Grief counseling approaches and therapeutic interventions

Grief Counseling

Experiencing loss can have a long-term effect on a person, especially if that loss is deeply personal, such as the loss of a loved one. Grief counseling thus exists to ease a person through the grief process, which is never the same for anyone. According to Jane V. Bissler, the stages of grief have been "borrowed" from the five stages of dying, yet these are not the same at all and thinking so is incorrect. Whereas with dying, a person goes through denial, anger, compromise, depression and acceptance, the stages of grief are not an exact number, or in a specific order, and will depend on what the loss consisted of. For example, some people go through anger and others through depression and some go through both. Thus, the grief process cannot be generalized. This paper will develop on the topic of grief counseling to better explain how to help those who are experiencing grief, be it in a family situation, with the loss of a child or the loss of a parent, or otherwise, and will end by reviewing psychology literature on this topic. [1: Bissler, J. (2009). "Five Stages of Grief: Myth or Consequence?" Counseling for Loss and Life Changes, Inc. Retrieved April 14, 2011, from . ]

To begin, grief counseling is a form of therapy, with a focus on helping an individual grieve and address personal loss in a healthy manner. This type of counseling is offered by psychologists, counselors, social workers, and even clergy members or support groups, whether led by a professional or by a community leader. In other words, there are many ways in which to help address grief in a healthy way. The tasks of grief counseling are to help an individual express emotional loss, accept the loss, adjust to life after loss and cope with all these changes. [2: Anonymous. (2011). "Grief counseling: Definition." Encyclopedia of Mental Disorders. Retrieved April 14, 2011, from .]

This therapy also helps with feelings such as sadness, anxiety, anger, loneliness, guilt, relief, isolation, confusion and numbness, all of which can be experienced after a loss. According to the mind disorder encyclopedia, behavioral changes such as being disorganized, feeling tired, inability to concentrate, sleeplessness, changes in appetite, vivid dreams and day dreaming, are also experienced by the person grieving. Such an overwhelming emotional and behavioral change needs some guidance, so it is recommended that grief counseling be considered by those affected by these emotions. [3: Anonymous. (2011). "Grief counseling: Definition." Encyclopedia of Mental Disorders. Retrieved April 14, 2011, from . ]

Grief counseling is thus a very useful therapeutic tool. It not only helps the individual work through the many feelings associated with the loss of a loved one, but also provides a medium for the individual to understand the normal grieving process and the normality of many of the experiences that he or she is experiencing. The counseling process, again, varies for everyone. Some individuals express deep physical and psychological pain, and many need help getting back to daily routine, while others only experience numbness.

If an individual feels overwhelmed by the loss, it is the psychologist's duty to find specific coping mechanisms to help that individual resume normal life in his or her daily routine. If a person's sleep is disrupted, for example, a counselor may include that individual's physician in the session to assist with increasing sleep. As with any counseling, the outcomes may be successful or unsuccessful. Those who have success can return to a normal life, while others continue to experience the prolonged grief with which they began. [4: Anonymous. (2011). "Grief counseling: Definition." Encyclopedia of Mental Disorders. Retrieved April 14, 2011, from . ]

As mentioned above, however, there are many support groups for those grieving. For example, the website griefnet.org, is an internet community of persons dealing with "grief, death, and major loss." This community claims to have over 50 e-mail support groups, and aims to provide grief support to both children and adults. The website is headed by a doctor who is a clinical psychologist and traumatologist located in Michigan, and is seen as a non-profit.

Another website aimed at helping people cope with grief is compassionatefriend.org, which focuses on grief support after the death of a child. The motto of this site is to transform the "pain of grief into the elixir of hope." The website and its 625 in 50 states exist to help those going through the grieving process after the loss of a child by providing friendship and understanding.

This website also has a letter to the New Bereaved, which can be found on its front page. Before even starting therapy, one can read through this and feel a sense of understanding, and perhaps, not feel so alone. The letter expresses understanding by acknowledging potential feelings that a parents, grandparent or sibling could have, such as that "meaning has been drained" from life, that it could be difficult to lead a normal life and that it does not seem like things will ever feel better. The website also offers compassionate advice by expressing that all its members have been under the potency of emotions experienced when losing a child. Furthermore, it includes a long list of "thoughts" that a parent might be experiencing. This list comprises:

"Thoughts of suicide briefly enter your mind. You tell yourself you want to die -- and yet you want to live to take care of your family and honor your child's memory,"

And

"You yearn to have five minutes, an hour, a day back with your child so you can tell your child of your love or thoughts left unsaid." [5: Compassionate Friends. (2011). "To the Newly Bereaved." The Compassionate Friends. Retrieved April 14, 2011, from < http://www.compassionatefriends.org/about_us/To_the_Newly_Bereaved.aspx>. ]

This section of the letter is important, because it will make the bereaved feel understood and part of a community that can help him or her recover from the loss and proceed forward with life.

As seen from these quotations, the loss of a child can be especially traumatic for close family. The case described below also deals with this loss, but it is from the point-of-view of an elementary school teacher. This case is written by Patricia Witt, a principal in Georgia, about mentoring Jodi Clark, an assistant principal, so that Clark may become the new principal. Clark, who has 10 years of experience in the classroom has just experienced the death of one of her students, and was deeply affected by this event, even though the victim was not her biological child.

Witt states that she was initially unprepared to console Clark on this matter for she had not training, but that she nevertheless spent time letting Clark just cry over the loss of this child. She continues to realize that, in fact, by crying and talking both women took time to grieve and speak "through the shock of having an event like this occur." Then, the two women started focusing on the community, and what it could do to help ease the pain of the father, a faculty member, who had just lost his only child. The two women also wanted to help the students, the other teachers, and the parents grieve. Thus, they decided to call each family personally and let them know what had happened so that they may help console the father of the child in their own way. [6: Witt, P. & Clark, J. (2010). "Losing a Child, Healing a Community." Principal Magazine 58(1). ]

However, the death of a child, whether it affects the parents, a school, or a whole community, is devastating, perhaps just as saddening is the death of a parent. For a child, this can be a traumatic event that can shape his or her life forever. The Journal of Consulting and Clinical Psychology includes a study on the long-term effects of the family bereavement program for parentally bereaved children and adolescents. As part of this study, a randomized trial of the effects of the Family Bereavement Program (FBP), was analyzed. This program measures grief experienced by children and adolescents alike over a six-year period. The method the trial employed was selecting 244 participants from ages 8 to 16, taken from 156 families that had experienced the death of a parent. This sample consisted, according to the study, of 53% boys and 47% girls, 67% non-Hispanic White and 33% ethnic minority participants.

The families were also randomly assigned to one of two conditions: FBP (N=135) or a literature control condition (N=109). Two grief measures were also utilized: the Texas Revised Inventory Grief (TRIG) and the Intrusive Grief Thoughts Scale (IGTS). The TRIG utilizes a 21-item scale to measure "the extent of unresolved or pathological grief." It relates to two points of time, past and present, and is comprised of two subscales. The first 8-item subscale measures "feelings and actions at the time of death," and the second, 13-item subscale, measures present feelings such as "continual emotional distress, lack of acceptance, rumination, painful memories." The IGTS is a 9-point scale meant to measure in a similar way as the TRIG. [7: Unknown. (2006). "A Systematic Review of the Literature on Complicated Grief." Australian Government: Department of Health and Aging. Retrieved April 14, 2011, from < http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-rsch-grief~palliativecare-pubs-rsch-grief-3>. ]

These two measures were thus administered for the participants at four times over six years, according to the study, and at three different junctures: pretest, posttest and 11-month and 6-year follow-ups. The results of this experiment are described below, and help us understand this important process and how we can help those bereaved grieve:

"Compared with the control group, the FBP group showed a greater reduction in their level of problematic grief (IGTS) at posttest and 6-year follow-up and in the percentage at clinical levels of problematic grief at the posttest. The FBP also reduced scores on a dimension of the ITG, Social Detachment/Insecurity, at 6-year follow-up for three subgroups: those who experienced lower levels of grief at program entry, older youths, and boys. Conclusion: These are the first findings from a randomized trial with long-term follow-up of the effects of a program to reduce problematic levels of grief of parentally bereaved youths." [8: Sandler, I.N. & Ma, Y. & Tein, J.Y. & Ayers, T.S. & Wolchik, S. & Kennedy, C. & Millsap, R. (2010). "Long-term effects of the family bereavement program on multiple indicators of grief in parentally bereaved children and adolescents." Journal of Consulting and Clinical Psychology, 78(2). ]

This study is also important because it helps us draw conclusions as to what kind of treatments is suitable, though again, grief therapy will vary for everyone.

This study, does not mention, however, whether the children were met by a psychologist individually or with family. The latter, called family intervention, is when a counselor meets with the group of survivors, sometimes individually, but also as a family unit. The focus of such meetings would be to facilitate expression of both positive and negative effects after an individual's passing and to identify how the roles of the deceased are being taken or rejected by the surviving family members. [9: Worden, J.W. (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing.]

Worden, who writes a book on Grief, explains that in the case of a father's passing, his roles may be taken up by an elder son. Yet this ought to be a careful transition, for the son may suppress his feelings to meet the demands and expectations of his new role. Thus, it is important to speak about these restructures roles within the family, especially where children are involved, and often this discussion cannot be held by a family alone. This situation must be helped by a counselor so that the family does not end up in conflict or emotional withdrawal from each other. Not only must the family talk about the newly assigned roles, but it must also find a new balance in relationships that the passing of a family member may have broken. According to Worden, after a passing in the family, "there is a need to shift and re-equilibrate family triangles. Various alliances that have been formed need to be altered. However, if no substitute is found, then the deprived member may seek homeostasis through various social, physical, or emotional illnesses." [10: Worden, J.W. (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing.]

The paper has so far presented an introduction to grief therapy, and various instances in dealing with a child or an adult death, form a social, but also from a scientific perspective. The remainder of the paper will thus focus on continuing the topic of means by which to deal with grief, by exposing literature on the psychology of crisis.

First, there have been innovations in the field of grief counseling, such as utilizing Christian psychology. According to an article, "Christian grief counseling includes the idea that a loved one is in Heaven and [offers] strategies for conducting life on earth without that person." This counseling method depends on a person's faith and the mode in which a loved one passed away, and is thus useful in tailoring a specific means by which to cope with grief for those affected. This concept further believes that bereavement counseling "may offer the same types of counsel even if belief in Heaven is absent" and that many Christian counselors will offer their services to non-Christians in order to "share faith with otherwise faithless people." [11: "Christian Grief Counseling." (2011). Christia.net. Retrieved April 16, 2011, . ] [12: "Christian Grief Counseling." (2011). Christia.net. Retrieved April 16, 2011, . ]

Support in this philosophy can also come from many different types of people. Counseling can be anyone who is willing to listen, but specific questions about the faith of either the deceased or the bereaved and the afterlife are better handled by a pastor who will have performed his studies up to the Master level of education and will assist the person from both a psychological or counsel point-of-view, but also help them with faith issues. The article goes on to state that even though Christian grief counseling "may not directly help with the problem of survival," it will "create confidence in the survivors through self-concept and organizing memories." [13: "Christian Grief Counseling." (2011). Christia.net. Retrieved April 16, 2011, . ]

Other innovations have been more scientific in scope and have evolved due to various studies. Two such measures of grief have been described in the study above. However, others exist as well and will be described in detail below.

For example, as part of an assessment, an examination of eight instruments of measuring grief was included. These theories were the Texas Revised Inventory of Grief (TRIG), the Hogan Grief Reaction Checklist (HGRC), the Grief Evaluation Measure (GEM), the Revised Grief Experience Inventory (REGI), the Core Bereavement Items (CBI), the Inventory of Complicated Grief (ICG), the Inventory of Complicated Grief-Revised (ICGR) and the Bereavement Risk Index (BRI). These eight "instruments," as the study calls them, for measuring grief were "examined for validity and reliability and the practical considerations of using the various tools in the clinical context." These tools are thus useful since the measurements for which they were utilized were very complex. In combination with these instruments, three grief assessment scales were also utilized, including the Grief Experience Questionnaire (GEQ), focusing on responses to suicide, the Perinatal Grief Scale, and the Perinatal Bereavement Scale (PBS). [14: Unknown. (2006). "A Systematic Review of the Literature on Complicated Grief." Australian Government: Department of Health and Aging. Retrieved April 14, 2011, from < http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-rsch-grief~palliativecare-pubs-rsch-grief-3>. ] [15: Unknown. (2006). "A Systematic Review of the Literature on Complicated Grief." Australian Government: Department of Health and Aging. Retrieved April 14, 2011, from < http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-rsch-grief~palliativecare-pubs-rsch-grief-3>. ]

As the TRIG has already been analyzed above, I would like to start this discussion with the HGRC. The HGRC is a questionnaire composed of 61 items and is structured as a five-point scale. Its development, according to the study, was based on various bereavement interview data that was obtained from adults. When the interviews were analyzed, the testers identified six categories, including despair, panic, blame, disorganization, detachment and personal growth. The interviews were administered to over 500 adults who were recruited through bereavement support groups. The HGRC was then able to identify correlations and detect changes in bereavement responses over time. Though a total score could not be calculated, the study mentions, "a range of grief theories are offered as rationale for the various types of grief responses to each subscale (i.e. Dual Theory, Attachment Theory, etc.)." Due to some persisting ambiguities, however, it has been decided that it would be difficult to recommend the method as an instrument to measure grief. [16: Unknown. (2006). "A Systematic Review of the Literature on Complicated Grief." Australian Government: Department of Health and Aging. Retrieved April 14, 2011, from < http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-rsch-grief~palliativecare-pubs-rsch-grief-3>. ]

The next method, the GEM, was newly designed to screen for development of "complicated mourning responses in a bereaved adult." The instrument, also comprised of several factors, uses both qualitative and quantitative examination to assess risk factors. It also includes in its questions various elements from pre and post bereavement, thus making the study a bit more complete. The GEM, despite the small sample study, was proven to validate established measure of trauma through its indexes including the Inventory of Traumatic Grief, Impacts of Events Scale and its Treatment Outcome Package. The study further describes, "the tool was also found to be predictive of mourner adjustment one year following the initial assessment […] the extent to which the tool is able to discriminate respondents according to the severity of their grief responses warrants further testing. The instrument is also very long, which may prohibit its use in this present form in clinical practice." [17: Unknown. (2006). "A Systematic Review of the Literature on Complicated Grief." Australian Government: Department of Health and Aging. Retrieved April 14, 2011, from < http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-rsch-grief~palliativecare-pubs-rsch-grief-3>. ] [18: Unknown. (2006). "A Systematic Review of the Literature on Complicated Grief." Australian Government: Department of Health and Aging. Retrieved April 14, 2011, from < http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-rsch-grief~palliativecare-pubs-rsch-grief-3>.]