Grief Counseling and Therapy
How individuals and families cope with dying, death, grief, loss, and bereavement is as unique as a fingerprint. The response to the death of a family member, relative, or close friend places one in the category of "bereaved." Those who are bereaved experience grief, a person's response or reaction to loss, which encompasses physical, psychological, social, and spiritual components. How one copes with other life events and adapts to one's present and future is also part of the grieving process.
In the broadest context losses can be thought of as the loss of one's possessions, one's self, one's developmental losses, or one's significant others. Historically, many grief counselors and grief therapists have chosen to follow the popular "grief counseling theory of the time." However, in the twenty-first century there are constantly changing theories regarding grief and loss, and new challenges and questions raised by researchers, clinicians, and the bereaved themselves regarding what is or is not helpful during the bereavement process. In addition to counselors and therapists as defined in the more traditional sense, "grief and bereavement specialists" have emerged to help people deal with their grief, both before and after death.
What Is Grief Counseling and Grief Therapy?
In Grief Counseling and Grief Therapy (1991), the clinician and researcher William J. Worden, Ph.D., makes a distinction between grief counseling and grief therapy. He believes counseling involves helping people facilitate uncomplicated, or normal, grief to a healthy completion of the tasks of grieving within a reasonable time frame. Grief therapy, on the other hand, utilizes specialized techniques that help people with abnormal or complicated grief reactions and helps them resolve the conflicts of separation. He believes grief therapy is most appropriate in situations that fall into three categories: (1) The complicated grief reaction is manifested as prolonged grief; (2) the grief reaction manifests itself through some masked somatic or behavioral symptom; or (3) the reaction is manifested by an exaggerated grief response.
Does a person need "specialized" grief counseling or grief therapy when grief, as a normal reaction to loss, takes place? Are people not able to cope with loss as they have in the past or are individuals not being provided the same type of support they received in previous generations? Individual and family geographic living arrangements are different in the twenty-first century than in past years. People have moved from rural to urban centers, technology has altered the lifespan, and the health care decisions are becoming not only more prevalent but often more difficult. Cost and legal issues become factors in some cases. Today, ethics committees in hospitals and long-term care facilities are available to help families and health care providers arrive at common ground. Traumatic and violent deaths have also changed the bereavement landscape. What had helped individuals and families in the past in many situations has eroded and the grief and bereavement specialist, or the persons, agencies, and organizations providing those services, is doing so in many cases out of default. Grief counseling is used not only by individuals and families, but in many situations by schools, agencies, and organizations, and in some cases by entire communities affected by death.
Can Sources Other than Professionals Act As Counselors?
Social worker Dennis M. Reilly states, "We do not necessarily need a whole new profession of . . . bereavement counselors. We do need more thought, sensitivity, and activity concerning this issue on the part of the existing professional groups; that is, clergy, funeral directors, family therapists, nurses, social workers and physicians" (Worden 1991, p. 5). Although there are professionals who specialize in grief counseling and grief therapy, there are still many opportunities for the bereaved to seek support elsewhere.
Churches, synagogues, community centers, and neighborhoods were (and in many cases still are) the "specialized" support persons. Cultural traditions and religious rituals for many bereaved persons did and still do meet their needs. In the past, friends, family, and support systems listened to one another and supported individuals through the death of their loved ones, during the rituals after the death, and during the days, months, and years after the death. Although American culture is used to having immediate gratification, not everyone processes grief at the same rate. Some cope and adapt to a death sooner, while others, based on similar factors and variables, may take a longer period of time.
Grief counseling and grief therapy are not for everyone and are not "cures" for the grieving process. Counseling and therapy are opportunities for those who seek support to help move from only coping to being transformed by the loss—to find a new "normal" in their lives and to know that after a loved one dies one does not remove that person from his or her life, but rather learns to develop a new relationship with the person now that he or she has died. In A Time to Grieve: Mediations for Healing after the Death of a Loved One (1994) the writer Carol Crandall states, "You don't heal from the loss of a loved one because time passes; you heal because of what you do with the time" (Staudacher 1994, p. 92).
Goals of Grief Counseling and Therapy
Professionals believe that there are diverse frameworks and approaches to goals and outcomes of the grief counseling and therapy process. Robert Neimeyer believes, "The grief counselor acts as a fellow traveler [with the bereaved] rather than consultant, sharing the uncertainties of the journey, and walking alongside, rather than leading the grieving individual along the unpredictable road toward a new adaptation" (Neimeyer 1998, p. 200). Janice Winchester Nadeau clearly reminds grief counselors and grief therapists that it is not only individuals who are grieving, but entire family systems. A person is not only grieving independently within the family system, but the interdependence within the family also affects one's actions and reactions. According to Worden there are three types of changes that help one to evaluate the results of grief therapy. These are changes in: (1) subjective experience, (2) behavior, and (3) symptom relief.
Where Is Counseling Done and In What Format?
Grief counseling and grief therapy are both generally done in a private area (generally an office setting). These private areas may be within hospitals (for both inpatients and their families and for outpatients), mental health clinics, churches, synagogues, chemical dependency inpatient and out-patient programs, schools, universities, funeral home aftercare programs, employee assistance programs, and programs that serve chronically ill or terminally ill persons. Additional sites might include adult or juvenile service locations for criminal offenders. Private practice (when a counselor or therapist works for herself) is another opportunity to provide direct client services.
Treatment options include individual, couple, and family grief counseling or grief therapy, and/or group counseling. Sessions are approximately one hour in length, or longer for individual sessions. Groups are either closed (for a set period of time with the same small group of individuals attending each session) or open (offered once, twice, or several times a month and open to whoever attends without previous registration or intake). Grief support groups are generally not therapy groups, but supportive therapeutic environments for the bereaved. Group sessions are generally ninety minutes long. Treatment plans are used by grief counselors in most individual and family counseling situations and in all grief therapy situations.
In some cases a grief counselor may be meeting with a person one time to help "normalize" what the person is feeling, while grief therapy requires multiple sessions. In most cases a fee is paid by the person utilizing the grief counseling or grief therapy service and is either paid on a sliding scale or by self-pay, third-party insurance, victim assistance programs, community charitable care programs, or some other type of financial arrangement. Some hospice/palliative care programs offer grief counseling and grief therapy services at no charge for a limited number of sessions.
Crisis intervention hotlines emphasize assessment and referral, and residential settings for children, adolescents, and adults are also locations where grief counseling or grief therapy is utilized. A number of grief therapists do consulting work with other grief therapists or grief counselors, or with agencies or organizations.
There is not one method or approach. Each counselor or therapist has his or her own techniques that he or she utilizes because they are effective, although counselors often defer to other techniques that suit a particular person much better based on the individual's circumstances. Counseling and therapy techniques include art and music therapy, meditation, creation of personalized rituals, bibliotherapy, journaling, communication with the deceased (through writing, conversations, etc.), bringing in photos or possessions that belonged to the person who has died, role playing, bearing witness to the story of the loved one, confiding in intimates, and participating in support groups. The "empty chair" or Gestalt therapy technique is also an approach widely used by grief counselors and grief therapists. This technique involves having an individual talk to the deceased in an empty chair as if the deceased person were actually sitting there; afterward, the same individual sits in the deceased person's chair and speaks from that person's perspective. The dialogue is in first person, and a counselor or therapist is always present. The Internet also provides a number of sites that address the topic of grief and provide links to counseling services and organizations.
When Is Grief Counseling or Therapy Needed?
According to many experts, including John Jordan, grief counseling and grief therapy approaches are challenged and redesigned by new research. In their article published in the journal Death Studies, Selby Jacobs, Carolyn Mazure, and Holly Prigerson state, "The death of a family member or intimate exposes the afflicted person to a higher risk for several types of psychiatric disorders. These include major depressions, panic disorders, generalized anxiety disorders, posttraumatic stress disorders; and increased alcohol use and abuse" (Jacobs, Mazure, and Prigerson 2000, p. 185). They encourage the development of a new Diagnostic and Statistical Manual of Mental Disorders (DSM) category entitled "Traumatic Grief," which would facilitate early detection and intervention for those bereaved persons affected by this disorder.
Researcher Phyllis Silverman is concerned that messages dealing with the resolution of grief, especially a new category entitled "Traumatic Grief," may do more harm to the mourner. She states, "If this initiative succeeds ('Traumatic Grief'), it will have serious repercussions for how we consider the bereaved—they become persons who are suffering from a psychiatric diagnose or a condition eligible for reimbursed services from mental health professionals" (Silverman 2001). She feels the new DSM category may help provide the availability of more services, but believes it is important to consider what it means when predictable, expected aspects of the life cycle experience are called "disorders" that require expert care. When one thinks of grief counselors and grief therapists one is again reminded that grief and bereavement is a process, not an event.
How do persons cope and adapt? Grief counseling or grief therapy intervention can be useful at any point in the grief process, before and/or after a death. Consider the following story from a thirteen-year-old who was participating in a bereavement support group for teens, and wrote the following biography in response to her mother's death:
My mom was born on January 12, 1942, in Minnesota. She had a brother who was 11 years younger than her and she had a mother and father. . . . She was married in 1965. She then had two children. In 1981 my mom found out she had a brain tumor. She then got spinal meningitis and was in a coma for 3 weeks. She then was blind, but overcame blindness in a few months. One year later she was diagnosed with breast cancer. She had a mastectomy. She had chemotherapy for about one year. Then she had uterine cancer and had her uterus removed. Then she was diagnosed with lung cancer. She tried to hold on, but she was so sick. She went around in a wheelchair and was in and out of the hospital for weeks. But she got worse. On September 21, 1984, my mom died. I think that everyone who knew her will never forget her. (Wolfe and Senta 1995, p. 218)
In this case, anticipatory grief took place before the actual death occurred. It is the assumption that if one knows a person is going to die then the grief after the death is not as intense as if the death were a surprise. Grief counseling and therapy do not only begin after death. However, is this really true? According to clinician, researcher and writer Therese Rando,
Anticipatory grief is the phenomenon encompassing the process of mourning, coping, interaction, planning, and psychosocial reorganization that are stimulated and begun in part in response to the awareness of the impending loss of a loved one and the recognition of associated losses in the past, present, and future. It is seldom explicitly recognized, but the truly therapeutic experience of anticipatory grief mandates a delicate balance among the mutually conflicting demands of simultaneously holding onto, letting go of, and drawing closer to the dying patient. (Rando 2000, p. 29)
How Effective Is Counseling?
Various factors will determine the effectiveness of grief counseling or grief therapy. Some counselors and therapists utilize instruments to measure the effectiveness of the helping sessions. Others rely upon subjective comments from the client, his or her family, behavior observations, cognitive responses, symptom relief, and spiritual discussions. Because grief is a process and not an event, what takes place along the grief journey may alter how one continues to cope and adapt to loss. One loss or multiple losses do not make a person immune to future hardships.
The clinical psychologist and researcher Nancy Hogan and her colleagues state, "Understanding this 'normal' trajectory of bereavement has been hampered, in part, by the use of questionnaires designed to measure psychiatric dysfunction, such as depression and anxiety, rather than instruments specifically developed to measure grief" (Hogan, Greenfield, and Schmidt 2000). The Texas Revised Inventory of Grief (TRIG), the Grief Experience Inventory (GEI), and the Inventory of Traumatic Grief (ITG) have been criticized by Hogan. She believes, "The lack of grief instruments with solid psychometric properties continues to limit the ability of researchers to study basic questions related to the bereavement process. To date, the normal trajectory of grief has still not been empirically defined" (Hogan, Greenfield, and Schmidt 2000, pp. 1–2).
Qualifications of Counselors and Therapists
Most grief counselors and grief therapists have advanced degrees in either social work, nursing, psychology, marriage and family therapy, medicine, theology, or a related field. Many have terminal degrees. Those with only undergraduate degrees may find employment doing grief counseling for various organizations or agencies, but any type of third-party reimbursement (in the United States) would be minimal if not impossible without a graduate degree. A number of universities around the world offer undergraduate course work on death-related topics and graduate courses drawing upon subjects related to grief counseling and therapy. Certification in the field of grief counseling and grief therapy is offered by the Association for Death Education and Counseling, while other organizations in death-related areas such as the American Association of Suicidology and the U.S. National Hospice and Palliative Care Organization, also offer certification specific to their subject areas. In the United States and Canada, there are no state or provincial grief counseling or grief therapy certification requirements as of 2001. However, to practice in the United States in fields such as social work, psychology, or marriage and family therapy, a state license is required.
Carl Hammerschlag, a Yale-trained psychiatrist, spent twenty years with Native Americans in the Southwest of the United States. While working as a family physician he was introduced to a patient named Santiago, a Pueblo priest and clan chief, who believed there were many ways for one to heal. In his book, The Dancing Healers (1988), Hammerschlag shares a time when Santiago asked him where he had learned how to heal. Hammerschlag rattled off his medical education, internship, and certification. The old man replied, "Do you know how to dance?" To humor Santiago, Hammerschlag got up and demonstrated the proper dance steps. "You must be able to dance if you are to heal people," Santiago admonished the young doctor, and then stated, "I can teach you my steps, but you will have to hear your own music" (p. 10).
Grief counseling and grief therapy are metaphorically, learning to dance. Each person looks at the world through a different set of lenses, and as a result, one's dances, steps, upbringing, hopes, dreams, and healing are dependent on many factors. Grief counseling and therapy are about sharing a person's journey before or after a death. The focus is on companioning them during difficult times and not rescuing or fixing them, and about listening to their stories and thoughts with an open mind and open heart. The grief counselor or therapist's role in helping others is about transitions and new beginnings for those with whom they work. There are many rewards for clients, counselors, and therapists.
Corr, Charles A. "Children, Adolescents, and Death: Myths, Realities and Challenges." Death Studies 23 (1999): 443–463.
Hammerschlag, Carl A. The Dancing Healers. San Francisco: Harper San Francisco, 1988.
Hogan, Nancy S., Daryl B. Greenfield, and Lee A. Schmidt. "Development and Validation of the Hogan Grief Reaction Checklist." Death Studies 25 (2000):1–32.
Jacobs, Shelby, Carolyn Mazure, and Holly Prigerson. "Diagnostic Criteria for Traumatic Grief." Death Studies 24 (2000):185–199.
Nadeau, Janice Winchester. Families Making Sense of Death. Thousand Oaks, CA: Sage, 1998.
Neimeyer, Robert. Lessons of Loss: A Guide to Coping. New York: McGraw-Hill, 1998.
Rando, Therese A. Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research Press, 2000.
Rubin, Simon Shimshon. "The Two-Track Model of Bereavement: Overview, Retrospect, and Prospect." Death Studies 23 (1999):681–714.
Sofka, Carla J. "Social Support 'Internetworks,' Caskets for Sale, and More: Thanatology and the Information Superhighway." Death Studies 21 (1997):553–574.
Staudacher, Carol. A Time to Grieve: Mediations for Healing after the Death of a Loved One. San Francisco: Harper San Francisco, 1994.
Stroebe, Margaret, and Henk Schut. "The Dual Process Model of Coping with Bereavement: Rationale and Description." Death Studies 23 (1999):197–224.
Wolfe, Ben, and John R. Jordan. "Ramblings from the Trenches: A Clinical Perspective on Thanatological Research." Death Studies 24 (2000):569–584.
Wolfe, Ben, and Linda Senta. "Interventions with Bereaved Children Nine to Thirteen Years of Age: From a Medical Center-Based Young Person's Grief Support Program." In David W. Adams and Eleanor J. Deveau eds., Beyond the Innocence of Childhood: Helping Children and Adolescents Cope with Death and Bereavement, Vol. 3: Beyond the Innocence of Childhood. Amityville, NY: Baywood, 1995.
Worden, J. William. Grief Counseling and Grief Therapy, 2nd edition. New York: Springer, 1991.
Silverman, Phyllis R. "Living with Grief, Rebuilding a World. Innovations in End-of-Life Care." In the Innovations in End-of-Life Care [web site]. Available from www.edc.org/lastacts .