Counselling for Grief and Bereavement

Geraldine M Humphrey, David G Zimpfer

• Publisher: SAGE Publications Ltd
• Year: 2007
• ISBN:
  9781446225295
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

`The authors have done their homework in reading and consulting with the prominent literature, especially regarding children. All this effort gives the book a solid background foundation and makes it readable, and well-usable, for both lay counsellors and professional providers, and for all of us who are engaged in the delicate and rewarding endeavor of Grief Therapy? - Naji Abi-Hashem, Clinical & Cultural Psychologist, Berkeley, California

Praise for the First Edition:

`The book provides an absorbing and challenging journey through the possible process involved in bereavement work, and encourages one to think broadly about how one can approach a bereaved person... this was a book I enjoyed reading very much, and which I found both theoretically sound and practically helpful? - Bereavement Care (Cruse)

Counselling for Grief and Bereavement, Second Edition is a bestselling, introductory guide for professionals who work with people experiencing bereavement through death and other forms of loss. Focusing on practical assessment and intervention strategies, Geraldine Humphrey and David Zimpfer guide readers through the essential theory and skills needed to work with clients in a way which sensitively facilitates the process of grief, initiates healing and promotes a sense of growth.

Setting out the broad principles for practice, the authors go on to show how these can be applied in working with individuals, families and groups and in relation to specific issues including chronic and life-threatening illnesses, palliative care and complicated grief. Carefully chosen case examples illustrate the counselling process, while specific attention is paid throughout to ethical considerations and the possible need for referral.

This fully revised and updated Second Edition features a new chapter on working with children and adolescents: both from the perspective of young people who are grieving losses and those who are receiving palliative care as patients. While focusing on the practical, the book provides a firm theoretical base by explaining key concepts such as attachment, grief and resilience.

Geraldine M. Humphrey is Counsellor in the Department of Psychology at the North Canton Medical Foundation, specializing in death, illnesses, and non-death and grief. David G. Zimpfer is former Director of the Cancer Center of Ohio.

1	Loss and Grief in Life

Loss is an integral part of life. It is not something that happens to us as we live; rather, it is life itself. Death is not the only loss a human might experience; yet it is often the only loss that is validated as a legitimate grief experience. In our view, any event that involves change is a loss that necessitates the process of grief and transition. A loss event requires that some part of the individual be left behind and grieved for before the process of transition and rebuilding can occur.

Loss is defined as the state of being deprived of or being without something one has had, or a detriment or disadvantage from failure to keep, have, or get. Grief is the pain and suffering experienced after loss; mourning is a period of time during which signs of grief are shown; and bereavement, as discussed by Raphael (1983), is the reaction to the loss of a close relationship.

The bereavement experience includes the concept of grief, as pain and suffering must be experienced in order to heal and resolve the loss event. It also includes ideas of reaction, adaptation, and process. Reaction involves a response. The bereaved person reacts emotionally as the pain of grief is experienced, and gradually reacts cognitively and behaviourally as a new identity is formed and a life is rebuilt. Adaptation refers to the concept of letting go of that which has been lost, compromising, and gradually adjusting to and accepting a new life. And process involves the total experience. The work of bereavement is not linear; it is cyclical in nature, with many painful returns to the beginning to start the process once more. Tailspins back to an earlier stage of grief are an inherent aspect of the bereavement experience.

Effective resolution entails an active involvement. Loss, grief, and bereavement violate personal boundaries and remove a sense of security and control. The bereaved person will never have the same identity as before. He or she is no longer attached in the same way to a person, object, or activity that provided security, meaning, or purpose. Although this has the potential to be positive in terms of growth, initially a person feels a sense of aloneness and helplessness. Models of loss have evolved over time, including theories of attachment and ways to conceptualize the severing of these attachments. Current models have moved from concern with mere coping towards interventions that foster growth and self-actualization. However, despite research and insight into this human condition, grief for many remains a passive process. Grief is often perceived as something to ‘get over’ in a fixed period of time. Yet we will come to understand in this book that process implies more than fixed tasks. Counsellors must continuously be aware that process involves trial and error, change, and frustrating returns back to earlier experiences of grief. It demands an active response in order to restore one’s sense of ability to be in control again. Moreover, loss cannot be narrowly viewed as one event. Each loss is influenced by past losses, and each loss will be affected by additional secondary losses that will occur as a result of the present loss at different times of the process.

In the discussion that follows, we will consider the evolution of models, plus the categories of loss, and the perspectives that influence a bereavement experience. These ideas provide frameworks for assessment and interventions and will be referred to throughout this book.

Evolution of Models of Loss and Bereavement

Models and theories have attempted to explain the complex process experienced after significant loss and change in our lives. Evaluating the models of bereavement over time shows more of an evolution of theory and practice than the creation of distinct models. The focus has gone from theories of attachment and loss, to concepts of acute grief, to tasks, to stages, to psychological processes and phases. There are numerous models and it is beyond the scope of this book to identify all of them or to discuss any one in detail. The intent is to identify several that have been particularly influential and useful to persons who counsel others in their loss and grief.

From Freud on there has been an emphasis on personal attachment to objects and people, and the giving up of some part of self following a loss (death or non-death) event. Attention to this loss of some aspect of self is an integral part of grief resolution; however, it is the part that is often negated and avoided today. During human history the experience of grief and its resolution has become more of a task to be accomplished, or something that must be gotten over and forgotten. The importance of healing the internal void within us, or that part of us that has been eliminated because of the loss, is not often understood as the foundation of self-restoration.

Freud offers one of the earliest models for consideration. He referred to the emotion present in melancholia as ‘mourning’, meaning that one is searching for an attachment that has been lost. Using the concepts of the ego and id, he discussed the need for the ego to disengage from that which has been lost and to eventually withdraw energy from the lost object. The bereaved was not grieving just one object; rather, he/she was grieving and letting go of multiple layers of attachments (stored memories and symbols) that are involved in the formation of a relationship. In a slow and arduous process, the reality of the loss is accepted by the ego and instinctual energy is withdrawn; thus the ego can accommodate the loss and search for new attachments. Although he does not provide a clear framework for operationalizing the process, his theory offers an understanding of the multiple levels of human attachment and the difficulty facing the bereaved who must undertake the task of grief work.

Lindemann’s (1944) work is considered a milestone in the development of ideas about bereavement. His study was based on his interventions with 100 bereaved individuals, following the deaths of family and friends in the Coconut Grove night club fire in the Boston area in 1942. After the disaster, Lindemann provided opportunities for the bereaved survivors to work through their grief. From his interventions he gathered and studied data, which resulted in his study that offered a description of various symptoms of normal grief, with additional signs that he believed might indicate potential pathology. In the initial stages, he conceptualized acute grief as a normal part of the process. Lindemann proposed six characteristics of acute grief: somatic distress, preoccupation with thoughts/images of the deceased, guilt related to the deceased or the death event, hostile reactions, loss of function, and a tendency to assume traits of the deceased in one’s behaviour. The last characteristic could indicate pathology in a later part of the process. In addition to these descriptions, Lindemann has provided a model and frame of reference that allow one to consider grief as work, with specific tasks to accomplish. His tasks included undoing emotional and psychological attachments with the deceased, readjusting to an environment without the deceased, and rebuilding new relationships.

Although Kübler-Ross was neither the first nor the last theorist in this field, her name and stage theory are still the connection that many people make today when death and grief are the topic of consideration. Her landmark contribution, On Death and Dying (1969), came at a time in the history of the United States when stage approaches to psychological theorizing were acceptable and death was a taboo subject. She opened the doors to discuss and acknowledge death and to address the loss experience. Her focus was on persons who were dying, not on those going through a bereavement process after a significant loss. Yet because of the simplicity of her stages, the ability to comprehend them, and the lack of other theorists in this field being as visible, hers is the theory and approach still most widely recognized today.

As a psychiatrist, Kübler-Ross acknowledged her allegiance to the psychological concepts proposed by Freud. Noteworthy among these were theories of the unconscious mind, and the belief that the psychiatrist was more capable than the layperson to understand and interpret what was occurring in the unconscious mind. This recognition of her background is important, as the tenets of her stage theory are grounded in Freudian concepts. Stephenson (1985) critiqued Kübler-Ross’s contributions to this field of study. He appreciated the fact that she opened pathways to communication of a subject that had been avoided; yet her psychoanalytical orientation has been a subject of debate. Her primary intention was to understand the experience of those who had a terminal prognosis and to facilitate a supportive process of coming to terms with one’s mortality. As she and her assistants listened to over 200 hospitalized patients who were terminally ill, she interpreted what she heard and subsequently identified five predictable stages of those who are dying. Through these interviews, she interpreted their actions and emotions and delineated the stages of denial, anger, bargaining, depression, and acceptance. Today these emotions and behaviours are not viewed as separate entities in a linear progression; rather, they are acknowledged as part of a larger and more cyclical process. Moreover, what is questioned today is the concept of the unconscious mind (i.e., whether or not it can control actions) and the ability of the psychiatrist to better understand the reality of the patient’s experience (i.e., the patient is not in touch with an inner reality, because he or she has not been professionally trained).

Debates in the counselling profession today focus on how accurate the counsellor can be in interpreting a client’s experience, diagnosing, and prescribing treatment. Emphasis is turning towards the concept of co-facilitation of a process, with the client’s perspective taking the lead.

Bowlby’s Attachment Theory is another important landmark in this field of study. In three volumes entitled Attachment and Loss (1969, 1973, 1980), he explores instinctive and attachment behaviours of humans and animals, the course of development (ontogeny) of human attachment, an ethnological approach to human fear, and the trauma of loss. In addition to his research, his clinical work with young children and adults (on issues of separation and grief) has provided a wealth of knowledge and a framework for interventions. His professional background was psychoanalytical; however, he broadened his theoretical groundwork to include cognitive psychology, developmental psychology, and ethnology. Cognitive psychology emphasizes that actions and emotions are a result of cognitions and belief systems. Developmental psychology is the framework for understanding an individual on the basis of one’s progression physically, mentally, and emotionally as compared to a chronological age and the developmental expectations for a particular age. And ethnology refers to the study of the characteristics and beliefs of communities and individuals.

Bowlby (1980) believes that attachments are developed early in life and have a basis of security and survival for the individual. When these attachments are endangered or broken, there is a normal human response of anxiety and protest. He bases much of his theory on findings from his work with children separated from their mothers. Papers written from the 1950s through to the 1980s reported findings from his infant studies that reflected the similarities between the responses of human infants separated from their mothers and other high-order primates. These similarities led him to believe that these responses had a biological basis, were instinctual and adapational, and provided a basis for survival of the species.

The conceptual framework that Bowlby (1980) brought to the study of mourning differed from what had been traditionally accepted. He believed that his new paradigm allowed him to dispense with some of the abstract concepts, such as psychic energy and drive, which he had found in the course of his research to be unsatisfactory. He stated that his attachment theory facilitated a way of understanding the distress and emotional disturbance experienced by humans when affectional bonds to particular others were broken. Underlying this theory is the belief that attachment behaviour is instinctive and mediated by a behavioural system that is developed early in life. This system is goal-directed and functions to maintain attachments. Attachment behaviour has the potential to remain active throughout life, and is often observed in situations of loss and grief that force bereaved individuals to fill painful voids and make new attachments. It should not be viewed as pathological in an individual after a significant loss; however, new attachments should not be sought with the intention of avoiding other aspects of the grief and mourning processes.

Bowlby also views mourning as including a variety of psychological processes that are set into motion by the loss of a loved one. He cites four general phases: numbing, yearning and searching, disorganization and despair, and reorganization. In addition to the phases that he conceptualizes an individual progresses through, he discusses cognitive biases (cognitive structures) which filter information and serve as the mechanisms that form individual perceptions and belief systems. He hypothesized, based on his research findings of the role of attachment figures throughout life, that experiences with these early figures form cognitive biases and serve as the basis for patterns of relationship that a person makes throughout life. Moreover, he maintained that future losses would be influenced and processed by these cognitive biases.

Bowlby’s interventions centre on cognitive insight and cognitive restructuring. He has emphasized the need to process information:

For it is only when the detailed circumstances of the loss and the intimate particulars of the previous relationship, and of past relationships, are dwelt on in consciousness that the related emotions are not only aroused and experienced but become directed towards the persons and connected with the situations that originally aroused them. (Bowlby, 1980: 200)

Once insight is gained and the cognitive and emotional aspects of relationships have been explored and experienced, the bereaved progresses towards changing cognitive constructs. How one viewed his or her world and experienced it, no longer applies. Life will never be exactly the same. Life can be meaningful again; however, this necessitates the creation of a new internal template of how one will view his or her world.

Worden (2002) did not propose a new theory. His intention was to provide a practical application of established theory in counselling sessions. His book Grief Counselling and Grief Therapy (2002) focuses on counselling for the tasks of grief. His contribution in the area of assessment and interventions has been recognized in the field as a milestone. His tasks of grief build on Lindemann’s (1944) approach that delineated three tasks and Bowlby’s conceptualization of attachment and loss. He views mourning as necessary and sees counselling as a facilitative process that allows the bereaved to take action and not just passively go through the painful experience. He identifies four specific tasks of grief: to accept the reality of the loss, to work through the pain of grief, to adjust to an environment in which the deceased is missing, and to emotionally relocate the deceased and move on with life.

Rando (1993a) has proposed her conception of ‘the six “R” processes of mourning’. She mainly addresses loss following a death; however, she states that her model may be generalized to other types of loss. Although there are some similarities to Worden’s (2002) tasks, this model elaborates the grieving tasks and includes phases during which they might occur. Moreover, Rando broadens considerations for each task or process beyond what is implied in Worden’s model, providing a more extensive base for assessment and intervention strategies:

• Avoidance phase: to Recognize the loss and achieve a meaningful understanding about the loss event.
• Confrontation phase: the bereaved must React to the separation from that which has been lost. During this phase it is also necessary to Recollect and re-experience the deceased and the relationship through reviewing and remembering. Lastly, during this phase, the bereaved must Relinquish the old attachments to the deceased and the old assumptive world.
• Accommodation phase: includes the processes of Readjusting to a new world without forgetting the old, and Reinvesting in meaningful life.

Since the first edition of this book there has been ongoing research and proposed concepts that facilitate greater insight into the process of grief. Continuing Bonds (Silverman and Klass, 1996; Silverman and Nickman, 1996b), the Dual Process Model (Stroebe and Schut, 1999, 2001), and Meaning Reconstruction (Neimeyer, 2001a) are three that will be considered in this edition.

Continuing bonds challenge prevalent beliefs that successful grief resolution involves a disengagement from the deceased in ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• About the Authors
• Preface
• Acknowledgements
• Introduction
• 1 Loss and Grief in Life
• 2 Assessment Strategies
• 3 Grief Counselling and Grief Resolution
• 4 Family Grief
• 5 Group Counselling
• 6 Children and Grief
• 7 Anticipatory Grief
• 8 Special Issues
• 9 When Grief is Not Resolved
• Appendix: Resources on Dying, Death and Grieving
• References
• Index