Grief counseling

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A man working with his counsellor. Counselling session.jpg
A man working with his counsellor.

Grief counseling is a form of psychotherapy that aims to help people cope with the physical, emotional, social, spiritual, and cognitive responses to loss. These experiences are commonly thought to be brought on by a loved person's death, but may more broadly be understood as shaped by any significant life-altering loss (e.g., divorce, home foreclosure, or job loss). [1]

Contents

Grief counselors believe that everyone experiences and expresses grief in personally unique ways that are shaped by family background, culture, life experiences, personal values, and intrinsic beliefs. [2] They believe that it is not uncommon for a person to withdraw from their friends and family and feel helpless; some might be angry and want to take action. Some may laugh while others experience strong regrets or guilt. Tears or the lack of crying can both be seen as appropriate expressions of grief. [3]

Grief counselors know that one can expect a wide range of emotion and behavior associated with grief. Some counselors believe that in virtually all places and cultures, the grieving person benefits from the support of others. [4] Further, grief counselors believe that where such support is lacking, counseling may provide an avenue for healthy resolution. Grief counselors also believe that where the process of grieving is interrupted, for example, by the one who is grieving having to simultaneously deal with practical issues of survival or by their having to be the strong one who is striving to hold their family together, grief can remain unresolved and later resurface as an issue for counseling. [5]

Counseling

Grief counseling is commonly recommended for individuals who experience difficulties dealing with a personally significant loss. Grief counseling facilitates expression of emotion and thought about the loss, including their feeling sad, anxious, angry, lonely, guilty, relieved, isolated, confused etc.

Grief counseling facilitates the process of coming to terms with the loss that the individual has experienced, and processing through the natural progression of feelings that might come with different stages of coping with the loss. Grief counselling sessions also encompass segments on increasing an individual's personal and social resources to cope better with grief. There are considerable resources online covering grief or loss counseling such as the Grief Counseling Resource Guide from the New York State Office of Mental Health. [6]

Types of grief

There are various types of grief that individuals might go through. [7] The most commonly seen types of grief fall into these four categories:

Anticipatory grief

Anticipatory grief refers to a sense of loss before the actual occurrence of loss. This can occur when a loved one has a terminal illness, [8] or one is personally being diagnosed with a chronic illness, or when one faces the imminent loss of some human function.

Normal grief

Normal grief is the natural experience of loss and emotions accompanies the death of a loved one, and usually subsides in intensity over time. Normal grief is usually accompanied by the symptoms of a depressed mood, sleep disturbances, and crying. [9]

Complicated grief

Grief that is prolonged and resultant in severe behavioral concerns such as suicidal ideation, addictions, risk-taking behavior, or displaying symptoms of mental health concerns. Research shows up to 10% of bereaved adults may experience prolonged grief. [10] In these situations, more in-depth counseling and psychotherapy would be important in helping the individual recover from the traumatic loss.

Disenfranchised grief

Disenfranchised grief is grief that is not made known to, or not recognized by, others. An example could be the case of an extramarital lover whose lover passed on. In these cases, the grieving process is compromised as they are unable to process through this grief with others and receive the social support they need to overcome their grief.

Theories on the grief cycle

Joanne Jozefowski in 1999 through The Phoenix Phenomenon: Rising from the Ashes of Grief [11] summarizes five stages to rebuild a shattered life.

The most commonly acknowledged and cited grief model is the Five Stages of Grief by Dr. Elizabeth Kübler-Ross, [12] which posits that individuals who experience grief tend to go through a cycle of these 5 stages:

  1. Denial - Arises as a result of the shock experienced by individuals, and can manifest in the form of numbness, nonchalence, or avoidance. This is a survival instinct of the mind to help individuals pace out the emotional impact that the loss has on the individual.
  2. Anger - After the reality of the individual's death has set in, anger sets in as well, as individuals starts placing the blame on others or themselves. They might also question their religion.
  3. Bargaining - At the stage, individuals might begin to ask many "If Only" and "What If" questions, imagining what could have been, should surrounding circumstances be different.
  4. Depression - This stage is when sadness and feelings of hopelessness sets in, as one realises the irreversibility of death. The emptiness experienced as a result of the gap that is left when the loved one passed on becomes apparent, and the grieving individual questions whether he/she would be able to live a happy life without the deceased. A common question asked at this point is, "Is there really a point in living?". It is important, however, to note that depression in this context does not refer to the mental disorder but rather strong feelings of sadness and hopelessness.
  5. Acceptance - After some time, the individual might adjust to life without the deceased. At this point, the individual might make the conclusion that this is a reality that he/she would have to manage, and make an effort to engage in new hobbies, activities, or create new memories with other friends and family members who are good emotional support to the grieving person.

Grief therapy

There is a distinction between grief counseling and grief therapy. [3] Counseling involves helping people move through uncomplicated, or normal, grief to health and resolution. Grief therapy involves the use of clinical tools for traumatic or complicated grief reactions. [13] This could occur where the grief reaction is prolonged or manifests itself through some bodily or behavioral symptom, or by a grief response outside the range of cultural or psychiatrically defined normality. [14]

Grief therapy is a kind of psychotherapy used to treat severe or complicated traumatic grief reactions, [13] which are usually brought on by the loss of a close person (by separation or death) or by community disaster. The goal of grief therapy is to identify and solve the psychological and emotional problems which appeared as a consequence.

They may appear as behavioral or physical changes, psychosomatic disturbances, delayed or extreme mourning, conflictual problems or sudden and unexpected mourning. Grief therapy may be available as individual or group therapy. A common area where grief therapy has been extensively applied is with the parents of cancer patients. [15]

Controversies

Efficacy and iatrogenesis

At present (as of 2008), a controversy exists in the scholarly literature regarding grief therapy's relative efficacy and the possible harm from it (iatrogenesis). Researchers have suggested that people may resort to receiving grief therapy in the absence of complicated (or abnormal) grief reactions and that, in such cases, grief therapy may cause a normal bereavement response to turn pathological. [16] Others have argued that grief therapy is highly effective for people who suffer from unusually prolonged and complicated responses to bereavement. [17]

In March 2007, an article in the APS journal, Perspectives on Psychological Science, included grief counseling and grief therapy on a list of treatments with the potential to cause harm to clients. [18] In particular, individuals experiencing "relatively normal bereavement reactions" were said to be at risk of a worse outcome (i.e., an abnormally prolonged or difficult grieving process) after receiving grief counseling. The APS journal article in turn has been criticized in the British Psychological Society's publication the psychologist as lacking scientific rigour. [19]

Validity of "complicated grief"

Some mental health professionals have questioned whether complicated grief exists. [20] [21] New diagnostic criteria for "complicated grief" have been proposed for the new DSM, the DSM-V. [22] One argument against creating a classification for "complicated grief" holds that it is not a unique mental disorder. Rather it is a combination of other mental disorders, such as depression, posttraumatic stress disorder, and personality disorders.

Empirical studies have been attempting to convincingly establish the incremental validity of complicated grief. [23] In 2007, George Bonanno and colleagues published a paper describing a study that supports the incremental validity of complicated grief. [24] The paper cautions, "the question of how complicated grief symptoms might be organized diagnostically is still very much open to debate." As this is a current debate in the field, new research on this topic is likely to appear in the scientific literature.

Trauma counseling

Anticipating the impact of loss or trauma (to the extent than anyone can), and during and after the events of loss or trauma, each person has unique emotional experiences and ways of coping, of grieving and of reacting or not. [25] Sudden, violent or unexpected loss or trauma imposes additional strains on coping. When a community is affected such as by disaster both the cost and sometimes the supports are greater.

Weeping, painful feelings of sadness, anger, shock, guilt, helplessness and outrage are not uncommon. These are particularly challenging times for children [26] who may have had little experience managing strong affects within themselves or in their family. These feelings are all part of a natural healing process that draws on the resilience of the person, family and community. [27]

Time and the comfort and support of understanding loved ones and once strangers who come to their aid, supports people healing in their own time and their own way. Research shows that resilience is ordinary rather than extraordinary. [28] The majority of people who survive loss and trauma do not go on to develop PTSD. [29] However, some remain overwhelmed and trapped in their fight-or-flight state.

This article addresses counseling with complex grief and trauma, [13] not only complex post-traumatic stress disorder but those conditions of traumatic loss and psychological trauma that for a number of reasons are enduring or disabling. For example, where an adult is periodically immobilized by unwelcome and intrusive recall of the sudden and violent death [30] of a parent in their childhood.

The post-trauma self

Because of the interconnectedness of trauma, PTSD, human development, resiliency and the integration of the self, counseling of the complex traumatic aftermath of a violent death in the family, for example, require an integrative approach, using a variety of skills and techniques to best fit the presentation of the problem.

The post-traumatic self may not be the same person as before. [31] Personality changes due to the effects of trauma can be the source of intense shame, secondary shocks after the event and of grief for the lost unaltered self, which impacts on family and work. [32] [33] Counseling in these circumstances is designed to maximize safety, trauma processing, and reintegration regardless of the specific treatment approach. [34] [35] Post-trauma individuals must have space to safely face and process the event. There is no specific treatment approach for each individual, but processing and reintegration must be the focus.

See also

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Grief</span> Response to loss in humans and other animals

Grief is the response to the loss of something deemed important, particularly to the loss of someone or some living thing that has died, to which a bond or affection was formed. Although conventionally focused on the emotional response to loss, grief also has physical, cognitive, behavioral, social, cultural, spiritual and philosophical dimensions. While the terms are often used interchangeably, bereavement refers to the state of loss, while grief is the reaction to that loss.

According to the model of the five stages of grief, those experiencing grief go through five emotions: denial, anger, bargaining, depression and acceptance. Although it is in common use, studies have not confirmed these stages, and the model has been criticized as outdated as well as unhelpful in explaining the grieving process.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences, with extreme examples being violence, rape, or a terrorist attack. The event must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se.

10.1002/jts.2490090204

Disenfranchised grief is a term coined by Dr. Kenneth J. Doka in 1989. This concept describes the fact that some forms of grief are not acknowledged on a personal or societal level in modern day Euro-centric culture. For example, those around you may not view your loss as a significant loss, and they may think you don’t have the right to grieve. They might not like how you may or may not be expressing your grief, and thus they may feel uncomfortable, or judgmental. This is not a conscious way of thinking for most individuals, as it is deeply engrained in our psyche. This can be extremely isolating, and push you to question the depth of your grief and this loss you’ve experienced. This concept is viewed as a ”type of grief”, but it more so can be viewed as a "side effect" of grief. This also is not only applicable to grief in the case of death, but also the many other forms of grief. There are few support systems, rituals, traditions, or institutions such as bereavement leave available to those experiencing grief and loss.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

In psychology, posttraumatic growth (PTG) is positive psychological change experienced as a result of struggling with highly challenging, highly stressful life circumstances. These circumstances represent significant challenges to the adaptive resources of the individual, and pose significant challenges to the individual's way of understanding the world and their place in it. Posttraumatic growth involves "life-changing" psychological shifts in thinking and relating to the world and the self, that contribute to a personal process of change, that is deeply meaningful.

<span class="mw-page-title-main">George Bonanno</span>

George A. Bonanno is a professor of clinical psychology at Teachers College, Columbia University, U.S. He is responsible for introducing the controversial idea of resilience to the study of loss and trauma. He is known as a pioneering researcher in the field of bereavement and trauma. The New York Times on February 15, 2011, stated that the current science of bereavement has been "driven primarily" by Bonanno. Scientific American summarized a main finding of his work, "The ability to rebound remains the norm throughout adult life." In 2019, Bonanno was honored with the James McKeen Cattell award from the Association of Psychological Science "for a lifetime of intellectual achievements in applied psychological research and their impact on a critical problem in society at large" and by the International Positive Psychology Association for "distinguished lifetime contributions to positive psychology".

The terms delayed grief and unresolved grief are variations of grieving after a loss. The meaning of unresolved grief is any aspect of grieving that has yet to be resolved.

<span class="mw-page-title-main">Prolonged grief disorder</span> Medical condition

Prolonged grief disorder (PGD), also known as complicated grief (CG), traumatic grief (TG) and persistent complex bereavement disorder (PCBD) in the DSM-5, is a mental disorder consisting of a distinct set of symptoms following the death of a family member or close friend. People with PGD are preoccupied by grief and feelings of loss to the point of clinically significant distress and impairment, which can manifest in a variety of symptoms including depression, emotional pain, emotional numbness, loneliness, identity disturbance and difficulty in managing interpersonal relationships. Difficulty accepting the loss is also common, which can present as rumination about the death, a strong desire for reunion with the departed, or disbelief that the death occurred. PGD is estimated to be experienced by about 10 percent of bereaved survivors, although rates vary substantially depending on populations sampled and definitions used.

Ambiguous loss is a loss that occurs without a significant likelihood of reaching emotional closure or a clear understanding. This kind of loss leaves a person searching for answers, and thus complicates and delays the process of grieving, and often results in unresolved grief. Some examples are infertility, termination of pregnancy, disappearance of a family member, death of an ex-spouse, and a family member being physically alive but in a state of cognitive decline due to Alzheimer's disease or dementia. An ambiguous loss can be categorized into two types of loss: physical or psychological. Physical loss and psychological loss differ in terms of what is being grieved for, the loss of the physical body, or the psychological mind. Experiencing an ambiguous loss can lead to personal questions, such as, "Am I still married to my missing spouse?," or "Am I still a child to a parent who no longer remembers me?". Since the grief process in an ambiguous loss is halted, it is harder to cope or move on to acceptance from the type of loss experienced. There are various types of grief that can occur due to the type of ambiguity experienced and corresponding therapy techniques to address the certain types of grief. The overall goal of therapy to cope with ambiguous loss is to overcome the trauma associated with it and restore resilience.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war. More recently, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder.

The dual process model of coping is a model for coping with grief developed by Margaret Stroebe and Henk Schut. They studied grief in their work "The Dual Process Model of Coping with Bereavement: A Decade On". It examines this model of coping and how it could be of benefit compared to others.

<span class="mw-page-title-main">Miscarriage and grief</span>

Miscarriage and grief are both an event and subsequent process of grieving that develops in response to a miscarriage. Almost all those experiencing a miscarriage experience grief. This event is often considered to be identical to the death of a child and has been described as traumatic. But the vast majority of those who have suffered both have said they are nothing alike. They describe losing a child as being in a category of its own when it comes to grief. "Devastation" is another descriptor of miscarriage. Grief is a profound, intensely personal sadness stemming from irreplaceable loss, often associated with sorrow, heartache, anguish, and heartbreak. Sadness is an emotion along with grief, on the other hand, is a response to the loss of the bond or affection was formed and is a process rather than one single emotional response. Grief is not equivalent to depression. Grief also has physical, cognitive, behavioral, social, cultural, and philosophical dimensions. Bereavement and mourning refer to the ongoing state of loss, and grief is the reaction to that loss. Emotional responses may be bitterness, anxiety, anger, surprise, fear, and disgust and blaming others; these responses may persist for months. Self-esteem can be diminished as another response to miscarriage. Not only does miscarriage tend to be a traumatic event, women describe their treatment afterwards to be worse than the miscarriage itself.

Child bereavement occurs when a child loses someone of importance in their life. There is substantial research regarding grief in adults, but there is less focus in literature about grief among children. Children will experience instances in their life that could involve losing a parent, sibling, or friend through suicide, unintentional injury, homicide, or natural causes. The levels of grief and bereavement differ among children, including uncomplicated and complicated bereavement. Unlike adults, children may experience and express their grief and bereavement through behaviors, and are less likely to outwardly express their emotions. The children who experience bereavement and grief can receive treatment involving group intervention, play therapy, and cognitive behavioral therapy. Different forms of treatment for children experiencing bereavement and or grief can help to reduce symptoms of anxiety, depression, social adjustment, and posttraumatic stress. Research has shown that it is important to be aware of the difficulties in predicting how losing a closed one can impact a child’s emotionality and how their coping abilities will differ across ages and cultures.

Mental disorders can be a consequence of miscarriage or early pregnancy loss. Even though women can develop long-term psychiatric symptoms after a miscarriage, acknowledging the potential of mental illness is not usually considered. A mental illness can develop in women who have experienced one or more miscarriages after the event or even years later. Some data suggest that men and women can be affected up to 15 years after the loss. Though recognized as a public health problem, studies investigating the mental health status of women following miscarriage are still lacking. Posttraumatic stress disorder (PTSD) can develop in women who have experienced a miscarriage. Risks for developing PTSD after miscarriage include emotional pain, expressions of emotion, and low levels of social support. Even if relatively low levels of stress occur after the miscarriage, symptoms of PTSD including flashbacks, intrusive thoughts, dissociation and hyperarousal can later develop. Clinical depression also is associated with miscarriage. Past responses by clinicians have been to prescribe sedatives.

Suicide bereavement is the experience of those who are grieving the loss of someone to suicide. Over 800,000 individuals die by suicide every year. It was stated by Shneidman (1978) that every suicide leaves behind 6 "survivor-victims". However, new research shows that each suicide leaves behind approximately 135 who personally knew the decedent. The #not6 hashtag has been used by Cerel and colleagues to represent that suicide bereavement is many more than publicly portrayed.

Social constraints are a psychological term that can be defined as "any social condition that causes a trauma survivor to feel unsupported, misunderstood, or otherwise alienated from their social network when they are seeking social support or attempting to express trauma-related thoughts, feelings, or concerns." Social constraints are most commonly defined as negative social interactions which make it difficult for an individual to speak about their traumatic experiences. The term is associated with the social-cognitive processing model, which is a psychological model describing ways in which individuals cope and come to terms with trauma they have experienced. Social constraints have been studied in populations of bereaved mothers, individuals diagnosed with cancer, and suicide-bereaved individuals. There is evidence of social constraints having negative effects on mental health. They have been linked to increased depressive symptoms as well as post-traumatic stress disorder symptoms in individuals who have experienced traumatic events. There seems to be a positive association between social constraints and negative cognitions related to traumatic events. Social constraints have also been linked to difficulties in coping with illness in people who have been diagnosed with terminal illness such as cancer.

Bereavement groups, or grief groups, are a type of support group that bereaved individuals may access to have a space to process through or receive social support around grief. Bereavement groups are typically one of the most common services offered to bereaved individuals, encompassing both formalized group therapy settings for reducing clinical levels of grief as well as support groups that offer support, information, and exchange between those who have experienced loss.

References

  1. ↑ Kneip, Richard. "Psychology of Grief". GLPG.
  2. ↑ Hoy, William G. (2016). Bereavement groups and the role of social support : integrating theory, research, and practice. New York, NY: Routledge/Taylor and Francis. ISBN   9781317416357. OCLC   942843686.
  3. 1 2 William, Worden, J. (2018-05-28). Grief Counseling and Grief Therapy : A Handbook for the Mental Health Practitioner (Fifth ed.). New York, NY. ISBN   9780826134752. OCLC   1032303183.{{cite book}}: CS1 maint: location missing publisher (link) CS1 maint: multiple names: authors list (link)
  4. ↑ Nadeau, Janice Winchester: Families Making Sense of Death. Thousand Oaks, CA: Sage, 1998
  5. ↑ "When Grief Shows Up (Sometimes) Years Later | Pathways". Pathways Home Health and Hospice. Retrieved 2022-11-16.
  6. ↑ "Archived copy" (PDF). Archived from the original (PDF) on 2017-08-08. Retrieved 2012-07-25.{{cite web}}: CS1 maint: archived copy as title (link)
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  8. ↑ Rando, Therese A.: Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research Press, 2000
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  12. ↑ Lapsley, James N. (April 1970). "On Death and Dying, by Elisabeth Kübler-Ross. 260 pp. New York, Macmillan, 1969. $5.95". Theology Today. 27 (1): 88–93. doi:10.1177/004057367002700112. ISSN   0040-5736. S2CID   170512579.
  13. 1 2 3 Jacobs, Shelby, Carolyn Mazure, and Holly Prigerson. Diagnostic Criteria for Traumatic Grief. Death Studies 24 (2000):185–199
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  20. ↑ Lichtenthal, Wendy G.; Cruess, Dean G.; Prigerson, Holly G. (2004). "Clinical Psychology Review - A case for establishing complicated grief as a distinct mental disorder in DSM-V". Clinical Psychology Review. 24 (6): 637–662. doi:10.1016/j.cpr.2004.07.002. PMID   15385092.
  21. ↑ "PsychiatryOnline | FOCUS: The Journal of Lifelong Learning in Psychiatry | Diagnostic Criteria for Complicated Grief Disorder". Focus.psychiatryonline.org. Archived from the original on 2011-10-24. Retrieved 2012-08-09.
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  23. ↑ Bonanno, G.A. (2006). "Is Complicated Grief a Valid Construct?". Clinical Psychology: Science and Practice. 13 (2): 129–134. doi:10.1111/j.1468-2850.2006.00014.x.
  24. ↑ Bonanno, George A; Neria, Yuval; Mancini, Anthony; Coifman, Karin G.; Litz, Brett; Insel, Beverly (2007). "Is There More to Complicated Grief Than Depression and Posttraumatic Stress Disorder? A Test of Incremental Validity" (PDF). Journal of Abnormal Psychology. 116 (2): 342–351. doi:10.1037/0021-843X.116.2.342. Archived from the original on July 21, 2018. Retrieved December 20, 2022– via Wayback Machine.{{cite journal}}: CS1 maint: bot: original URL status unknown (link)
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  27. ↑ Peterson, Sarah (2018-01-30). "Effects". The National Child Traumatic Stress Network. Retrieved 2022-11-17.
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  30. ↑ Rynearson E.K, Editor: Resilience and Intervention Beyond the Crisis, Routledge, 2006
  31. ↑ Wilson J.P, The Posttraumatic Self Restoring Meaning and Wholeness to Personality, Routledge, 2005
  32. ↑ Arsova, Slavica; Manusheva, Nensi; Kopacheva-Barsova, Gabriela; Bajraktarov, Stojan (2016-09-15). "Enduring Personality Changes after Intense Stressful Event: Case Report". Open Access Macedonian Journal of Medical Sciences. 4 (3): 453–454. doi:10.3889/oamjms.2016.083. ISSN   1857-9655. PMC   5042633 . PMID   27703573.
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  34. ↑ Julian D. Ford, Christine A. Courtois, Kathy Steele, Onno van der Hart, Ellert R. S. Nijenhuis Treatment of complex posttraumatic self-dysregulation, Journal of Traumatic Stress Volume 18, Issue 5, Pages 437 - 447
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