GRIEF AND LOSS
In counselling and other mental health disciplines, loss and grief have often
failed to be a focus of care compared to the search for empirically supported
interventions for more ‘serious’ diagnosed disorders. Loss has largely only been
considered when dealing with death and bereavement. As with many other conditions
we have sought the most appropriate means of ‘fixing’ grief. But grief has not been a
‘condition’ that fitted the mould of clear definable symptoms, single definitive theories
and targeted session specific interventions.So why would we argue that grief and loss
is fundamental to our work in counselling? There are many reasons why knowledge
of loss and grief is vital for counsellors.
• Grief is universal and inevitable irrespective of age, culture, socio-economic
status (SES), gender, or context; independent of all ways of categorising
people. As such loss and grief offer a shared language and a shared experience
among us all, including counsellor and client. Loss and grief are not confined to
situations of death and includes whenever someone is separated from
something of importance to him or her.
• Grief is commonly comorbid with, or integral to understanding other disorders.
• Grief and loss as a universal experience offers a key integrating concept that
can underpin prevention and early intervention when dealing with adverse life
events.
Besides these above reasons for knowing about loss and grief, there is ample
evidence that failure to deal with issues of loss and grief can lead to long term
problems of diagnosable disorders. These include Prolonged Grief Disorder as defined
in the ICD11 (WHO, 2019; Killikelly & Maercker, 2018). This diagnosis is also proposed
for the DSM-V-TR version (Prigerson et al., 2021) but is currently termed Persistent
Complex Bereavement-Related Disorder within the current DSM-V section on
Conditions for Further Study (APA, 2013). Other disorders such as mood disorders
(Hensley, 2006) and Post Traumatic Stress Disorder ([PTSD] Horowitz, 2011) have
been associated with grieving. In particular there has existed a blurring between the
symptoms of depression and the sadness of grief leading to misdiagnosis of grieving
as a disorder or confusion as to a differentiation of the conditions (Zisook & Kendler,
2007).
TOPIC DESCRIPTION
Before we go any further, let us gain some consensus around some of the
concepts we will use in this chapter. Change: Besides death and taxes, change is
about the only other thing that can be guaranteed in this life. Sometimes change alters
our world in ways that we do not wish to occur. We ache to return to the world as it
used to be. Such a change involves loss. Loss: Loss is not a particular event but a
lived experience, a sense of ‘being kicked in the guts’, a desire to want the hands of
time to turn back to a time where our world hadn’t come crashing down around us.
Miller and Omarzu (1998) offer a useful definition of this experience as: “Loss is
produced by an event which is perceived to be negative by the individuals involved
and results in long term changes to one’s social situations, relationships or cognitions”
(p. 12). This definition recognises that loss is a) experienced, b) perceived and defined
by the person experiencing it, c) involves many adverse life events; and d) has far
reaching effects. Grief: Put most simply, grief is the reaction to loss; whatever that
reaction happens to be. The reported symptoms of grief can be manifest across all
domains of the biopsychosocial-spiritual model (Engel, 1977; Sulmasy, 2002).
Biological effects may include crying, headaches, tremors, appetite changes, sexual
problems and a compromised immune system. Psychologically, people may report
anxiety, sadness, anger, confusion, concentration difficulties, suicide ideation, among
other symptoms, while socially, those in grief can report loneliness, estrangement from
others, role confusion, and social network changes. When we speak of spiritual and
existential effects, these often move beyond religious crises of faith to more general
effects such as loss of purpose and meaning, and questions about life and death. The
symptoms across all the domains also interact leading to an even greater sense of
confusion and feeling overwhelmed. Grief affects the whole person and may manifest
itself very differently in people even if they are facing the same type of loss or situation
of loss.Mourning/Grieving: Grief is the manifestation of an internal process as people
try to deal with varying levels of disarray and struggle to find some stability in this
altered world. This internal process is what we call grieving. Mourning then is this
process in situations of bereavement. Consistent with the theorists such as Raphael
(1984) and Rando (1993), I prefer to use the terms grieving and mourning to reflect
this internal process of adjusting to loss. Some prefer to define mourning in terms of
the public expressions of grief, including culturally relevant rituals (Stroebe et al.,
2001).
Grieving is a natural healing process experienced in all cultures and societal
groups. It is a process that has been part of the human experience ever since people
became attached to things or people of importance in their lives and lost those things.
It is reflected in the art, music, stories and rituals of all peoples around the world. In
considering grieving from a medical model viewpoint that sees grief as a condition to
be treated, it may be more useful to see grieving as being a natural healing process
rather than a disease in need of treatment.
COMPLICATED GRIEF/PROLONGED GRIEF (ICD11; DSM-V-TR)
For most people, the process of grieving proceeds to the point where people
are able to re-establish themselves in their lives; although in many ways, changed.
For a significant minority of grieving people, this natural process of healing does not
proceed toward restoration but rather leads to some form of perceived deterioration.
Common patterns of symptoms are associated with problems in grieving a death. Few
areas of adversity besides death have been defined in terms of grieving a loss and
hence attempts to categorise problematic patterns in adjustment have been confined
to the area of bereavement. In the area of bereavement, these patterns of symptoms
have been defined by terms such as Complicated Grief, Prolonged Grief Disorder or
Persistent Complex Bereavement-Related Disorder.
While intense distress after a death is normal and anticipated, symptoms that persist
at least six months after the death become concerning. The patterns of symptoms
indicating problems in grieving a bereavement include:
• a searching or yearning for the deceased that preoccupies the person to a
disabling degree
• severe distress when reminded of the deceased or circumstances of the death
• avoidance of reminders
• a loss of the sense of self and role in life
• ongoing impaired functioning in life domains
• patterns of distress that are outside what is expected from usual cultural, social
or religious norms. (Killikelly & Maercker, 2018; Shear, 2015). The prevalence
of such problems in grieving following a death is difficult to determine. Unlike
other mental disorders where only those diagnosed with the condition meet the
full diagnostic criteria for the range of symptoms, all those grieving a death
display intense symptoms in the early days following the bereavement. Hence
determining when normal grieving becomes problem grieving can be difficult to
ascertain clearly. Shear (2015) and Aoun et al. (2015) estimate between 2-3%
and 6-7% display these patterns of symptoms, and this appears consistent
across a number of different national studies (Fujisawa et al., 2010; Kersting et
al. 2011; Williams et al., 2017).
Problems associated with non-death losses have been less likely studied in
terms of grief responses. In such cases grieving people may be diagnosed with other
disorders such as depression, anxiety, adjustment disorder, PTSD or substance use
disorder (Kendler et al., 2008). Problems associated with grieving losses may be
underestimated, with their impact spread across many disorders.
RISKS FOR PROBLEMS IN GRIEVING
If we accept that some people will struggle to heal through grieving, being able
to ascertain who may be at risk for problems in grieving is valuable to counsellors.
Many explanations for problems in grieving will be offered through the theories of
grieving that we shall discuss later in this chapter. Some studies though have
determined various risk factors through statistical means in exploring outcomes among
grieving people. Many studies have considered risks associated with problem grieving.
We see risk associated with three broad categories: the person of the griever him or
herself, circumstances surrounding the loss; and the context of the loss. In reviewing
empirical studies of complicated grief, Lobb et al. (2010) found risks within the person
included previous loss, previous mental health, attachment style as well as cognitive
appraisals and high distress at the time of the death. Factors associated with the loss
itself included death involving violence and other trauma, the quality of the caregiving
or dying experience, close kinship relationship to the deceased, marital closeness and
dependency, and lack of preparation for the death. In terms of the context of the loss,
perceived social support played a key role.
It is difficult to easily separate these risk factors as their interactions may be
more important than their singular effects. The risk factors may also influence grieving
in discrepant ways in different populations. For example, there is risk of being a young
widow; yet there is also noted risk in losing a lifelong partner in older people. Hence
rather than simply assuming risk based on noted characteristics, we need to hear the
story of the client in depth for possible risks, and the priority of those risks or their
interaction in terms of disruption to the normal process of healing through grieving.
Understanding how risks work against healing occurring through grieving is through
recognition of the loss and grief theories that suggest how the grieving process
progresses and how it may be compromised for some people. So let us consider very
briefly the major theories concerning this process of grieving.
MAJOR THEORIES
Counsellors have often become wedded to a single theory or school of thought
and view all people experiencing a condition only through the lens of this favoured
theory. With such a limited view, we risk missing the true story a person tells in all its
complexity. We hear only the part of the story that ‘fits’ our theoretical view of the world.
Loss and grief is one of the best examples of a concept or condition that refuses to be
boxed into a single theory. There is no ‘one size fits all’ definitive theory of grief. Rather
what we have is an amazing picture of a deeply complex human experience for which
each theory offers us part of the picture. Just like the story of a person’s grief, the story
of the theories of grief is complex and much more interesting than a singular view of
grief offered by only one theory.Theories around grief and loss are largely considered
WHY models (why grief occurs) and/or HOW models (how the process of grieving
proceeds). To suggest that theories of grieving began in the 20th century is naïve.
Philosophy, religions and stories from every culture have sought to understand grief,
loss and suffering and comfort it. We should never discount the innate and cultural
understandings of grief that a person brings. They form an integral part of the story
they will tell and so form the basis of understanding how we best care for grief.
From a more formal psychological perspective, we can follow a story of the theories
of grief and loss. However, we need to recognise that the theories mainly discuss loss
through death. Moving to non-death losses will require us to go even beyond this
theoretical story.
Early theories came from the psychodynamic work of Sigmund Freud in
Mourning and Melancholia (1917). He largely argued that as people became attached
to love objects, they attached psychic energy (libidinal bonds) to these things, a
process known as cathexis. While these love objects remained, the internal energy
remained in equilibrium and the mind remained stable. Any disequilibrium, and hence
mental instability caused by loss of these love objects was seen in the intense grief
reactions. The key to successful grieving was the removal of this psychic energy from
the lost love object, a process of decathexis, and its placement in new available
objects. This required an exchange process whereby the griever undertook ‘grief
work’. By repeatedly re-examining aspects of the relationship with the lost object, the
griever can relinquish the libidinal bonds that bound him or her to the lost object. A
failure in this exchange process through unresolved ambivalence would then result in
problems in grieving. While also a psychodynamist, John Bowlby (1970, 1973) in his
attachment theory, enhanced the understandings of grieving. Bowlby argued the need
to consider the interpersonal perspective of grief with emphasis on the early
experiences and attachment patterns developed between the griever and the
deceased. He argued that yearning and searching for the lost loved one was normal.
Therefore, the intense feelings and behaviours of grief were not indicative of pathology
but were aimed to try to restore the lost love object to the griever. It was Bowlby who
suggested that problematic attachment patterns may lead to problems in grieving.
These theories were later expanded (Fraley and Shaver, 1999; Stroebe, 2002). This
idea of an ongoing relationship with the deceased was expanded to the concept of
continuing bonds by Klass, Silverman and Nickman (1996).
Bowlby (1980) was also the first to suggest that the process of grieving seemed
to follow a pattern of stages and/or phases: Shock and numbness, Searching and
yearning, Disorganisation, Reorganisation. These Stages/Phasic theories were also
advocated by others (Parkes, 1972; Raphael, 1984; Hardt, 1978-79). The most
popularised stages model was offered by Kübler Ross in her book On death and dying
(1969). However, her stages were concerned with the process of dying and not on the
situation of bereavement itself. Stages theories often spoke of the symptoms most
noted in each stage rather than the part of the grieving process that was occurring that
underpinned these symptoms. A number of theorists (Worden, 1991, 2009; Rando,
1993) tried to bring together the idea of grief work and stages in the Task Based
models, which described the work the griever may be doing in each stage. Worden
spoke of four tasks, being: to accept the reality of the loss; processing the pain of grief;
to adjust to a world (both external and internal) where the deceased is no longer; and
finding an enduring connection with the deceased within a new life. Anything that
prevents a person moving through the stages of healing by successfully undertaking
the tasks required of that stage can lead to problems in grieving.
As social beings our grief is more socially than individually constructed. The
Social Learning/Social Constructionist theories increase our understanding of grief by
helping us understand: a) what our social context considers a loss, and so determines
the ‘right’ to be grieved or not, b) the rituals around the grief, c) the adjustments that
will be needed to deal with the loss, and d) the language and attitudes around grief
itself (Glick et al., 1974). At times the loss is not given legitimacy by the surrounding
social environment and the grief is disenfranchised by others leading to its lack of
recognition by others and a ‘loneliness’ for the griever (Doka, 1989).
The Cognitive-Behavioural school of thought argues that rather than grieving
being a process over which a person had little control, cognitions and behaviours could
alter the experience. The cognitions that people hold concerning the lost object, the
process of grieving itself, as well as understanding the use of problem- solving and
planning to rebuild the world are all important aspects of grieving. Irrational thought
patterns, problematic core beliefs and depressive/avoidant coping patterns are often
viewed as at the root of problems in grieving (Boelen et al., 2006). Personal Construct
Theory (Kelly, 1955) is a humanistic theoretical approach that argued that each of us
constructs our individual reality based on patterns or ‘templates’ that we create. The
theory recognises that an important question we then need to consider in loss is: What
is the meaning of the loss to the person? From a constructivist perspective, problems
in grieving occur when the person is unable to construct or re-construct a meaningful
personal reality following the loss (Neimeyer et al., 2002).
These theories noted above are the main schools of thought that guide our
thinking about loss and grief, and collectively offer a much better representation of the
lived experience of grieving. A number of theoretical models have been developed that
bring together aspects from several theories of grief. Bonanno and Kaltmann (1999)
offered a Four Component model, while Rubin (1999) offered a Two Track model of
bereavement. Maccallum & Bryant (2013) offered a cognitive attachment model that
distinguishes both adaptive and prolonged grief by integrating aspects of attachment,
memory, and identity. The most influential integrative model is the Dual Process model
(Stroebe and Schut, 1999). It argues there are two forms of stressors related to
grieving: loss oriented stressors and restoration oriented stressors. Throughout
grieving people oscillate between reacting to these two stressors. Initially people
spend more time with loss oriented stressors and as healing occurs, move to spend
more time working with restoration oriented stressors. However, it is the oscillation
between the two forms of stressors that assists with grieving.
Neurobiology offers us new insights. However, rather than a new theory,
neurobiology offers us a greater understanding of the mechanisms of grieving and
explanations as to why good theory has persisted and been validated within people’s
experiences of grief. When we look at the grieving brain we see areas in the brain that
are associated with processing of emotions, understanding the mental states of others,
retrieval of emotion- laden episodic memories, processing of familiar faces, visual
images, unconscious automatic motor responses, autonomic regulation and
modulation, and coordination of a combination of functions (Freed et al., 2009;
O’Connor, 2005). Neurobiology shows us how important it is for a grieving person to
deal with the oscillation between approaching and avoiding the memories and finding
a sense of accommodation of both (Freed & Mann, 2007). Hence a counsellor needs
to have comfort in sitting with the person’s often changing state of ‘moving toward’ and
‘running from’ their confusion and pain by ‘sitting in the rubble’ with people.
Neurobiology also points to potential mechanisms of problem grieving finding the
nucleus accumbens, the centre of the brain that determines if something is worth doing
over and over again, working hard in those reporting complicated grief (O’Connor et
al.,2008).
NON-DEATH LOSS
These many theories offer us a fuller understanding of grieving associated with
death rather than any other loss. If we look at the definition of loss more broadly, we
see that loss and resultant grief occurs following many non-death situations. Grief
symptoms have been found among people experiencing situations as diverse as brain
injury (Carroll & Coetzer, 2015), parenting children with mental disorders (Schofield et
al. 2010), migration (Gitterman & Knight, 2019), unemployment (Archer & Rhodes,
1987), foster care (Mitchell, 2018), and nursing home placement (Van Humbeeck et
al., 2016). However, often these symptoms of distress have not been interpreted as
grief reactions but designated as adjustment disorders or their sadness interpreted as
depression or anxiety. In trying to categorise the many non-death losses, Sofka (1999)
suggests: a) obvious losses such as relationship breakdown, b) not so obvious losses
such as loss of a dream, c) developmental losses across the life span, d) temporary
losses and mini-losses such as small changes in life and; e) limbo losses associated
with an uncertainty or a tenuous situation.
Boss (1999) offered the term ambiguous loss to describe a situation of loss in
which a person is unsure if a loss really has occurred or not. For example, the loss
surrounding the situation of a missing person or a threatened miscarriage or the
diagnosis of a life-threatening but potentially curable condition may all involve
ambiguous loss. This contrasts with what are termed non-finite losses that occur over
a long period of time where an endpoint may not be clear (Bruce & Schultz, 2001).
These non-finite losses are associated with a different grieving to that of the grieving
of a death. This grieving is often termed chronic sorrow (Teel, 1991). Chronic sorrow
is long-term sadness that accompanies ongoing loss and that sometimes comes to
the fore, and sometimes sits uncomfortably on the periphery of the consciousness
(Olshansky, 1962). The grief associated with death tends to display an intensity of
distress that, while it may fluctuate to some extent short term, generally lessens over
time. Chronic sorrow may be episodic in nature, but the intensity of distress in difficult
times remains consistent over the long-term.
GRIEF COUNSELLING AND GRIEF THERAPY
Grief following a loss is normal. Distress in itself is not indicative of pathology
and hence does not necessarily require therapy. What is required is support for the
healing process of grieving. Basic supportive counselling is a vital area of prevention
and early intervention. Loss threatens a person’s sense of safety, mastery and control.
The basic aim of all grief counselling for normal grief is the stabilisation of the griever
and the returning of some sense of safety. It will be the grieving person who
determines how best to return to a sense of safety as they will tell you what aspects of
the loss are making them feel most ‘unsafe’. They will also tell you what makes them
feel ‘safe’ as paradoxically loss can increase safety in some areas. For example, a
relationship breakdown may cause grief, but if that relationship was emotionally taxing
or harmful to the person, there may be a sense of increased safety in some aspects of
this loss. Safety will always be defined by the griever and needs to be respected and
understood by the counsellor.
Safety can be felt internally, interactionally or organisationally. Internal safety
comprises the thoughts, memories, feelings or sensations, making the person feel
most safe or unsafe. Interactional safety may be enhanced through helping the person
to improve communication with health professionals, or partners or family and friends.
It may also be enhanced through community education to reduce stigma or ignorance
about grief. Supporting organisational safety requires interaction with systems that may
cause concern, such as hospitals or coroners or mental health services.
GENERAL PRINCIPLES OF GRIEF COUNSELLING
Several writers (Humphrey & Zimpfer, 1996; Worden, 1991) have offered
general principles of care. In situations of loss, basic processes of support and
symptom modulation will be needed initially to build trust, stabilize the person and
allow the experience to be put into words. Once this personal sense of greater
equilibrium has been supported in the griever, other important issues can be dealt with
utilising the most appropriate therapeutic approaches. Currier, Holland & Neimeyer
(2008) surveyed 119 practitioners concerning their approaches to grief counselling and
found three overarching categories. The first category is the importance of the
presence of the helping professional. The study found the need for cultivating a safe
and supportive environment, providing deep and empathic listening, and assuming a
respectful and non-judgemental stance. The second category concerned the elements
of the process of therapy and included: storytelling; facilitating integration or finding
meaning; expressing and processing emotions; facilitation of continuing bonds;
psychoeducation; focussing on the good, and exploring of spirituality and existential
concerns; drawing and expanding upon existing resources and re-orienting toward
future and hope. In terms of facilitating these processes, all psychological techniques
may be potentially valuable for caring for someone affected by the loss. More than one
approach is required over time to assist a person in grief. A continual process of
‘assessment’ and ‘intervention’ and ‘reassessment’ is needed.
COUNSELLING TO THERAPY
As we discussed, it is often difficult to determine when normal grief that simply
requires support for the natural healing process becomes problematic and in need of
more in-depth support or therapy. Bonanno (2004) found that resilience, characterised
as a pattern of high initial distress for a few weeks, followed by quite low levels of
distress, is common among between 30%-60% of grieving people. Resilience is
different from recovery, and chronic or delayed grief and can still be exhibited in
traumatic losses and alongside PTSD. Even for those who display symptoms of
problematic grieving that fits a diagnosable category, there is no one definitive
evidence-based method of intervention that fits all grieving people. As much as we
would like to have an easy definitive ‘treatment’ for problem grieving, this is not the
reality. Rather, a holistic thorough assessment for what may be causing problems in
healing for one griever may not be applicable for another. For example, for one person,
the problem may be due to an inability to process grief because of the avoidance of the
memories due to trauma; while for another, the grieving difficulties occur due to a
problematic attachment pattern that existed between the griever and the deceased.
Different theories and the techniques of care associated with such theories may
then be required to assist the grieving person. For the first person, trauma techniques
such as prolonged exposure or EMDR may be a first step necessary, while for the
second person, attachment or psychodynamic work or Interpersonal Therapy (IPT)
may be the most valuable approach. As such, an integrative, person-centred approach
is vital in caring for problems in grieving.
A COUNSELLING MODEL EXAMPLE BUILT FROM THEORY
According to the Dual Process Model (DPM) of grief, problem grieving occurs
when a person becomes ‘stuck’ in dealing with one category of stressors, most
commonly the loss oriented stressors. According to the DPM, the healing of grieving
requires an ability to accommodate the oscillations between loss-oriented and
restoration- oriented stressors. As they are restored, grieving people find the ability to
live with their experiences of the loss within their new world where the lost object is no
longer present. When oscillation is reduced, and the griever remains ‘stuck’ in one
group of stressors, healing does not occur. Such problems may be manifested in the
symptoms of Prolonged Grief Disorder.
According to the model then, intervention needs to restore this oscillation
between the stressors, so the normal process of grieving is then restored. Complicated
Grief Treatment (Shear,2010) is a manualised bereavement-focused individual
therapy. It is grounded in the DPM, Attachment Theory and with techniques modelled
from both Interpersonal Therapy and Cognitive Behavioral Therapy. It also includes
elements of Compassion-focused Therapy (Gilbert,2014) and self-determination theory
(Ryan & Deci, 2000).
