as primarily affect) and the ways that responses to grief are influenced by culture, gender and spirituality
Seeing the possibilities of transformation and growth in mourning rather than coping passively with loss
Moving from understanding grief simply as a normal transitional issue to recognizing its more complicated variants and the necessity for careful assessment
Acknowledging that certain individuals show great resilience as they cope with loss and grief
Maintaining a continuing bond with the deceased rather than pushing to relinquish ties to the deceased

It is this last area of continuing bonds where I wish to focus. Sigmund Freud, over a century ago in Mourning and Melancholia, argued that bereaved individuals must detach from the deceased by withdrawing emotional energy from the person who has died and reinvesting it in others to go forward with a healthy life.

This notion has been deeply challenged in recent years. In their groundbreaking 1996 book Continuing Bonds: New Understandings of Grief, Dennis Klass, Phyllis Silverman and Steven Nickman drew on research with bereaved children, spouses and parents, as well as teachings of Eastern religions, to both emphasize and demonstrate the importance for many bereaved persons and groups to maintain an ongoing connection to the individual who has died. They stressed that connections of this type were comforting and eased the grief of those who were bereaved.

Bonds are maintained in several different ways. First, we always retain memories of the deceased. This is critical. Many bereaved individuals fear that as they cope with loss, those memories will fade. This exacerbates their sense of loss and impedes the grief process. Counselors should affirm to clients near the beginning of grief therapy that the goal is not to diminish memories of the deceased but rather to help them find comfort in such memories as the pain of loss lessens. The amelioration of grief means that over time, the intensity of the grief experience lessens, and individuals function in ways comparable to (or perhaps even better than) the way they did prior to the loss.

The fact that these memories are always retained is also a reason for subsequent surges of grief that may occur years after the loss. For example, think of a young woman whose father died when she was a little girl. Two decades later, as she walks down the aisle to be married, she has deep pangs of grief that her dad is missing this event. In fact, at the termination of a counseling relationship, it is helpful to suggest, and even to identify, the significant life events or major transitions that might generate such surges of grief in clients.

Second, important attachments become part of one’s own biography. We are influenced by so many factors. The ways that one interacts with others who are important in one’s life frame an individual’s personality. In addition, significant attachments in one’s life leave their legacies, and sometimes their liabilities, on the identity of the bereaved individual. Those legacies (and sometimes liabilities) can include everything from personal gestures to beliefs to the ways that one views self and relates to others and the world.

Third, survivors retain spiritual ties such as the belief that the deceased is interceding for them (or will intercede) and that they will be reunited in an afterlife. Many spiritual systems have beliefs and practices that strive to retain a connection with the deceased, such as Roman Catholic Anniversary Masses or the Jewish Mourner’s Kaddish — a prayer said at the memorial service as well as for 11 months following the person’s death. In fact, Klass’ interest in Eastern religions was one influence on the development of his theory. Klass pointed out that in traditional Chinese worship, the veneration of one’s ancestors was a common practice that served to reinforce a continuing family bond across generations.

Furthermore, many bereaved persons report extraordinary experiences in which they have sensed the continued presence of the deceased in their lives, whether it is dreaming about the deceased or other ways in which they believe they have encountered the deceased. Such experiences are, in fact, quite common in bereavement.

Finally, increasing numbers of bereaved persons are using the internet and social media, particularly Facebook, to provide death notifications and to continue ongoing relationships with the deceased. For example, they may visit the Facebook page of the person who died, comment there on pictures, post memories and even leave messages to the deceased. It is not unusual for mourners to “keep alive” the digital identity or Facebook page of a person who is deceased.

Continuing bonds can be applied to groups, communities and even nations. Communities may name parks, streets or buildings after individuals or erect memorials to the person. Nations may honor ties with deceased leaders by naming cities after them and building monuments or establishing holidays to celebrate them.

While continuing bonds are generally healthy, they can at times be problematic when we fail to acknowledge the death or are burdened by promises made to the deceased prior to death. For example, one client, a young widow, promised her spouse prior to his death that she would never remarry. Now she feels torn between her promise to her dead husband and her desire to engage in a new romantic relationship.

Continuing bonds are natural and normal responses in bereavement. Yet we need to guide clients so that these bonds do not become chains that inhibit their adaptations to loss and perhaps even their personal growth.

— Kenneth J. Doka is professor emeritus of counseling at the College of New Rochelle and senior vice president for grief programs at the Hospice Foundation of America. Contact him at kndok@aol.com.

****

School counseling: Grieving children and adolescents

By Jillian M. Blueford

We often see grief as a common reaction to loss, but at times we try to separate it from who we are and who we want to be. We treat grief the way we treat many life stressors, tending to what is most immediate in hopes that one day, that stressor will be a thing of the past — something we have “overcome” or “persevered” through. However, grief involves a lifelong shift that does not work on a timeline or according to expectations.

This experience is especially true for children and adolescents, who are not immune to grief and who could have a longer time to navigate their grief while anticipating additional losses in the future. Grief can permeate every aspect of life, and it affects children and adolescents in ways that are as unique as they are during these fast-moving developmental stages. Reflecting on my professional experiences counseling grieving children and adolescents, I have yet to encounter two young people with the same grieving response.

Although we have established that a child’s or adolescent’s response to loss will vary and can appear at any time, we can expect for their grief to influence their presence at school. School is a significant part of many children’s and adolescents’ upbringing. So, naturally, their grief might make an appearance in the classroom, in the cafeteria, on the playground, at sporting events, during choir performances, at club meetings and elsewhere.

This also means that school counselors may be called on to provide services. These services are often introduced after a school staff member is made aware that a student has endured a death-related loss. According to Judi’s House/JAG Institute, 1 in 14 children in the U.S. will experience the death of a parent or sibling by age 18. This statistic does not account for the deaths of other family members, friends or community leaders, nor does it cover the nondeath losses that children and adolescents endure (e.g., moving, separation of caregivers, pandemics, changes in health, financial instability). COVID-19 has shone a light on some of these losses, but the truth is that many of these losses happen so frequently that we do not recognize these changes as they happen, nor do we seek to understand how children and adolescents grieve these losses long term.

In my experience providing counseling services in schools and outpatient settings, I have often been asked, “What does grief look like for children and adolescents?” I perceive this question to mean “what behaviors stand out for grieving children and adolescents?” But I tend to shift the focus to time and circumstances.

When we first encounter a loss, it can throw many of us for a whirl. Our appetite, sleep patterns and engagement level with our relationships may be affected. It is typical and expected to be bombarded with an influx of thoughts and emotions. This is no different for children and adolescents who experience a loss.

Furthermore, I expect the academic performance of children and adolescents who are grieving to change. I expect them to become more distracted in class, to potentially distance themselves from others, and to ask more questions about death and the safety of their world. I particularly try to understand how recently the loss occurred and the relationship or attachment the child or adolescent had with what they lost (e.g., a person, experience, material item, health). Those markers give me a better idea of how the child or adolescent has been responding and areas within their grieving process that negatively affect their daily activities over time.

If we tend to focus only on the losses that children and adolescents endure during an academic year, then we may forget to ask about their history of losses. Having this information can help us conceptualize current grieving responses that may otherwise feel sudden and unusual. Understanding the timing also helps illuminate “re-grief,” or the understanding that as children and adolescents mature, their recognition of their losses will change. This can lead to a resurgence of grief, especially as children and adolescents reach developmental milestones, many of which happen while in grades pre-K-12.

On top of the other responsibilities that school counselors have, fully addressing a child’s or adolescent’s grief can be overwhelming. Given that grief does not have an end date, engaging with grieving students is an ongoing responsibility and requires different care and attention levels. School counselors may believe they have already put in intense effort to support a grieving child or adolescent, but in fact this effort requires a lot of ongoing listening, empathy, validation and education.

Any adult can benefit from a refresher on how children and adolescents respond to a loss. I have seen these educational conversations make all the difference when students are mislabeled as “problematic” but are really just having a difficult time with their grief. Caregivers and families, who are often grieving themselves, can especially benefit from understanding the unique aspects of child and adolescent grief. School counselors should identify resources and strategies that adults in other environments can use as well.

The organizations listed below provide curricula, podcasts, interactive activities and strategies supported by data. Share these resources with families and any adult who interacts with children and adolescents.

Coalition to Support Grieving Students
Judi’s House/JAG Institute for Grieving Children and Families
The Dougy Center
National Alliance for Children’s Grief
National Center for School Crisis and Bereavement
Grief-Sensitive Schools Initiative

In addition, connect with local counseling professionals, particularly in bereavement settings. Often, these organizations will host grief camps and services for children, adolescents and their families at little to no cost. They can also serve as consultants to supplement your understanding of grief and loss and perhaps provide in-person individual and group services.

My first experience providing counseling was through my time as an intern for a hospice bereavement center. In visiting schools and facilitating grief groups, a passion was sparked in me for addressing grief and loss. It was the school counselors who often advocated for our services, referred families and empowered grieving children and adolescents to believe that they were cared for and not alone in their grief.

— Jillian M. Blueford is a licensed professional counselor, national certified counselor and clinical assistant professor in the Department of Counseling Psychology at the University of Denver. Her primary research expertise falls under grief counseling training and preparation and counseling grieving children and adolescents. Contact her at jillian.blueford@du.edu.

****

Working with military grief of noncombat deaths

By Joanne Steen

In the United States, there seems to be a widely held belief that military personnel die only in war. However, total military deaths since 9/11 paint a much different picture of how and where U.S. service members have died. In the first seventeen years after 9/11, a total of 22,365 U.S. military personnel died on active duty, according to the Department of Defense (DOD). Of this number, 31% died in Iraq or Afghanistan, while the remaining 69% died in the line of duty, but not in armed combat or war.

These statistics are surprising to many, and they emphasize a sobering reality of military service: Military personnel regularly die in the line of duty, both in peacetime and in war.

I learned this lesson the hard way. I married a Navy pilot several years before 9/11 and never worried when he flew. He loved to fly, was well-trained, and the U.S. was not at war. Life was better than good — until the day the helicopter he was flying exploded in midair as he and his six-person crew were returning to Naval Station Norfolk in Virginia. There were no survivors.

War deaths embody the ultimate sacrifice made by military personnel in the defense and protection of our rights, freedom and homeland. But apart from armed combat and war, service members also lose their lives in other military operations worldwide; in terrorist attacks at home and abroad; in training to maintain their operational readiness levels; because of accidents, equipment failure or human error; by suicide or homicide; and because of illness and disease.

Counselors who work with surviving families or veterans benefit from knowing these common causes of death in the military, because how a service member died is very important within the military culture. The cause of death can deprive survivors of validation of their loved one’s service and unfavorably affect the support they receive.

Prior to 9/11, there was little in the way of literature and military-focused grief resources for family members or professional service providers. Survivors such as myself struggled to cope with this life-changing loss and a grief that few others seemed to fully grasp. The grief constructs of prolonged grief disorder or complicated grief didn’t easily adapt to military grief. As a survivor, I sometimes felt like a fish out of water, isolated in military grief and unable to chart a path forward on my own.

In hindsight, here are three things I wish my therapist and I had known when my late husband was killed.

1) Military grief has a long shelf life. Military grief can be complex, complicated and messy. Contrary to another popular belief, military families are not prepared for the loss of their loved ones.

Like a perfect storm, military grief is the result of the intersection of three powerful circumstances: the death of a loved one who died much too early in life (the average age of death is 28, according to the DOD); the high likelihood that death was sudden, unexpected and potentially violent in nature; and the unique factors that military service brings to death. A few of these factors include a sudden death far from home; a traumatic notification and casualty assistance process; limited details or classified information; unrecoverable, unviewable or partial remains; the soul-searing traditions of a military funeral; and the realization that common symbols of our country, such as the American flag, have become personal symbols of loss.

Some military families live on base or post, and when their service member dies, they are given a limited time to relocate off the military installation. When Laura Monk asked for a few more weeks to move off post after her husband, U.S. Army Specialist Austin Monk, died of leukemia at age 22, her request was denied. “All the grief books I had read said not to make any major decisions the first year,” Laura recalled, “but before I was ready, I had to leave the home Austin and I shared, plus my support network on post.”

2) Noncombat deaths can be marginalized and the associated grief disenfranchised. In many areas of our country, knowing a military family is the exception rather than the norm. As a result, the challenges faced by these families and veterans are often unrecognized or misunderstood.

Couple this limited awareness with the pervasive belief that military personnel die only in war, and the families who experience noncombat losses often find their service member’s death marginalized. U.S. Air Force Master Sgt. Steven Monnin battled posttraumatic stress disorder before ending his life in 2004. His surviving spouse, Elizabeth Monnin, recalled going to an event in support of surviving families and seeing an object that was akin to a traveling memorial. When she inquired if her husband’s name could be added, she was asked how he died. After Elizabeth explained, she was told, “No, this is for real heroes.” While not all replies are this extreme, many conversations send a not-so-subtle message that combat deaths garner more appreciation and greater respect than do noncombat deaths.

3) Finding meaning in noncombat deaths can be challenging. Families of military personnel who were killed in armed combat or war usually find meaning in their loved one’s direct actions to protect or defend the nation from those who want to do great harm to America. They find purpose in their loved one’s ultimate sacrifice for the greater good.

But what happens when the death seems senseless? Finding meaning in a live-fire training accident or an exploding helicopter can be difficult. Families sometimes turn to making meaning out of their loved one’s life rather than their death.

My search for meaning in my late husband’s death was long and painful. Eventually I concluded there was no great meaning in his death, but I found renewed meaning in his short life. He loved his family, loved his country and loved to fly. He was simply one of the good guys and was memorialized by his commanding officer as “the man every father secretly hopes his daughter will bring home.” What more did I need to search for?

— Joanne Steen has more than 20 years’ experience as a national certified counselor, author, and educator on grief, loss and resilience, with a specialty in traumatic and line-of-duty losses. She is the co-author of Military Widow: A Survival Guide and the author of We Regret to Inform You: A Survival Guide for Gold Star Parents and Those Who Support Them. She is the founder and principal consultant of Grief Solutions, which offers customized training and resources on grief. Contact her at joanne@griefsolutions.net.

****

‘You aren’t grieving correctly’

By Claudia Sadler-Gerhardt

“Why are you still wearing your wedding ring?”

“You shouldn’t be dating yet. It’s too soon.”

“Why aren’t you dating yet? It’s been long enough.”

“Your kids need a dad. Find another husband.”

“Are you really still sleeping in your marital bed? Still living in the same house?”

“Plenty of divorced people are single parents, so this isn’t any different.”

Losing an intimate partner is profoundly life-altering at any time, but for a young adult (those ages 20 to 40), the loss is atypical and unexpected. There also appear to be societal expectations regarding what such off-time widows or widowers should do or should not do during this time of grief. Research supports that partner death increases the risk of physical and mental health concerns, including depression and anxiety, financial insecurity, loss of identity and loss of social connections. For the young widow or widower with children at home, becoming a sudden and unexpected single parent and the only income earner can be overwhelming.

There is a paucity of research and literature about off-time widowhood. There is also a lack of role models for the young widow or widower because cohort members are unlikely to have lost partners. Additionally, there is ambiguity about what behavior is socially acceptable for this age group. Support programs are often geared toward widows or widowers in later stages of life who have different needs and concerns than the younger widow or widower does. In addition, young parents who are simultaneously working and raising children have a lack of discretionary time for obtaining grief support.

Given the current COVID-19 pandemic, the continuing opioid crisis and high rates of motor vehicle accidents, it is likely that rates of young spousal death may increase. A colleague and I recently conducted a qualitative research investigation (unpublished) with six young widows and one young widower (all 20 to 40 years of age) whose partners had died within the past 10 years. We hoped to learn about their lived experience of widowhood, including relational, financial, parental and personal changes resulting from the death of a spouse or partner.

The first blatant phenomenon was that all of these widows and widowers had been told by someone that they were not grieving or acting correctly. Most of the issues revolved around when to date again (or not), when to remove wedding rings, when to change beds and whether to allow children to join the parent in the bed, and how to relate with their in-laws. Comments ranged from “children need a dad/mom” to opinions that it was way too early for the widow or widower to be dating. Another concern was the awkwardness of possibly dating someone who had known the spouse before their death. In-laws often disapproved of the surviving spouse returning to dating because that could essentially result in their adult child being “replaced” in the family. Additionally, it can be challenging for the surviving spouse to interact with or to maintain a relationship with their in-laws after the death of their spouse.

Another big change involved social and friendship relations. The participants reported losing friends who were uncomfortable having someone who was now single in a group of couples. In addition, friends were often uncomfortable asking or talking about the spouse or partner who had died, under the guise of not upsetting the griever. Widows reported feeling as if they didn’t fit in. Many were encouraged to “move on,” to remember that they were still young and needed to find someone to be with. Others were told that being widowed was similar to being divorced. Although in death, unlike with divorce, there is no other parent to help out.

Another big area of struggle related to identity. Who is this person now that they have been widowed? Are they still married or suddenly single? Stereotypical widows are not 40 years old. The young widow or widower often deals with being the only wage earner, a solo parent and the primary housekeeper and has little time to work on self-identity.

Most of the participants in our study were parents who expressed a need to stay healthy for their children. Children often were scared that the surviving parent might die. Work, parenting and other tasks left little time for the surviving parent to engage in self-care or grief support. Finding some semblance of balance was challenging. Social media was a convenient resource for helping these individuals learn about grief and obtain supportive networks. There are online groups for young widows, and there are also hospice services for their families. Making time to exercise was another challenge that was noted, although most of the study participants acknowledged its importance.

I have worked with many grievers for several years, taught undergraduate and graduate grief counseling courses, and presented numerous grief workshops. So, what have I learned about young off-time widows and widowers from a clinical counseling perspective?

Assessment is absolutely critical. Do not make assumptions. Assess from a biopsychosocial-spiritual perspective. Obtain referrals if appropriate. Assess family and in-law relationships.

Recognize the unique needs of the widow’s or widower’s developmental stage.

Give consideration to the utility of telehealth appointments if appropriate.

After ensuring that basic needs are being met, work with the widow or widower on areas such as identity and roles, social support, self-care and grief support.

Be aware that widows and widowers will likely experience others telling them how to grieve in the right way. Foster their ego strength in making their own decisions.

Above all, be a safe companion for these grievers while allowing time for their stories to be shared.

— Claudia Sadler-Gerhardt is a licensed professional clinical counselor with supervision designation in Ohio. She is a past president of the Association for Spiritual, Ethical and Religious Values in Counseling, a division of ACA. Contact her at drclaudiasadlergerhardt@gmail.com.

****

Behavioral manifestations of grief in young clients

By Rebekah Byrd

I had been working with Kai in play therapy for about six months because he was at risk of being kicked out of his third preschool due to problematic behaviors. He had been working hard and making progress but seemed to regress and was also experiencing a recent and intense overdependence on his mom.

Jordan, an adolescent, was referred to me because he was having explosive emotions. His temper tantrums had become so aggressive that his grandmother no longer felt safe around him.

As counselors, we are often working with children and adolescents because of an identified behavioral issue. We know that the presenting issue is rarely the problem. Rather, it is often a behavioral manifestation of the real underlying concern. Similarly, other reasons for seeking counseling services, such as anxiety or depression, are frequently manifestations of unrecognized grief and loss that have been unidentified, untreated or, often, misdiagnosed.

It is imperative that we remember and help other important figures in a child’s and adolescent’s life understand that what adults may understand as grief and loss might look very different for children and adolescents. Many of the concerns raised in Kai’s and Jordan’s cases are behavioral manifestation of grief. Regression, volatile emotions, acting-out behavior, temper tantrums, overdependence, a constant demand for attention, and aberrant activity are all common manifestations of grief among children and adolescents. The question is, how often do we miss these?

In the third edition of his book Play Therapy: The Art of the Relationship, Garry Landreth noted that when we focus on the problem, we miss the child. In my experience, children and adolescents are always communicating. Kai told his parents that his teacher had died. He was struggling to understand this. His parents assumed he was regressing into his old ways of lying. They were in disbelief that we had come so far in six months only to be right back where we started. Kai’s behavior had amped up to a level that seemed worse than when his preschool teachers were stating that he was at risk of losing his spot in the school’s program.

Full of frustration, worry and fear, Kai’s parents were asking me what to do. I understood that Kai was dealing with some very real themes of death and dying in the playroom. He was doing difficult work and trying to process these concepts through play in a very real way. I encouraged the parents to see these behavioral concerns as symptoms of grief and loss instead of assuming that Kai was reverting to old behaviors. We turned our focus to the child rather than on the problem.

Almost immediately, Mom started sobbing. She kept saying, “The assistant T-ball coach!” Dad then realized what was happening. They both remembered that Kai’s assistant T-ball coach had recently passed away. When Kai reported that his teacher had died, his parents had dismissed it as a lie, never considering the impact that an assistant T-ball coach could have on their 4-year-old and not thinking about how many 4-year-olds call any adult who works with them their “teacher.”

The parents felt awful that they had dismissed Kai’s real feelings of grief and loss and had also missed the opportunity to comfort him when he reached out to them using his words. (This was a major accomplishment for Kai, as it would be for most 4-year-olds who don’t understand grief and loss, much less why they are feeling such strong emotions.) The parents felt ridiculous for not putting this together sooner, and we were able to process that.

As counselors, we don’t always have this information, and as school counselors, we might not meet with parents or other important adults as much as we would like in order to put these pieces together. So, it is imperative that we recognize the many facets of grief and loss and the impact on children and adolescents so that we can assist in the healing process.

Jordan had suddenly lost his mom, and his grandmother was now his guardian. His loss was front and center for him and for those around him daily. However, his family had thought that Jordan had already worked through the loss of his mother. These “new” behaviors he was exhibiting (explosive emotions, temper tantrums, aggression) were treated as somehow being separate. It can be easy to assume that caregivers will make the connection between an adolescent’s acting out and their experience of grief, but what happens when the family/caregiver doesn’t see it that way or is too mired in their own grief and loss and is triggered by what this is bringing up for them?

When parents or caregivers are also grieving, adolescents may keep their sorrow to themselves. They may feel pressure to be “OK,” or they may feel responsible for not causing their grieving parents or caregivers further distress.

In addition, adults may recognize the issue of “primary loss” with children and adolescents — the substantial loss that often refers to the death of a loved one (in this case, Jordan losing his mother) — but overlook or lack awareness of the many secondary losses. “Secondary loss” refers to all the subsequent losses associated with the primary loss. In Jordan’s case, the secondary losses included losing his sense of safety and attachment to the world, his main source of support, his family role, his carefree attitude and happiness, his home (his mother’s death meant he needed to move in with his grandmother), his regular bus route and bus ride with familiar faces, and the list goes on and on.

Counselors must also understand how culture plays a role in child and adolescent processing and displays of grief and loss. Many types of grief and loss exist (e.g., ambiguous loss, anticipatory grief, complicated grief, delayed grief, disenfranchised grief, traumatic grief), along with different models for engaging in this process. Counselors must be able to recognize, acknowledge and affirm needs associated with grief and loss issues to assist clients in their healing journey. Because children and adolescents are not always able to verbally process feelings, the use of play therapy and expressive arts may be essential to the process of helping them cope and heal.

— Rebekah Byrd is a licensed professional counselor in Tennessee, a licensed clinical mental health counselor and licensed school counselor in North Carolina, a national certified counselor and a registered play therapist supervisor. She is an associate professor and director of the Institute for Play Therapy and Expressive Arts Education and Research at Sacred Heart University and co-author, with Chad Luke, of Counseling Children and Adolescents: Cultivating Empathic Connection. Contact her at byrdr@sacredheart.edu.

****

Helping professionals and the experience of personal loss

By Barb Kamlet

Two significant worlds collided in my life on Aug. 28, 2006. On that date, I started graduate school to earn my master’s degree in counseling and, earlier that day, my father and my family learned of his terminal diagnosis. In my first journal entry for my first class, Cultural Issues and Social Justice, I wrote the following: “Today I learned about two new cultures — those who believe they are living and those who know they are dying.”

It was a poignant and challenging time to be the grieving daughter of my dying father as I was going to graduate school to become a grief counselor. During the next 21 months, until my father’s death, I discovered yet another culture — that of helping professionals experiencing personal loss. It was a time filled with painful support gaps and myriad self- and other-imposed expectations that, as a therapist-to-be, I “should” already possess whatever coping skills I would need to navigate through the experience of my dad’s illness and death.

I rose to the occasion by confusing my roles. I became the counseling professional in interactions with my family — interpreting what I thought they needed to know and screening out what I thought they didn’t — and the grieving daughter with my colleagues — people who couldn’t remotely understand the relationship I had with my dad or the grief I was experiencing. Clearly, this was my way of avoiding what was really going on inside me.

Perhaps it was because I was working as a hospice grief counselor where my dad died that those expectations were so prevalent and that my questions eventually became twofold: Was I the only therapist who felt like this and, whether I was or not, could I go someplace for support where I wouldn’t be known, where I wouldn’t be using my “therapist brain” and where I wouldn’t run into my own clients if I chose to attend a grief support group?

Sadly, when I tried to research grief support for hospice professionals for my group’s class project, there wasn’t much, if any, to be found. So, real-time research became my invaluable go-to. In the course of that research, I learned there were other counselors and helping professionals who were experiencing similar challenges around their own personal losses.

Many spoke about a logistical challenge: In trying to find their own grief counselor, they faced a very real possibility of creating a dual relationship, particularly if they lived in a small community. Another common theme that echoed my own experience was the self- or other-imposed pressure to stay in role as a counselor, particularly with other grieving family members and counselor colleagues. Yet another widely expressed concern centered on the issue of transference, countertransference and possibly crossing professional boundaries when sitting with their own grieving clients. One interviewee expanded on that challenge, stating, “As a provider of grief support myself, this also led to my delayed reaction, as when I felt something, I intellectualized it.”

As Marion Conti-O’Hare wrote in The Nurse as Wounded Healer: From Trauma to Transcendence, “All too often … health professionals are reluctant to reveal themselves because of the potential for vulnerability, created largely by an orientation toward perfection and flawless performance.” For counselors and other helping professionals, hiding behind their professional role can serve as a protection or mask that allows them to compartmentalize or intellectualize their own grief. This is a means of avoiding potential vulnerability and the painful feelings of grief that we encourage our clients to journey through.

As a result of my research, I have had the opportunity to present at several national conferences, and the question I am asked most frequently is this: “We have a colleague whose loved one died recently, and we’re wondering how to help.” Knowing the challenges that we, as grief counselors, experience around finding our own support when we are grieving, I think the answer is a simple one. We should do just what we do for our clients and other grieving people in our lives — meet them where they are and ask them to share their story. Pervasively during my research, grieving colleagues, much like our grief clients, wanted the opportunity to share their story and have it heard without judgment.

A grief counselor captured the essence of that need when she wrote: “This time has been utterly transformative as I have experienced it through many lenses of the heart and mind and soul — and with both personal and professional perspectives. It would help me to be able to share this with someone interested in the many facets and [to be] able to ask questions that might assist me in organizing, integrating and reconciling my experience.”

Another colleague wrote more succinctly, “Not sure if you’ll find any added themes from my story, but I felt like sharing it anyway as a way to deal with my own grief.”

To paraphrase something ACA President S. Kent Butler wrote recently in his column for Counseling Today, when it’s us as counselors who are the bereaved, can we allow ourselves to be our human self rather than our counselor self? I challenge every counselor working with grieving clients to be the role model for your clients and for our grief-denying society at large by giving yourself the grace to be your human self when you find yourself in that sacred space of grief.

— Barb Kamlet is a licensed professional counselor and national certified counselor. Her private practice, GriefJourney Counseling PLLC, is in Aurora, Colorado. In addition, she is the co-founder and executive director of Shimmering Wings, a nonprofit dedicated to providing support and resources to individuals who have experienced a childhood death loss. She continues to do hospice grief counseling. Contact her at griefjourneycounseling@gmail.com.

samuelwong/Shutterstock.com

****

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.

****

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.

A firsthand experience of grieving pet loss

By Corban Smith August 10, 2021

Dallas came into my life at eight weeks old when I was only 19. The small brown bundle of rolls and wrinkles that clumsily paraded around my house with oversized paws never had any chance of developing into what most would consider a classically “good dog.” As he grew into his oversized appendages as a 115-pound lap dog, I was also developing through the tumultuous stage of emerging adulthood. As my social, occupational and personal identities solidified, Dallas remained a constant denominator across each dimension of my self-identity. I was a “dog owner,” and most who knew me were unable to picture me without my enormous and drooly companion at my side.

As life progressed, Dallas effortlessly provided the unconditional positive regard that so many counselors strive to exude to clients. He was present during graduations, new jobs, loss of family members and personally devastating health diagnoses. Whether I was joyous or tormented, Dallas was there to share in my experience and offer the validation I needed through his droopy brown eyes.

Eventually our family was complete when I met my now fiancée, a veterinary student at the time in the university where I was receiving my master’s in counseling. She promptly told me that Dallas was overweight and kindly pointed out other ways I could best serve Dallas. As we reached relationship milestones and eventually added another companion animal, Willett, Dallas seemed to become even more joyful and content.

Dallas (Photo courtesy of Corban Smith)

Dallas gets diagnosed

In the 11 years leading up to August 2019, Dallas had survived dozens of mischievous acts that threatened his well-being. So much so that although I knew his life eventually would come to an end, I couldn’t envision a world where anything could cause his demise. One morning that began as any other, I took Dallas outside to produce his abnormally large morning “business” deposits. I heard him emit a strange noise and looked down to see him convulsing on the grass. As he continued to seize, I held him as I never had before. Covered in morning dew, grass and dirt, I had never felt so helpless. I screamed for my partner, and once Dallas emerged from his postictal phase, we took him to his veterinarian.

The news was grim. Given my financial status, the veterinarian advised against costly diagnostic techniques, reasoning that I likely would be unable to afford the likewise costly treatments for whatever was discovered. He concluded that Dallas likely had a sinister brain tumor lurking in his furry brown head and said we should focus on making his remaining time with us as comfortable as possible. As the first pains of grief and guilt set in, I began experiencing shame that I could not afford to give Dallas the care that might prolong our time together just a little longer.

Armed with anti-seizure medication and the terrifying knowledge that Dallas would, in fact, no longer be with me one day, I began one of the most stressful years of my life. A pattern soon developed in Dallas’ symptom management. He would have an extended period of time with no symptoms, then a breakthrough seizure would emerge in the middle of the night like an evil intruder. My partner, now Dallas’ primary veterinarian, would reassess his medication, and the cycle would continue. Slowly, the periods of well-being shortened, and the breakthrough seizures increased in intensity.

This slow end-of-life process was excruciatingly unpredictable and painful as I began to experience a feeling of learned helplessness. Each evening, I crawled into bed terrified that at some point in the night, I would hear the initial gag that signaled an episode. During the day, I walked around the house dreading the discovery of puddles from postictal incontinence. I lamented this emotional roller coaster immensely. Periods of health were bright spots in my life, while breakthrough seizures were increasingly darker reminders of reality. I knew eventually, I would have to say the words: “This is it.”

The event

The gagging and thrashing noise signaling a seizure came, as it always did, in the middle of the night, just when I imagined that things were OK. This one felt different though. Not only did it last longer and cause more confusion afterward, but the unsettling truth that Dallas was at his maximum dosage for medication signified that this was, in fact, “it.” We waited apprehensively with a semblance of hope to see if another seizure came. Previous recurrent seizures had presented eight hours after the first; this next round came in just four.

Making the decision that this particular day would be Dallas’ final day was shamefully easy. A combination of emotional exhaustion, stress surrounding the impending doom, and the reality of treatment limitations all likely contributed. My partner was forced to go and work at the practice where we would remind Dallas that he was a “good boy” for the last time, while I got the privilege of spending Dallas’ last day with him. I was disassociated from what was coming later that day and treated it as simply any other day for Dallas. In between additional seizures that day, Dallas got to play his favorite game, “What Won’t Dallas Eat?” We lay on the couch and watched The Fifth Element (the movie in which Dallas’ namesake, Korben Dallas, is the protagonist) while his sister, Willett, licked his ears, attempting to rid his head of any hint of ill will. Eventually, the time came to load up, and I experienced the first sense of loss that snapped me back to reality. Leaving Willett behind, I told her, “We’ll be back,” then quickly amended that statement to “I’ll be back,” tears forming in my eyes.

I had experienced euthanasia of a pet only once before, when I was a little boy. I was transported back to my younger self on that day, attempting to organize thoughts of death and meaning of life in an intellectual way instead of experiencing the present pain. What had made this unavoidable outcome cognitively distant was Dallas’ presentation when he was not seizing. Even in the euthanasia room, Dallas presented in his usual demeanor. He happily ate Cheez Whiz sprayed on the floor for him, selflessly sharing the remnants on the clothes and faces of my partner’s co-workers as they came in one by one to say goodbye. Eventually, we were left alone with him.

My partner and I sat there, attempting to say our final goodbyes while Dallas tried to reassure us that everything would be OK. My partner was forced to take on the role of veterinarian in telling me what to expect. She kindly outlined the euthanasia process, as I am sure she had previously with countless other mourning owners, but her voice was shaky, and tears were forming in her eyes. Another veterinarian timidly knocked on the door and asked if we were ready. I shakily answered “yes” but truly was not. She knelt next to Dallas and began administering the chemical as I tried to remember every detail of my beloved companion lying on the floor. In true Dallas fashion — being the dog that could handle anything and survive — it took an extra dose of the lethal concoction for him to pass into the next world. Once my fiancée’s co-worker told us Dallas was gone, I embraced him wholly, one last time, and then truly broke down in a way that only a deep loss can provoke.

The Grief Process

Grief truly is a unique and unavoidable part of the human experience. We are all forced into grief through loss at some point in our lives. I had experienced loss before in the form of relationships, failed endeavors and hobbies deemed too dangerous for someone of my growing age. But these things were nothing compared to the way Dallas had deeply embedded himself within my self-identity. The pain of this loss permeated through my core.

As a counselor, I have been trained on grief, bereavement and the strategies we use to empower our clients. All of that knowledge and experience seemed to dissipate as soon as Dallas was diagnosed. Suddenly, grief and loss were not topics discussed in a classroom; they had become deeply personal.

Soon after Dallas was diagnosed, I had begun preparing for his loss as best I could through that classroom knowledge. I dusted off my crisis intervention textbook and attempted to remember the works of Elisabeth Kübler-Ross and William Worden. I quickly landed on Worden’s tasks of mourning model as I tried to intellectualize my now inevitable loss of Dallas. As a counselor, I try to promote resilience and empowerment in my clients. As I embarked on the dangerous endeavor of becoming my own counselor, I told myself to focus on the tasks I could accomplish to help myself emerge from this process more resilient than I had been going in.

Tasks of mourning

Worden’s tasks of mourning are not intended to be completed in any particular order and may be revisited throughout the mourning process. As soon as Dallas was diagnosed — and before I sought out knowledge of grief — I had begun to complete the tasks, and I continue to do so after the loss of Dallas. Sometimes I feel content in my accomplishment of tasks, whereas other times I am caught off guard by signs suggesting a lack of progress. My understanding of the grief process so far is that it ebbs and flows in a nonlinear, somewhat unpredictable manner throughout.

Task: Accept the reality of the loss. I began to accept the loss of Dallas conceptually as soon as he was diagnosed with the potential brain tumor. During the year of symptom management, I was able to work through this task on a surface level so that I thought I would be ready for my new reality when Dallas was gone.

Once Dallas had passed, I struggled with this task on a much deeper core level. I naively believed that the previous work on the task prior to Dallas’ departure would help insulate me from not accepting this new lonely reality. Returning home from the veterinary clinic on the day he was euthanized, I was most struck by the sense of numbness. The rest of that week’s activities and responsibilities seemed to pass me by because this new reality I was living in was foreign from the one I had known.

Technology was both a curse and a blessing as I attempted to gain footing on this task. I found myself clinging to Dallas’ presence through endless scrolling of the camera roll on my iPhone. As I scrolled upward, Dallas became younger and more the companion I idealized. Photos of him jumping as high as houseguests offered a stark comparison with the old man that had required assistance to get on the bed. The Live Photo feature was particularly unsettling. By holding my finger on a photo, Dallas all of a sudden sprang back to life, my phone emitting the daily sounds and visuals that I desperately longed for again in our home.

Social media did, however, provide one of the best mediums for memorializing Dallas as I continued through this task. My favorite photos discovered while scrolling were shared with friends and family in a memorial post. As others expressed sadness and condolences, I was astonished to learn how many other lives Dallas had touched. Friends and contacts long forgotten reemerged to share stories and memories of Dallas. Many of them validated my new reality without Dallas as being both painful and uncomfortable. Their support helped me better accept this different world and motivated me to move closer to it instead of resisting and staying in the one that was comfortable.

Task: Process the pain of grief. I am very fortunate in that any inhibition to process the pain of my grief was self-inflicted rather than being promoted by those around me. I have heard stories of those who lost pets whose grief was disenfranchised by those around them. Expectations to continue working while compartmentalizing grief plague many people after the loss of a companion animal. I was extremely fortunate that no one in my life placed such expectations on me. I was supported and understood as having just lost a family member that was deeply integrated in my self-identity.

My work on this task was predominantly inhibited by self-imposed restrictions. I falsely believed that the processing of loss completed since Dallas’ diagnosis would be sufficient for the actual event to be a mild speed bump on my road of productivity. The counselor in me said, “It is OK for you to experience this pain and have difficulty functioning,” but my cultural background stated simply, “Get over it.”

Toxic masculinity is prevalent in our world, and I am also guilty of propagating it. People who do not know me well would consider me a classic stereotype of masculinity by most metrics. I am genetically broad-shouldered and proudly wear a full beard. My previous hobbies have included skydiving, riding motorcycles and owning German sports cars. I drive an SUV to my Olympic weightlifting club, and my bias toward men who are similar to me says that the loss of a dog should not break such men down to tears or inhibit their ability to participate in life roles. As I viewed myself through this lens, I repressed the pain and the experiencing of it longer than I should have. Eventually, I could no longer be the stable and stoic presence in my home and work; I had to succumb to the pain.

As I began to reconcile my views on masculinity with what I knew as a counselor, I realized the feeling of pain and the expression of my emotions were among the manliest endeavors I could partake in. I shared my feelings and experience more freely with those around me and continued to be validated and supported as I tried to meet life’s demands while experiencing such pain.

Task: Adjust to a world with the deceased missing. Articles I read in advance of Dallas’ loss described the new home environment as having a “deafening silence.” As I attempted to mentally prepare for Dallas’ departure, I became attuned to the noises he emitted on a day-to-day basis. I tried to steel myself for what an absence of those noises might be like, but the void upon returning home after his passing was still debilitating.

My partner and I did our best to make this task as quick as possible. We removed all the reminders we could think of shortly after Dallas’ passing. Toys that were Dallas-sized and unattractive to Willett were donated to my partner’s practice for other dogs to enjoy. The tumbleweeds of short brown fur were sucked up from the various surfaces where they always clung. Dallas’ medications and food were removed. These physical reminders were easy to erase; classic conditioning ingrained over the span of 12 years was much more difficult to ignore.

Given the enormity of Dallas, there was little he could do that did not resonate throughout our small home. The clicking of his nails as he walked, the thud of furniture as he forcibly followed his intended path, even the heavy panting echoing through the house from his mere existence were all instantly gone. There was no longer a giant brown speed bump in the kitchen to navigate while we were cooking or a face of pure joy at the bottom of the steps when we returned home. Even watching TV at night without the occasional burst of flatulence from the corner of the sectional seemed a foreign experience.

Countless other experiences have become isolating and lonely affairs since Dallas passed. Thankfully, as time passes, this task becomes easier as the frequency of unexpected reminders diminishes. Eventually, I know the relationship between daily activities and Dallas’ presence will erode and disappear, shifting this void from absence to a new normal.

Task: Find an enduring connection with the deceased while embarking on a new life. Worden’s previous iterations of this task involved the phrases “emotional reallocation” and “emotional reinvestment.” This task is characterized by a sense of moving on while accepting and appreciating the impact of the loss on the griever’s life and self-identity. As I move forward in my life, it is impossible not to consider the impression my relationship with Dallas has left and the residual effects it will have in the future.

I think of all the lessons I learned from Dallas and how they will present in the future. I wonder how my capacity for caring for those around me would have changed without first caring for Dallas. I wonder how differently I would experience frustration without first building patience through Dallas’ destructive behaviors. Lastly, without experiencing the loss of Dallas, I wonder how much less prepared I would be for loss in the future. I feel that my experience of being a caregiver to Dallas has greatly elevated my ability to show compassion and kindness in other roles. Thanks to Dallas, I am able to be a bit better in my many life roles as a counselor, partner, son and friend.

Conclusion

As I continue to bounce between and progress within these tasks, I sometimes find myself wondering, “Am I doing this right?” Questions about whether I removed reminders too soon, carried on with life too soon or even made the decision to euthanize too soon have dominated my grieving process.

This experience has provided me better insight into a process that I had conceptualized only in a classroom previously. Being forced to confront this inevitable human experience has taught me to give clients who are grieving a lot of room and compassion and to hold minimal expectations about how they grieve. Grief is an individualized experience. While there are models, none perfectly encapsulates what it means, feels and looks like to grieve.

Our grieving process culminated last year as we traveled home for Christmas. Dallas lived his life, with the exception of his final five months, in my small home in Alabama. Before we moved into a proper home in Virginia with a fenced-in backyard, his outside time was spent on a picturesque patch of land next to a lake. Closing my eyes, I can still picture my happy and healthy Dallas splashing around and chasing geese, frequently looking back at me for encouragement. This location, where Dallas seemed his happiest, is where we spread his ashes on a cold Alabama day with tears in our eyes but a sense of resolve in our hearts. I hope that one day I do find him there again, splashing and galloping, just over the Rainbow Bridge.

****

Corban Smith is a doctoral student in the counseling and supervision program at James Madison University (JMU) with a specific interest in substance use and offender counseling. He currently works as both an adjunct faculty at JMU and as a jail/emergency services clinician at Valley Community Services Board. He and his wife reside in Harrisonburg, Virginia, where they enjoy being of service to any being they come across. Contact Corban at smitcor@icloud.com.

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

****

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.

Untangling trauma and grief after loss

By Lindsey Phillips May 4, 2021

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

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

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

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

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

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

Identifying traumatic grief

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

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

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

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

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

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

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

A new layer of loss

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

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

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

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

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

Grief is personal

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

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

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

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

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

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

Unspoken words

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

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

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

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

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

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

Processing the trauma

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

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

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

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

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

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

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

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

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

Creating new meanings

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

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

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

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

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

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

Finding a way forward

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

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

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

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

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

****

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

****

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

Gone but not missed: When grief is complex

By Bethany Bray January 27, 2021

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

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

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

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

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

It’s complicated

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

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

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

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

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

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

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

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

Related emotions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Unwrapping

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

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

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

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

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

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

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

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

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

Making meaning

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Leaning in

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

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

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

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

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

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

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

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

Forgiveness and compassion

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

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

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

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

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

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

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

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

****

Grief and doing your own work

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

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

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

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

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

****

Action steps for more information

Search for articles with the tag “grief and loss” at CT Online
Read Counseling Strategies for Loss and Grief by Keren M. Humphrey, published by ACA (imis.counseling.org/store).
Join the ACA Grief and Bereavement Interest Network (counseling.org/aca-community/aca-connect/interest-networks).

****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

****

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

Grief and the COVID-19 pandemic

By Sophia Caudle December 21, 2020

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

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

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

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

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

Traditional grief

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

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

Ambiguous grief

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

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

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

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

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

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

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

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

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

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

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

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

Original grief

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

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

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

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

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

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

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

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

****

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

****

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.

****

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.