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Bereavement and grief counselling

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  • Independent Researcher

Abstract

Bereavement and grief counselling for nurses. A systemic perspective
1
Bereavement and grief
counselling
61
HUGH PALMER
Introduction ......................................1
What do the terms ‘bereavement’ and
‘grief mean?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Models of grief and bereavement .................2
Freud and attachment-based models of grief .....3
Stroebe and Schut’s dual process model ..........4
Continuing bonds ................................4
Narrative therapy: ‘saying hullo again’ and
‘re-membering’ ...................................5
Bereavement and mental health ..................5
Interventions and counselling ....................7
Conclusion .......................................9
Reference list .....................................9
Further reading ................................. 10
Relevant web pages ............................10
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 bereave-
ment can be more problematic for people with exist-
ing 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
is 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
diculties and that people experiencing mental health
problems will also experience bereavement too. It is now
recognized that there can be value in limited interventions
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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. is
chapter is very much concerned with the cra 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 under-
standing what the concepts of grief and bereavement entail.
e 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 aer’.
Modern use of the term bereavement is associated with
the loss of a loved one, usually of a person or animal, nor-
mally through death. e 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, associ-
ated with our attachment to that which is lost. Our strong-
est 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 nd; 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?
Oen our immediate reaction to a loss is panic; per-
haps even thinking that it cannot be true, that there must
be some mistake. is 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 emo-
tional aspect of the item can never be replaced.
Many approaches to grief and bereavement identify simi-
lar processes to those discu ssed 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 theoret-
ical ideas and consider how you might use them in practice.
MODELS OF GRIEF AND BEREAVEMENT
Bereavement aects all of us, and up until recently, grief
oen was treated as if it was an illness, with models draw-
ing on Freud’s4 writing on mourning and melancholia,
which conceptualized loss as a state that required a path
to ‘recovery’, oen identifying various stages of grief (for
example, Worden’s5 four tasks of mourning or Kübler-
Ross’s6 ve 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 consider-
ing that bereaved people have a continuing bond with
the deceased. Independently, some social construction-
ist, 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 indiv idual to maintain a relationship
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with the dead person. ey keep open possibilities of stay-
ing in love with a dead partner and the possibility of being
able to continue to maintain and shape the identity of that
person. is 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.
inking about the concept of the cra of caring, it is
ev ident that the ex periences of bereaved people can be viewed
through two dierent 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 patho-
logical; or one that views these experiences holistically, and
considers them normal, even if no more than a means to con-
tinue 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 identied 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 identied 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 sug-
gests that in melancholia, the loss suered 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 inuenced by
Freud’s writing about the relationship people have to ide-
alized objects and real gures, and attachment theory in
turn inuenced later writers on bereavement, particularly
William Worden and Colin Murray Parkes. Bowlby iden-
tied 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
dierent times. ese stages are:
Shock and numbness. In this phase, there is a sense that
the loss is not real and is not easy to accept. ere 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 le by the loss, with a loss of the imag ined
future that included the person. At this time, attempts to
ll this void are made and the person may appear preoc-
cupied with the deceased.
Despair and disorganization. Here, the bereaved per-
son 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 inuenced by
Bowlby and Parkes and her well-known model of grief
appeared in her book On death and dying,6 which outlines
ve stages of grief: denial, anger, bargaining, depression
and acceptance. ese 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. ey might feel
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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. ey
may become angr y at the person who has been lost or towards
other people – for example, friends, relatives or caregivers.
e 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. e 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 nd an enduring connection with the dead person.
Task I: To accept the reality of the loss. When someone
dies, there is oen a sense of unbelief; that it cannot
really have happened. is is sometimes referred to
as denial, and part of this rst 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 oers us lots of opportunities to distract our-
selves, 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 dicult
to work through.
Task III: To adjust to a world without the deceased.
Losing a loved one requires the bereaved to make exter-
nal, internal and spiritual adjustments. External adjust-
ments 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 rela-
tionship with the world, perhaps with a revision of
spiritual beliefs.
Task IV: To nd an enduring connection with the
deceased in the midst of embarking on a new life. In this
task the clients may nd 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 nding
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 experi-
ence 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 restora-
tion-orientation refers to coping with issues related to the
secondary changes brought about by the loss (for example,
dealing with nancial 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 nances,
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 dierent life.
is 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 shi 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
ere has been a recent move towards thinking about ‘contin-
uing bonds’ with the deceased person rather than ‘lettinggo’,2
and some social constructionist, narrative therapists (for
example, Michael White7 and Hedtke and Winslade3) oer
therapeutic approaches intended to enable the bereaved indi-
vidual to maintain a relationship with the dead person.
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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.
ey argued that the bereaved maintain a link with the
deceased, which leads to the construction of a new rela-
tionship. is 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 (oen in
heaven), experiencing them in their dreams, visiting the
grave, feeling the presence of the deceased, and partici-
pating in mourning rituals.
Fraley and Shaver12 suggested that some forms of con-
tinuing bonds may be ‘healthier’ than others, and Epstein
et al.,13 in a study that conates 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.
ey concluded that:
this may imply a conscious wish for the
deceased to be alive again, a process reected
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 nd 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 con-
sidering 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’,
oered an alternative to the predominant ‘saying good-
bye’ metaphor characterized by ‘letting go’ in tradi-
tional 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 com-
fort in keeping the deceased person’s membership cur-
rent in their own ‘membership club’ of life. ey 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, identied 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 impor-
tance 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 mourn-
ing (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 redening 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 mourn-
ing and pathological grief that numerous terms came into
existence to further clarify dierent factors of complicated
mourning or pathological grief.
Complicated grief occurs in about 10 per cent of
bereaved people, and results from the failure to transi-
tion from acute to integrated grief.16 In these situations,
acute grief is prolonged, in some cases even indenitely.
Individuals experiencing complicated grief generally are
those who have diculty accepting the death, and the
intense separation and traumatic distress may last well
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beyond six months. Bereaved individuals with complicated
grief nd themselves in a repetitive loop of intense yearn-
ing and longing that becomes the major focus of their lives,
along with sadness, frustration and anxiety. e 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
A bereaved individual with a pre-existing psychiat-
ric 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 oen turn to their ser-
vice providers when facing bereavement. ey noted that,
as the majority of individuals with serious mental illness
are middle-aged and have aging parents, it seems imper-
ative that mental health services are able to provide prac-
tical planning for bereavement as an essential service. e
authors added that planning for this type of service should
incorporate counselling, help with funeral arrangements
and nancial planning, and may include arranging for a
move to supported housing.
Something to bear in mind is that the persons 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 underly-
ing mental health problem rather than considering that the
person may actually be grieving. For this reason, it is impor-
tant 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
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 inuence 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 per-
son in some way. ese 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 ‘hallucina-
tions’, while popular literature attributes these experiences
to ‘aerlife communication’, ‘aerlife encounters’ or some-
times ‘aer death communication’ (for example, Arca ngel,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 expe-
rience (for example, Guggenheim and Guggenheim,19
Heathcote-James,23 Arcangel,21 and Newcomb).22 While all
of theseauthors speculate on the signicance of these expe-
riences in providing evidence for an aerlife, none of them
explore in any depth the meanings that are made by the
people who have had the experiences. One notable excep-
tion is a paper by Sormanti and August,1 who have explored
this type ofphenomenon in terms of the eects upon the
perceiver, and they identied that most parents in their
study beneted 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. ey identied that one of
these strategies is the:
Table 61.1 Complicated grief
A. Stressor Loss of a signicant other
B. Intrusion 1. Occurrence of distressing, intrusive images, ideas, memories, recurrent dreams, or
nightmares; the mind is ooded 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.
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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 aer
death communications. is is based upon their research,
which largely has been a collection of more than 3,500 reports
of aer 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 aerlife 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.
Rees’s study was repeated in Canada by Dunn and
Smith,27 who also found that 50 per cent of widows and wid-
owers 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 t hese studies underta ken in the West (even discount-
ing Guggenheim and Guggenheim’s estimate) indicate that
between 30 and 50 per cent of bereaved spouses experience
some sense of aerlife contact with their deceased partner,
and it can be sa fely assumed t hat 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 hospi-
tal, 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 peo-
ple 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 bereave-
ment 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 eorts 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 oering 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 benet from coun-
selling, 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 nor-
mal, healthy response to loss, and is a necessary experience
for the bereaved.
Nevertheless, both Wimpenny30 and Arthur et al.31 sug-
gest that health, education and social care sta require a
basic understanding and awareness of grief reactions in
order to provide the condence to provide the care that
many say they lack.
To provide appropriate support to those who a re bereaved
requires basic counselling skills along with an appreciation
of the process of grief, such as that proposed by Worden.5
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Bereavement and grief counselling
61
8
While it is not the purpose of this chapter to explore
specic 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 counsel-
ling 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 med-
ication is not benecial 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. is can be encouraged through ask-
ing questions about the death; for example, where it hap-
pened, how the person found out about the death; or talk ing
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 per-
son who is bereaved. When talking to a bereaved person,
using the terms ‘dead’ or ‘died’ are unambiguous and rein-
force the reality of the loss.
Helping the client deal with both the
emotional and behavioural pain
Oen, 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 per-
son 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 peo-
ple, 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 nor-
mal and providing a safe space for the person to ventilate
them can be very healing. Gently encouraging the person
to nd 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
e focus of interventions here is on support ing 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 prob-
lem-solving approach that explores the specic 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 fullled several roles in the life of the
bereaved person – for example, friend, companion, sex-
ual partner, nancial organizer, cook or decision-maker.
Depending on these roles, the bereaved partner might
feel quite lost, and sometimes help in developing practi-
cal, nancial or decision-making skills can be valuable.
Sometimes advice regarding social activities will encour-
age the bereaved person to create networks that provide
company and companionship. Issues regarding the loss of
a sexual partner will need handling with sensitivity, espe-
cially 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 help-
ing the bereaved person maintain a bond with the deceased
person, with the aim of keeping the voice of the dead per-
son 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. is 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 oers a helpful process of armation, decon-
struction and reconstruction during therapy or counselling
for people who are grieving. is process includes dening
the problem, exploring the context and exploring options
for the future.
Dening 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
K22262_C061.indd 8 10/25/16 10:35 AM
Conclusion 61
9
how clients construct their views of the context within
which those emotions arose.
Exploring the context. When clients relate their prob-
lem to loss, the role of the therapist is to arm the cli-
ent’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, oen involving blaming and linear thinking. e
role of the therapist is to deconstruct the client’s view,
oering another context in which to view the problem.
erapists then can arm the client’s changes and uti-
lize creative resources to express unresolved grief.
Options for the future. erapists and clients mutually
reconstruct a context which oers 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 counsel-
ling, 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 men-
tal 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 trau-
matic 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 expe-
rience, while highlighting that bereavement can be more
problematic for those with existing mental health prob-
lems. 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 counsel-
ling 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-re-
lated physical illnesses. I feel it is particularly important to
remember that a high percentage of individuals with seri-
ous 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 deal-
ing with anger at the person who has died. Loneliness, anxi-
ety 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 bereave-
ment and grief counselling, while acknowledging that it
does not provide all the skills and knowledge necessary for
formal grief counselling.
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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
K22262_C061.indd 10 10/25/16 10:35 AM
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What are the different theories of grief? What skills do you need for effective counselling? How can you support people experiencing loss and grief? This handbook provides a comprehensive guide to counselling and supporting people experiencing loss and grief. It introduces the different models and theories of grief, how theory relates to practice and what the essential skills are, and how to work with people in practice. Working with families, understanding diversity and assessing clients are all covered, as well as a chapter on personal and professional development. Case studies and real life examples demonstrate skills in action, and each chapter concludes with notes for trainers. This essential guide will help all those working with people suffering loss and grief to understand grief and how to help. Counsellors, bereavement support volunteers, palliative care nurses, hospice volunteers and students in these fields will all find this an invaluable resource. It can be used as a training guide as well as a resource for individuals, both as a learning tool and for continuing professional development.
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This paper reports on a systematic literature review of bereavement and bereavement care commissioned in Scotland to assist the development of policy and practice there. The review identified and appraised papers from a range of health and social care settings in which bereavement care b a feature, such as acute, hospice- and hospital-based care including neonatal and obstetric, community and primary care, mental health and learning disability services, and care of older people, families and children. Specific types of death were also reviewed, eg traumatic and from (tiseases such as HIV/AIDS. Key messages for each setting and type were identified and overall themes were drawn out which cut across at settings and types. These, it is proposed, represent important features of bereavement and bereavement care which, if acknowledged and addressed, could enhance services.
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Our aims in this chapter are to summarize J. Bowlby's theoretical contributions to the study of bereavement, and to review recent research and controversies concerning attachment theory and loss. We begin with a broad review of Bowlby's key ideas as expressed in the Attachment and Loss trilogy. We discuss Bowlby's ideas on the function and course of mourning, and review theory and research on patterns of "disordered" mourning. Next we discuss recent controversies that question 2 of Bowlby's important claims: his claim that the suppression of grief has negative consequences, and his purported claim that recovery from loss entails arriving at a state of "detachment". In both cases, we conclude that Bowlby was essentially correct, although not privy to recent findings that allow elaboration and further specification of his ideas. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The nature of the ongoing bond between the bereaved and the deceased has attracted some considerable attention in recent years. Early theorists proposed that the continuing maintenance of such a bond is indicative of a failure to adjust to the loss, whereas more recent work has questioned the validity of this position. Problematic within these opposing positions is the fact that many different theorists and researchers have operationalized the notion of “continuing bonds” in different ways, and consequently have found different relationships with adjustment. The current study investigated the different types of ongoing bonds endorsed by a group of spousally-bereaved participants (n = 45), and by subjecting the results to principal components analysis found three independent facets of continuing bonds: sensing the presence of the deceased, communicating with the deceased and re-living the relationship, and dreaming of and yearning for the deceased. Each of these factors was found to have a different relationship with various indices of current adjustment, and the clinical implications of these are considered.