Bereavement and grief counselling

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Bereavement and grief counselling HUGH PALMER

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Bereavement and mental health. . . . . . . . . . . . . . . . . . 5

What do the terms ‘bereavement’ and ‘grief’ mean?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Interventions and counselling . . . . . . . . . . . . . . . . . . . . 7

Models of grief and bereavement. . . . . . . . . . . . . . . . . 2 Freud and attachment-based models of grief . . . . . 3

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Reference list. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Stroebe and Schut’s dual process model. . . . . . . . . . 4

Further reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Continuing bonds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Relevant web pages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Narrative therapy: ‘saying hullo again’ and ‘re-membering’. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

LEARNING OUTCOMES • To be able to describe current models of grief. • To be aware of the mental health problems that result from bereavement. • To understand the impact of bereavement upon people with existing mental health problems. • To be able to consider interventions, including counselling, for people experiencing bereavement and loss.

SUMMARY OF KEY POINTS • Bereavement and grief are not illnesses – they are a normal part of the human experience. • Bereavement can sometimes become complicated and lead to mental health difficulties, and bereavement can be more problematic for people with existing mental health problems. • There are different approaches to bereavement, and more recent models have moved away from the idea of ‘moving on’ to the concept of maintaining a bond with the deceased person. • Most people who are bereaved do not necessarily need or benefit from counselling.

• Providing support to those who are bereaved requires basic counselling skills along with an appreciation of the process of grief. If you listen long enough and are open and nonjudgmental you will hear at least one story from each person about something ‘weird’ and unexplainable that connects them with the one who died. It’s there. They may not choose to disclose it for fear of ridicule. (Mother, aged 33, cited in Sormanti and August1 (pp.467–8))

INTRODUCTION This chapter is intended to introduce the reader to the topic of grief and bereavement work, with the recognition that bereavement can sometimes be a source of mental health

difficulties and that people experiencing mental health problems will also experience bereavement too. It is now recognized that there can be value in limited interventions 1

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Bereavement and grief counselling

made by health care practitioners (including mental health practitioners) in better outcomes for the bereaved. In the chapter, we will explore models of grief and bereavement, beginning with earlier approaches arising from Freud’s writing on melancholia, and moving on to cover attachment and more recent moves toward the idea of continuing bonds2 and ‘re-membering’.3 Following this, we will begin to think about bereavement and mental health, identify problems that arise as a result of bereavement, and

consider issues related to bereavement in people who have existing mental health problems. A section on interventions will consider approaches to working with the bereaved, and the chapter will conclude with a general discussion. This chapter is very much concerned with the craft of caring; even though this concept is not discussed in great detail here, the topic of grief and bereavement, especially with recent moves away from pathologizing some aspects of grief, mark this as a subject that encourages a holistic approach.

WHAT DO THE TERMS ‘BEREAVEMENT’ AND ‘GRIEF’ MEAN? Before exploring models of bereavement, it is worth understanding what the concepts of grief and bereavement entail. The English word bereavement comes from an ancient Germanic root word meaning ‘to deprive of, take away, seize, rob’, and the word grief stems from Middle English version of the Old French grief, from grever, ‘to burden’, which itself stems from the Latin gravare, ‘to cause grief, make heavy’. Another word frequently used in this context is mourn, from the Old English murnan, ‘to mourn, bemoan, long after’.

Modern use of the term bereavement is associated with the loss of a loved one, usually of a person or animal, normally through death. The response to this loss is typically grief, which can include a sense of sorrow, burden and heaviness, and mourning the loss is associated with feelings of longing for the person. All of us will have experienced loss of one sort or another, but how we respond to the loss is, in part, associated with our attachment to that which is lost. Our strongest attachments are usually to other people, especially family and close friends.

REFLECTION Spend a few moments thinking about something that you lost and did not find; perhaps a key or a favourite object. Write down your answers to the following questions: • What was your immediate reaction when you realized you had lost the item? • What words might describe your feelings at this time? • After your initial reaction, what were your following responses? • What other responses are you aware of having in the days and weeks following the loss? Often our immediate reaction to a loss is panic; perhaps even thinking that it cannot be true, that there must be some mistake. This is sometimes followed by searching for the lost object, eventually realizing that the object may never be found, perhaps feeling angry or sad about the loss and, in time, accepting that the object is gone. Depending on what the object was, we might replace it with something

else, but of course, if it had sentimental value, that emotional aspect of the item can never be replaced. Many approaches to grief and bereavement identify similar processes to those discussed above in describing responses to the loss of a loved person, and as the chapter progresses you will be able to relate your own experiences to the theoretical ideas and consider how you might use them in practice.

MODELS OF GRIEF AND BEREAVEMENT Bereavement affects all of us, and up until recently, grief often was treated as if it was an illness, with models drawing on Freud’s4 writing on mourning and melancholia, which conceptualized loss as a state that required a path to ‘recovery’, often identifying various stages of grief (for example, Worden’s5 four tasks of mourning or KüblerRoss’s6 five stages of grief), before a resolution culminating in the redirection of emotional ‘energy’ elsewhere.

More recent bereavement theorists, particularly Klass et al., 2 have challenged this approach, instead considering that bereaved people have a continuing bond with the deceased. Independently, some social constructionist, narrative therapists, notably White7 and Hedtke and Winslade, 3 have also questioned traditional approaches to working with death and bereavement, instead exploring ways for the bereaved individual to maintain a relationship

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Freud and attachment-based models of grief

with the dead person. They keep open possibilities of staying in love with a dead partner and the possibility of being able to continue to maintain and shape the identity of that person. This is in stark contrast with help that is directed towards enabling the bereaved person to recognize their feelings of loss and sadness, to accept the reality of the death and emotionally to move on to a life without the deceased person.

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Thinking about the concept of the craft of caring, it is e vident that the experiences of bereaved people can be viewed through two different lenses; one that considers aspects of grief (particularly those experiences that might be perceived as denying the reality of the loss) as abnormal or even pathological; or one that views these experiences holistically, and considers them normal, even if no more than a means to continue the relationship or bond with the deceased person.

REFLECTION Take a few minutes to consider your own views on bereavement and grief. Write down your answers to the following questions: • Do you think it is best for a person to ‘move on’ and get on with their life when someone close to them has died? If so, when should this happen? • Do you think that it is common for people to have unusual experiences, for example seeing or hearing a deceased person, when they are grieving? What explanations might there be for these experiences? What is your opinion?

FREUD AND ATTACHMENT-BASED MODELS OF GRIEF In his seminal paper, ‘Mourning and melancholy’, Sigmund Freud4 identified two forms of grief: Trauer (mourning) and Melancholie (melancholy). According to Freud, mourning is a normal reaction to the loss of a loved person, or to the loss of some abstraction (for example, ‘home’ or ‘liberty’). He identified that this is normal response to loss and should not considered to be an illness, and, following a period of grieving, a person will overcome their sorrow and become free and unburdened. In contrast to mourning, Freud suggested that, although melancholy derives from the same circumstances, it can present in more extreme and damaging ways, where the individual experiences profoundly painful dejection, loss of self-esteem, and loss of interest in the outside world. He suggests that in melancholia, the loss suffered can be of a real person or an idealized entity and the person sometimes does not know what they have lost; therefore melancholy can be related to the unconscious loss of a love object. According to Freud, someone with melancholia is preoccupied by the loss of the idealized object and can become extremely self- destructive and have very impaired self-esteem. Bowlby’s8 attachment theory was heavily influenced by Freud’s writing about the relationship people have to idealized objects and real figures, and attachment theory in turn influenced later writers on bereavement, particularly William Worden and Colin Murray Parkes. Bowlby identified three stages of grief – shock and numbness, yearning and searching, despair and disorganization. Later, Parkes9 added a fourth: reorganization. Bowlby agreed with Parkes and he also supported the idea of four stages that did not

necessarily follow sequentially, but might be experienced at different times. These stages are: • Shock and numbness. In this phase, there is a sense that the loss is not real and is not easy to accept. There can be physical distress during this phase, which can result in physical symptoms. • Yearning and searching. Here, the person is aware of the gap in their life left by the loss, with a loss of the imagined future that included the person. At this time, attempts to fill this void are made and the person may appear preoccupied with the deceased. • Despair and disorganization. Here, the bereaved person is able to accept that life has changed and cannot go back to how it was or how the person hoped. Some of the emotions associated with this phase are hopelessness, despair and anger and questioning. • Re-organization and recovery. In this phase the person begins to rebuild their life without their loved one and move on. Elizabeth Kübler-Ross was strongly influenced by Bowlby and Parkes and her well-known model of grief appeared in her book On death and dying,6 which outlines five stages of grief: denial, anger, bargaining, depression and acceptance. These stages are usually remembered by the acronym ‘DABDA’. As with the previous model, these stages are not necessarily experienced in sequential order. During the stage of denial, grieving people are unable or unwilling to accept the reality of the loss. They might feel 3

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as though they are experiencing a bad dream, that the loss is unreal, and they are waiting to ‘wake up’ as though from a dream, expecting that things will be normal. Once accepting the reality of the loss, the person may begin to feel anger at the loss and the unfairness of it. They may become angry at the person who has been lost or towards other people – for example, friends, relatives or caregivers. The next phase, bargaining, is characterized by the person begging a higher power to undo the loss, perhaps saying that if the person is returned to them, they will change. The next stage is one of depression, where the person confronts the reality of the loss and their own helplessness to change it. Ultimately, according to Kübler-Ross, the person will enter a stage of acceptance when they will have processed their initial grief reactions, accept the loss and begin to move on and plan for a future without the loved one. A similar model to these earlier approaches was proposed by Worden,5 whose tasks of mourning followed a similar set of stages, although in the latest edition, instead of the idea of ‘moving on’, he incorporated the concept that the bereaved can find an enduring connection with the dead person. • Task I: To accept the reality of the loss. When someone dies, there is often a sense of unbelief; that it cannot really have happened. This is sometimes referred to as denial, and part of this first task is to arrive at the realization, both intellectually and emotionally, that the person is dead and will not return. Rituals, such as funerals, are helpful to clients as they signify the reality of the death. • Task II: To process the pain of grief. Sometimes clients will try to avoid the intense pain of losing a loved one. Society offers us lots of opportunities to distract ourselves, and it encourages this due to subtle messages

about not showing distress and a general discomfort with grieving. However, processing the pain of loss and grief is necessary, and can help stop individuals carrying the pain into their future where it may be more difficult to work through. • Task III: To adjust to a world without the deceased. Losing a loved one requires the bereaved to make external, internal and spiritual adjustments. External adjustments might include having to take on roles previously undertaken by the dead person and having to undertake the normal tasks and activities of living in their absence. Internal adjustments are those changes that are required to create a new sense of identity without the person; ‘Who am I now?’ Spiritual adjustments are about the wider meaning of being bereaved and a changed relationship with the world, perhaps with a revision of spiritual beliefs. • Task IV: To find an enduring connection with the deceased in the midst of embarking on a new life. In this task the clients may find themselves considering how to stay emotionally connected with the deceased without it preventing them moving on in their own life. It is not a forgetting of the deceased, but rather the client finding themselves reconnecting and enjoying their life while remembering the memories and thoughts of and feelings about the loved one. Worden makes the point that there is no set time for these tasks to be completed, although it is likely that it would occur over months and years. He also acknowledges that, while it is essential to address these tasks to help adjust and assimilate to loss, any given individual may not experience loss or its intensity in the same way.

STROEBE AND SCHUT’S DUAL PROCESS MODEL Stroebe and Schut’s10 model proposes that the bereaved tend to cope with stressors by oscillating between two types of coping processes that they describe as ‘loss-orientation’ and ‘restoration-orientation’. Loss-orientation refers to how the bereaved cope with issues that are directly related to the loss (for example, feeling lonely or sad), and restoration-orientation refers to coping with issues related to the secondary changes brought about by the loss (for example, dealing with financial matters), and adapting to them. Stroebe and Schut consider that loss-oriented coping behaviours, such as crying and talking about feelings, can help people to process their emotions. On the other hand,

restoration-oriented coping behaviours, which might include developing new skills, such as managing finances, can help the bereaved person by distracting them, to an extent, from the focus on ‘loss’ as well as helping them to adapt to a different life. This dual process model proposes that the bereaved oscillate between confronting their stressors and taking breaks from their stressors. Stroebe and Schut recognize that the focus will shift between these dual processes, and that there will be times when individuals may be more focused on coping with the loss itself, while at other times they may be more focused on adapting to an altered life.

CONTINUING BONDS There has been a recent move towards thinking about ‘continuing bonds’ with the deceased person rather than ‘letting go’,2 and some social constructionist, narrative therapists (for

example, Michael White7 and Hedtke and Winslade3) offer therapeutic approaches intended to enable the bereaved individual to maintain a relationship with the dead person.

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Bereavement and mental health

Klass et al. 2 used the expression ‘continuing bonds’ as an alternative to the familiar model of grief that requires the bereaved to ‘let go’ from the deceased. They argued that the bereaved maintain a link with the deceased, which leads to the construction of a new relationship. This relationship continues and changes over time, typically providing the bereaved with comfort and solace. According to Normand et al.,11 ways in which the bereaved person can build a ‘new’ relationship with the deceased include talking to them, locating them (often in heaven), experiencing them in their dreams, visiting the grave, feeling the presence of the deceased, and participating in mourning rituals. Fraley and Shaver12 suggested that some forms of continuing bonds may be ‘healthier’ than others, and Epstein et al.,13 in a study that conflates dreaming and yearning, found that those who looked for their deceased partner in a crowd would also tend to dream of them still being alive. They concluded that:

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this may imply a conscious wish for the deceased to be alive again, a process reflected in, and occurring in parallel with, dreams of the deceased, and may constitute a lack of willingness to accept the death of their spouse.13 (p.264) It seems that incorporating the idea of continuing bonds within the traditional model still leaves considerable room to find pathology, especially if the overriding discourse is materialistic. However, if we can accept the view that maintaining a relationship, rather than ‘letting go’, might be a helpful approach to working with the bereaved, instead of considering whether or not experiences of contact with the deceased person are imagined or real, simply considering them as a means to continue the bond with the deceased person may prove to be useful.

NARRATIVE THERAPY: ‘SAYING HULLO AGAIN’ AND ‘RE-MEMBERING’ White,7 in a brief article entitled ‘Saying hullo again’, offered an alternative to the predominant ‘saying goodbye’ metaphor characterized by ‘letting go’ in traditional approaches to bereavement and, following on from his work, Hedtke and Winslade14 describe a focus of ‘re-membering’: a process that redirects the focus of grieving toward maintaining an ongoing relationship with the dead person. Here the bereaved can seek comfort in keeping the deceased person’s membership current in their own ‘membership club’ of life. They utilize the subjunctive as a means to open up new possibilities and new ways of understanding situations; in terms of bereavement, moving away from talking about the dead person in the past (she or he was a keen reader of Hello!) to ways of including the dead person in the present (she or he would enjoy this edition of Hello!).

Nell,15 also inspired by White’s paper, identified several strategies for saying hullo again, including writing letters to the deceased, visiting the grave and remembering them with others, but importantly also recognized the importance of using dreams as a means to say hullo again. According to Nell:15 Dreams of the deceased have an immense, yet mostly underutilized potential for assisting clients in dealing with their grief. Such dreams can powerfully instigate a saying hallo process in therapy which can be built upon by other methods in order to aid the client in reincorporating the lost relationship back into his or her life. Ignoring such dreams would be to unnecessarily deprive the client of a valuable connection with the deceased, and a powerful opportunity for healing. (p.8)

BEREAVEMENT AND MENTAL HEALTH Mental health problems as a result of bereavement Complicated grief refers to a description of the normal mourning process that leads to chronic or ongoing mourning (see Table 61.1). Psychoanalytically, mourning refers to the conscious and unconscious processes and behaviour related to the development of new ties, adapting to the loss (the internal process of redefining one’s view of self and the world) and adaptation to the loss (the external process of relating to the world, people, one’s roles, responsibilities

and so on). It has been in this area of complicated mourning and pathological grief that numerous terms came into existence to further clarify different factors of complicated mourning or pathological grief. Complicated grief occurs in about 10 per cent of bereaved people, and results from the failure to transition from acute to integrated grief.16 In these situations, acute grief is prolonged, in some cases even indefinitely. Individuals experiencing complicated grief generally are those who have difficulty accepting the death, and the intense separation and traumatic distress may last well 5

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Table 61.1 Complicated grief A. Stressor

Loss of a significant other

B. Intrusion

1. Occurrence of distressing, intrusive images, ideas, memories, recurrent dreams, or nightmares; the mind is flooded with emotions without a sense of reduction in intensity. 2. Illusions or pseudohallucinations. The mind is ‘haunted’ by a sense of presence of the deceased without a sense of reduction in intensity.

C. Denial

1. Maladaptive reduction in or avoidance of contemplation in thought, communication or actions on some important topics related to the loss. 2. Having an implicit relationship for more than 6 months with the deceased as if alive; keeping the belongings of the deceased exactly or completely as before.

D. Failure to adapt

1. Inability to resume work or responsibilities at home beyond 1 month after the loss. 2. Barriers to forming new relationships beyond 13 months after the loss. 3. Exhaustion, excessive fatigue or somatic symptoms having a direct temporal relation to the loss event and persisting beyond 1 month after the loss.

beyond six months. Bereaved individuals with complicated grief find themselves in a repetitive loop of intense yearning and longing that becomes the major focus of their lives, along with sadness, frustration and anxiety. The person experiencing complicated grief may perceive their grief as frightening, shameful and strange, and might believe that their life is over and that the intense pain they constantly endure will never cease.

Bereavement in mental health

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A bereaved individual with a pre-existing psychiatric disorder is especially vulnerable to depression and depression-related physical illnesses,17 and a study by Macias et al.18 found a correlation between the severity of grief and increased service contact by individuals with serious mental illness, who would often turn to their service providers when facing bereavement. They noted that, as the majority of individuals with serious mental illness are middle-aged and have aging parents, it seems imperative that mental health services are able to provide practical planning for bereavement as an essential service. The authors added that planning for this type of service should incorporate counselling, help with funeral arrangements and financial p lanning, and may include arranging for a move to supported housing. Something to bear in mind is that the person’s pre- existing mental health problems may overshadow a grief reaction, and consequently practitioners may be tempted to explain a change in symptoms as a change in the underlying mental health problem rather than considering that the person may actually be grieving. For this reason, it is important to be aware of baseline behaviour that would normally be expected for the person, and be alert for exacerbation of pre-existing mental illness. Sometimes previous unresolved losses may resurface during bereavement, particularly if the person is ambivalent about the relationship they had

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with the person who died. It is important that practitioners do not avoid discussions about the concepts of death, and maintain an awareness of the level of cognitive ability of the person that may influence their experience of loss.

Sense of ‘presence’ of the deceased One particular aspect of grief that many bereaved people report is that of sensing the presence of a deceased person in some way. These experiences are not uncommon – between 30 and 50 per cent of bereaved people experience this, according to some studies (for example, Guggenheim and Guggenheim19 or Marris20 ). Traditional grief literature typically describes these types of experience as ‘wishful thinking’ symptoms of grief (Parkes9) or even ‘hallucinations’, while popular literature attributes these experiences to ‘afterlife communication’, ‘afterlife encounters’ or sometimes ‘after death communication’ (for example, Arcangel,21 Newcomb,22 and Guggenheim and Guggenheim).19 Surprisingly little research has been undertaken into this relatively common phenomenon; most research done so far focuses largely on recording the types of experience (for example, Guggenheim and Guggenheim,19 Heathcote-James,23 Arcangel,21 and Newcomb).22 While all of these authors speculate on the significance of these experiences in providing evidence for an afterlife, none of them explore in any depth the meanings that are made by the people who have had the experiences. One notable exception is a paper by Sormanti and August,1 who have explored this type of phenomenon in terms of the effects upon the perceiver, and they identified that most parents in their study benefited from such experiences following the death of a child. According to Sormanti and August, bereaved parents use a range of strategies to handle their grief and to integrate both their experience of their child’s death and the dead child into their lives. They identified that one of these strategies is the:

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Interventions and counselling

phenomenon of continuing connection between parents and their deceased children, which has received little attention in the literature. In intensive work with a large number of bereaved parents, the authors have heard numerous reports of what might be termed ‘spiritual’ encounters with their deceased children. The encounters have included visions, physical sensations, dreams, and a variety of other experiences that made the parents feel connected to the children and seemed to help them in dealing with their grief.1 (p.461)

Prevalence of after death communication experiences One of the earliest studies of these phenomena was reported by the sociologist Peter Marris20 in his book on widowhood, in which he reported that 50 per cent of widows experienced the presence of their deceased spouse. More recently, Guggenheim and Guggenheim18 estimated that at least 50 million Americans (40 per cent of the population) have had one or more after death communications. This is based upon their research, which largely has been a collection of more than 3,500 reports of after death communication sourced from their project which began in 1988. It is not clear, however, how they arrive at their estimate, as their study consists largely of people who self-reported afterlife contacts, so it is hard to understand how they measured their sample against the wider population. In an earlier 1973 study, reported by Greenley,24 27 per cent of a sample of 1,467 Americans who were asked if they had ever felt they had contact with someone who had died replied that they had. In the UK, Rees25 discovered that of a sample of widows in Wales, 47 per cent had experiences (sometimes repeatedly over several years) that convinced them that their dead spouses had been in contact with them, although it is worth noting that this study described these experiences as ‘hallucinations’ and discounted dreams of the deceased. It is worth noting that Rees26 returned to this study nearly 30 years later, as he revised his opinion on the nature of the experiences, considering them to have important philosophical and psychological implications not only for individuals, but for society as a whole.

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Rees’s study was repeated in Canada by Dunn and Smith,27 who also found that 50 per cent of widows and widowers reported experiences of contact with their deceased spouse. Many of these respondents reported that they thought that they were ‘going crazy’ and had not previously informed anyone of their experiences as they expected to be ridiculed. All these studies undertaken in the West (even discounting Guggenheim and Guggenheim’s estimate) indicate that between 30 and 50 per cent of bereaved spouses experience some sense of afterlife contact with their deceased partner, and it can be safely assumed that this is a common feature of bereavement. Costello and Kendrick,28 in an ethnographic study that retrospectively explored the grief experiences of 12 older people whose partners had recently died in hospital, noted that in all but one case, the respondents reported having dreams about their partners. While recognizing these experiences are normal, they have been located as ‘hallucinations’ but ‘real to the people who experience them’, and this perhaps sums up the attachment-based tradition that suggests people who report a sense of contact with the deceased could be considered to have not completed the mourning process. Stroebe et al.29 went so far as to describe the traditional view of bereavement as the ‘breaking bonds perspective’, which holds that bonds with the deceased need to be broken for the healthy adjustment of the bereaved, and that any efforts to retain ties are abnormal and can lead to maladjustment.

REFLECTION Take a few minutes to think about someone you know who has been bereaved, and what might have helped them in the process. Write down your answers to the following questions: • What sort of skills do you think might be needed to support a bereaved client? • What issues might you need to consider before considering offering interventions? • How might you approach working with bereavement holistically?

INTERVENTIONS AND COUNSELLING It is important to remember that most people who are bereaved do not necessarily need or benefit from counselling, and in fact, according to a literature review by Wimpenny,30 interventions for some people experiencing normal grief may even be harmful. Intervening too early can impair the experiencing of emotional pain that is a normal, healthy response to loss, and is a necessary experience for the bereaved.

Nevertheless, both Wimpenny30 and Arthur et al.31 suggest that health, education and social care staff require a basic understanding and awareness of grief reactions in order to provide the confidence to provide the care that many say they lack. To provide appropriate support to those who are bereaved requires basic counselling skills along with an appreciation of the process of grief, such as that proposed by Worden.5 7

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While it is not the purpose of this chapter to explore specific counselling skills, any intervention with a bereaved person should be undertaken with the core conditions of warmth, empathy and genuineness outlined by Rogers.32 According to Worden,5 the overall goal of grief counselling is to ‘help the survivor adapt to the loss of a loved one and be able to adjust to a new reality without him or her’ (p.84). He goes on to link the process of counselling with the four tasks of mourning. It is important to bear in mind that, occasionally, medication might be required for depression or anxiety associated with chronic grief (see chapter 61 for more on psychopharmacology in clinical practice), but usually medication is not beneficial in resolving the sadness associated with bereavement;33 it is advisable that the grieving person experiences the pain of loss in order to move forward and recover.

Increasing the reality of the loss At this point, it is important to help the bereaved person talk about their loss. This can be encouraged through asking questions about the death; for example, where it happened, how the person found out about the death; or talking about the funeral: who was there and what was said about the dead person. Rituals such as visiting the gravesite, or the place where ashes were scattered, can also be helpful in reinforcing the reality of the loss. Careful and attentive listening can enable the bereaved person to talk and process the reality of the loss, especially as in most social and family situations the person may feel actively discouraged from being able to talk about their feelings. One important tip is to avoid using euphemisms such as ‘passed away’ or ‘resting in peace’ when counselling a person who is bereaved. When talking to a bereaved person, using the terms ‘dead’ or ‘died’ are unambiguous and reinforce the reality of the loss.

Helping the client deal with both the emotional and behavioural pain Often, people who are bereaved will want to avoid the pain they are experiencing and may even ask for medication to help them. However, it is really important to help the person accept and work through their pain, which may also include feelings of anger, guilt, anxiety, helplessness and loneliness. Sometimes a bereaved person will be angry – at the person who died, with themselves or towards other people, perhaps family members or professionals who cared for the person who died. Sometimes this anger will be directed at you. Letting the person know that these feelings are normal and providing a safe space for the person to ventilate them can be very healing. Gently encouraging the person to find counterexamples to the anger, perhaps feelings of forgiveness and acceptance, can be helpful, although this

should be undertaken with care and sensitivity so as not to appear to be invalidating the person’s feelings.

Helping the client overcome various impediments to readjustment after the loss The focus of interventions here is on supporting the bereaved person to adapt to a loss by facilitating their ability to live without the deceased and to make decisions independently. Worden5 recommends that the counsellor uses a problem-solving approach that explores the specific problems the survivor faces, and the means by which they can be resolved. It is worth bearing in mind that the person who died may have fulfilled several roles in the life of the bereaved person – for example, friend, companion, sexual partner, financial organizer, cook or decision-maker. Depending on these roles, the bereaved partner might feel quite lost, and sometimes help in developing practical, financial or decision-making skills can be valuable. Sometimes advice regarding social activities will encourage the bereaved person to create networks that provide company and companionship. Issues regarding the loss of a sexual partner will need handling with sensitivity, especially as some bereaved people will not feel ready to engage in intimate relationships for a considerable time following the death of a partner, if at all.

Helping the person to ﬁnd a way to maintain a bond with the deceased while feeling comfortable reinvesting in life Utilizing the narrative therapy concept of ‘re-membering’, described previously, can be tremendously helpful in helping the bereaved person maintain a bond with the deceased person, with the aim of keeping the voice of the dead person as a resource. Being able to talk freely about the dead person can bring renewed strength into a person’s life. You might consider asking the person about their relationship with the deceased person, and what they would think about the client now. This type of conversation has the potential to raise a new sense of worth and suggest that memories of their deceased loved one may serve as a resource for the future.

Systemic approaches to counselling From a more systemic, constructionist perspective, Gunzburg34 offers a helpful process of affirmation, deconstruction and reconstruction during therapy or counselling for people who are grieving. This process includes defining the problem, exploring the context and exploring options for the future. • Defining the problem. Here, the role of the therapist is to encourage clients to describe their emotions related to unresolved grief; therapists gain an understanding as to

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Conclusion

how clients construct their views of the context within which those emotions arose. • Exploring the context. When clients relate their problem to loss, the role of the therapist is to affirm the client’s view, highlight their strengths, and utilize creative resources to express unresolved grief. Alternately, some clients may relate their problem to a cause other than loss, often involving blaming and linear thinking. The role of the therapist is to deconstruct the client’s view,

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offering another context in which to view the problem. Therapists then can affirm the client’s changes and utilize creative resources to express unresolved grief. • Options for the future. Therapists and clients mutually reconstruct a context which offers autonomy, increased options, freer emotional expression, creative and holistic thinking, and new direction towards a more rewarding life and agreeable relationship.

CONCLUSION While this chapter is not intended to provide all the skills and knowledge that are necessary for formal grief counselling, it has provided an up-to-date overview of bereavement and grief counselling that will equip the reader with an awareness of the need for the bereaved to talk through their

loss, and an ability to recognize that people experiencing mental health problems can experience bereavement too. An awareness of the value of limited interventions by mental health practitioners in appropriate situations can lead to better outcomes for the bereaved.

SERVICE USER COMMENTARY I lost my mother in 2010, aged 77. Although it was at the end of a long illness, the passing of mum was a very traumatic time for me. I was already having an episode of depression; then losing mum escalated the deterioration of my mental state. I consider this chapter to give a very comprehensive insight into the issues surrounding bereavement and grief and the connection with mental illness. It emphasizes that bereavement and grief are a normal part of the human experience, while highlighting that bereavement can be more problematic for those with existing mental health problems. Quite importantly, it states that recent approaches to bereavement have moved away from the idea of ‘moving on’ to the concept of maintaining a bond with the deceased person. I believe it is a matter of personal choice whether a person should ‘move on’ and get on with their life when someone close to them has died. My experiences of my deceased mother are often moments of reflection on the happy times we spent together, and also remembering her words of wisdom and encouragement. Though I knew mum had gone, there was this void in my life which is very difficult to explain, but it left me with a very empty feeling of total loss. At this stage the rebuilding

process began as I accepted that my life has to go on, with my focus being my wife, children and myself. The chapter suggests that many people who are bereaved do not necessarily need or benefit from counselling. This I would agree with, as counselling sessions may not necessarily be the most effective way of dealing with such a great loss. However, support for the bereaved may require basic counselling skills and appreciation of the process of grief. I would agree that a bereaved individual with a pre-existing disorder is more vulnerable to depression and depression-related physical illnesses. I feel it is particularly important to remember that a high percentage of individuals with serious mental illness are middle-aged and have ageing parents. I strongly believe that the bereaved should be supported to accept and work through their pain, which may include dealing with anger at the person who has died. Loneliness, anxiety and helplessness can also be a major challenge. Therefore I want to stress the importance of having an active, supportive network of family and friends to help with the grieving process. For me, this chapter gives a good overview of bereavement and grief counselling, while acknowledging that it does not provide all the skills and knowledge necessary for formal grief counselling.

Reference list 1. Sormanti M, August J. Parental bereavement: spiritual connections with deceased children. American Journal of Orthopsychiatry 1997; 67(3): 460–9. 2. Klass D, Silverman P, Nickman S (eds). Continuing bonds. New York: Routledge, 1996. 3. Hedtke L, Winslade J. Re-membering lives: conversations with the dying and the bereaved. Amityville: Baywood Publishers, 2004. 4. Freud S. Mourning and melancholia. Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. XIV (1914–1916): On the history of the psycho-analytic movement,

papers on metapsychology and other works. London: Hogarth Press, Institute of Psycho-Analysis, 1957: 237–58. 5. Worden W. Grief counselling and grief therapy: a handbook for the mental health practitioner, 4th edn. New York: Springer, 2009. 6. Kübler-Ross E. On death and dying. London: Routledge, 1969. 7. White M. Saying hullo again. In: White M (ed.). Selected papers. Adelaide: Dulwich Centre Publications, 1989: 17–29. 8. Bowlby J. Attachment. Attachment and loss. Volume 1. New York: Basic Books, 1969.

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9. Parkes CM. Bereavement: studies of grief in adult life. London: Tavistock, 1972. 10. Stroebe MS, Schut H. The dual process model of coping with bereavement: rationale and description. Death Studies 1999; 23(3): 197–224. 11. Normand C, Silverman P, Nickman S. Bereaved children’s changing relationship with the deceased. In: Klass D, Silverman P, Nickman S (eds). Continuing bonds. New York: Routledge, 1996: 87–111. 12. Fraley RC, Shaver PR. Loss and bereavement: attachment theory and recent controversies concerning ‘grief work’ and the nature of detachment. In: Fraley RC, Shaver PR (eds). Handbook of attachment theory and research. New York: Guilford, 1999: 735–59. 13. Epstein R, Kalus C, Berger M. The continuing bond of the bereaved towards the deceased and adjustment to loss. Mortality 2006; 11(3): 3. 14. Hedtke L, Winslade J. The use of the subjunctive in re- membering conversations with those who are grieving. Omega 2005; 50(3): 197–215. 15. Nell HW. The saying hallo metaphor as alternative approach to death-related counselling. Paper presented at 3rd Global Conference on Making Sense of Dying and death, Vienna, Austria, 2004. Available from: https://www.inter-disciplinary. net/ptb/mso/dd/dd3/nell%20paper.pdf [Accessed 25th July 2016]. 16. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry 2009; 8(2): 67–74. 17. Mazure C, Bruce M, Maciejewski P, Jacobs C. Adverse life events and cognitive-personality characteristics in the prediction of major depression and antidepressant response. American Journal of Psychiatry 2000; 157(6): 896–903. 18. Macias C, Jones D, Harvey J, Barreira P, Harding C, Rodican C. Bereavement in the context of serious mental illness. Psychiatric Services 2004; 55(4): 421–6.

19. Guggenheim B, Guggenheim J. Hello from heaven! New York: Bantam, 1997. 20. Marris P. Widows and their families. London: Routledge & Kegan Paul, 1958. 21. Arcangel D. Afterlife encounters. Charlottesville: Hampton Roads, 2005. 22. Newcomb J. Angels watching over me. London: Hay House, 2007. 23. Heathcote-James E. After-death communication. London: Metro Publishing, 2004. 24. Greenley AM. The sociology of the paranormal: a reconnaissance. London: Sage, 1975. 25. Rees WD. The hallucinations of widowhood. British Medical Journal 1971; 4(5778): 37–41. 26. Rees WD. Death and bereavement: the psychological, religious and cultural interfaces, 2nd edn. London: Whurr, 2001. 27. Dunn E, Smith J. Ghosts: their appearance during bereavement. Canadian Family Physician 1977 (October):121–2. 28. Costello J, Kendrick K. Grief and older people: the making or breaking of emotional bonds following partner loss in later life. Journal of Advanced Nursing 2000; 32(6): 1374–82. 29. Stroebe M, Gergen MM, Gergen KJ, Stroebe W. Broken hearts or broken bonds: love and death in historical perspective. American Psychologist 1992; 47(10): 1205–12. 30. Wimpenny P. Literature review on bereavement and bereavement care. Aberdeen: Robert Gordon University, 2006. 31. Arthur A, Wilson E, James M, Stanton W, Seymour J. Bereavement care services: a synthesis of the literature. London: Department of Health, 2011. 32. Rogers CR. On becoming a person: a therapist’s view of psychotherapy, 4th edn. London: Constable, 1967. 33. Warner J, Metcalfe C, King M. Evaluating the use of benzodiazepines following recent bereavement. British Journal of Psychiatry 2001, 178: 36–41. 34. Gunzburg J. ‘What works?’ Therapeutic experience with grieving clients. Journal of Family Therapy 1994; 16: 159–71.

Further reading Wilson J. Supporting people through loss and grief: an introduction for counsellors and other practitioners. London: Jessica Kingsley, 2014.

Worden W. Grief counselling and grief therapy: a handbook for the mental health practitioner, 4th edn. New York: Springer, 2009.

Relevant web pages These websites provide useful information on bereavement and resources for both professionals and clients. Cruse Bereavement Care. http://www.cruse.org.uk/ NHS. Bereavement. http://www.nhs.uk/Livewell/bereavement/ Pages/bereavement.aspx

Royal College of Psychiatrists. Bereavement. http://www.rcpsych. ac.uk/healthadvice/problemsdisorders/bereavement.aspx

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