Grave Monument

Loss and Grief Counseling Skills
By Daniel Keeran

The primary goal of grief counseling is to deal with the seven most painful feelings; everything else is a derivative of them. Every other painful feeling can be related to those. For example, anger is at the root of resentment and frustration, fear is the source of anxiety and insecurity, and emptiness gives rise to abandonment and loneliness. Shame is a combination of fear and guilt. It's a fear about what other people may think if they knew.

There are three goals in grief counseling. The first and fundamental goal is to identify and experience the range and intensity of painful feelings that make up grief. We're going to help the client to identify the feelings cognitively, and then to experience the full range from fear to despair as well as the intensity of the painful feelings related to his loss, or losses.

The second goal is to identify changes or maladaptive behaviour decisions which are related to the loss. This goal is very important in cases of complicated loss, which occurs when the painful feelings have not been dealt with in a healthy way. Instead of being expressed and shared, they've been defended against and protected, resulting in unhealthy or maladapted behaviours. By maladaptive we mean ineffective or unworkable or unhealthy behaviour decisions. When we see these behaviours continuing over years, over a long period of time, then we're seeing this as a complicated bereavement experience of our client.

"Decisions" is an interesting word because the behaviour choices, or ways of coping with the pain, are often done unintentionally or unconsciously, but they are decisions nonetheless. A person can re-decide, can make different decisions about that pain and how to cope with it, how to deal with it.

The third goal of grief counseling is to complete unfinished business, and to say goodbye in order to say hello. It's difficult to say hello to new life experiences until we say goodbye to old painful ones, and by goodbye we mean letting go. Saying goodbye, and letting go, and learning acceptance, which is a commonly used term, all mean the same thing.

Saying goodbye really encompasses all three objectives for grief counseling. A person hasn't completely grieved, or said goodbye, or let go, until he has worked through the pain, identified and changed the behaviour decisions, and finished his unfinished business.

You can see that these goals correspond to the counseling process as we've been discussing it. It's simply a reiteration of what we've been talking about. As we're discussing loss and grief, I'd like for you to be thinking about your own losses. These could be deaths of loved ones, break-up of relationships, loss of parental caring and relationships are the major ones, the most difficult ones.

Once you've identified a loss and the person can express the sadness, how often do you go back to that loss? Maybe you think a person could experience those feelings surrounding a loss indefinitely just by putting himself back in that place again. How do you know when enough is enough?

There are two different views. The cognitive school says you don't really get rid of the pain, you just know all about it. You become so familiar with it that it no longer has power over you. And the only way to know all about it is to experience it. There's no other way. So there is a point at which cognitive therapy has to include grieving, otherwise there's no true knowledge of the pain.

The other school of thought which is represented, for example, by people who use psychodrama a lot, is that when you express the pain it's possible to release it, and to purge yourself of it. It may take a long time for that catharsis to be complete, but eventually the pain will be completely gone.

I tend to think it's a combination of both. There is a catharsis effect, and some of the pain is released, but then there is also the cognitive aspect of knowing about the intensity of the pain, that takes the power away from it. I'm no longer frightened of the pain. I know about it and I've accepted it as mine, and as okay. I have embraced the pain.

INTERVENTIONS FOR THE EMOTIONS OF GRIEF

Now let's go on to looking at the painful feelings. The first goal of grief counseling is to identify and experience the range and intensity of painful feelings. It's going to be important for us to review these feelings and to suggest some therapeutic interventions for working with the grieving person. We also need to realize what the fear of painful feelings is about.

Imagine a successful executive of a corporation who has never experienced any tragedy in his life, any major loss. He has a wife and three kids and he gets a phone call that one of his children, a six or seven year old child, has just been hit by a truck and killed in front of the house. The child came home from school and crossed the road in front of a gravel truck coming from a nearby construction site, and was killed. Now this man has a lot of responsibility to provide for his family and to keep his company going, and since he has experienced a tragic loss he goes for counseling. It's very difficult for him to engage his pain, because he's afraid of what?

He's afraid of falling apart and of not being able to get on with all of the things he has to do. He needs to maintain the image of the corporate person. And he's been working on being able to do this for many years and to continue with his heavy responsibilities. So not having experienced intense grief before, he doesn't know that it's not going to cause him to fall apart.

In fact he doesn't realize that if he doesn't allow himself to grieve, then he's going to fall apart. It's going to be just the opposite of what he's afraid of. So we need to help that person get past the fear, and the way to do that is to encourage him to talk about the fear, to validate the fear, to reflect how scary it may be, and then invite him just to say a little bit about it.

Fear

I find this is a very effective approach when working with the very blocked, resistant client: invite him to say just a little bit about the little bit of fear that he may have. And once he feels supported with that, then he can go on to another painful feeling.

A gradual approach to the feared object is fundamental to working with fear. Remember that whenever there is fear, there is resistance, defenses. So it is important to go slowly, invite the person to say what the fear is about and after he has disclosed, ask him what it was like to talk about that. Then invite him to say a little more.

Whenever, there is disclosure of difficult, painful experience, be sure to process the process by saying, "What was it like talking about that? Is it OK?" This allows the client to control the pace and amount of disclosure and to validate the process and to maintain his sense of safety.

Sometimes the fear is about feeling so much of the pain, he will become depressed or so sad that he will never stop crying. So we can say, "I wonder if you are afraid that if you start crying you may never stop, and you will fill the whole world with your tears." This can free up the sadness, and he will discover that the crying does end and he survived it. This will help the healing, and life will be easier and less sad.

Anger

Some grieving people find it easier to access anger than their sadness. They'll use their anger to defend against their sadness. They feel strong with anger but weak and vulnerable with sadness. Generally the person who finds it easier to access anger in grief has an aggressive personality. They are usually outspoken, direct, and opinionated. In working with the very angry, grieving client, we can validate that anger for as long as he needs it to be validated. Draw it out and encourage him to express it, entitle him to that anger.

If we're able to validate or support a person's anger, what feeling comes next? The sadness will come out more easily if the anger has been properly supported. Now with the passive individual, who accesses sadness more easily, we need to help him express the anger. The passive individual feels guilty about anger and is afraid of its destructiveness. So to reach for anger we can use the word "cheated," or another word that the person feels safer with.

So we can say, "I wonder if you feel a little cheated? Your husband has died, you expected you'd be able to retire together, you were looking forward to that. And now he's gone. I wonder if you feel just a little bit cheated about that?" And sometimes what I find is that if I minimize a feeling and use the word cheated with that individual, she'll maximize and say, "Yes, I feel really cheated." And I'll say, "Go on and say more about being cheated." In fact she is talking about her anger, but she is just not using that word.

Try to find words that don't offend the client or that don't trigger the guilt or fear around anger. Try to use other approaches and other words. Here are some other approaches.

You can say things like, "What are some 'why' questions? If you were to ask 'why' questions about the death of your father, or the death or your child, what would they be?" What are some of those 'why' questions? Why did you die? Why him? Why did he leave me? Why not me? Why did God let this happen? Often the anger is directed at God. So then I'll say, "What's the feeling that goes with that why question? Fear, anger, guilt, sadness, emptiness?"

If it was a child the client may ask why a child died. Why not an older person? Why not someone who'd lived a full life? Why a child? Anger is what goes with that question; the outrage, the sense of injustice, the unfairness. Sometimes your client will come up with anger. Then you can invite him to say more about the anger. And you can validate it, support it.

Another thing we can do is say, "Talk about the lost hopes and dreams." Lost hopes and dreams are about being cheated because those hopes and dreams can't be fulfilled now that this death and this loss has occurred. There's a sense of feeling cheated about that. Another thing I may do to draw anger is to design a statement for my client to repeat. I may design a why question or a blaming statement.

For example in the case of an abusive parent, in working with loss of parental caring and closeness, I may suggest the statement, "You didn't care about anyone but yourself. You didn't care about me, all you cared about was the bottle." Try on that statement. I may say it without any affect in my voice.

You can tailor a statement, invite your client to repeat it, and then reach for a feeling. "What's it like saying that? Does that fit? What feelings come up when you say that? What choice words do you have for this man?" Go for choice words or strong words, if your client has them in his vocabulary. For the type of client that has choice words available to him, ask him what some choice words may be. The passive client may not have choice words in his vocabulary. Some of these words could possibly be very coarse and powerful.

We are facilitating the expression of emotion through name-calling, I'm talking here about the client who has been severely abused, mistreated. We need to have a way to vent that anger in a therapeutic setting, not face to face with the abuser. So you don't really want to escalate it but you want to allow this person to feel that it's okay to feel angry.

Sometimes anger is directed toward the counselor as a defense. When a client becomes very resistant and begins to struggle with the counselor, we can say, "So I wonder if hanging on to the struggle is a way of not getting on with your healing." When he acknowledges this, direct him, "Now talk about what's behind the struggle, talk about what's hard to talk about, what's hard to face."

Sadness

When I'm starting to bring out anger and sadness with a client, I may also say, "I wonder if you're using that anger to defend against another feeling." Or "I wonder if that anger is easier than the sadness." Or if a client identifies both anger and sadness I'll say, "Which of those two feelings is easier for you to express?"

She may have identified anger as a primary feeling, and I may reach for a little sadness. She may have owned a little sadness, and then I would say, "Which one is easier for you to feel?" And whichever one she chooses I'll invite her to talk about the opposite one because it's the one she doesn't want to talk about that needs to be worked through. The key to a person's progress is to invite him to explore and integrate whatever is most difficult.

Other ways to get to sadness is to say the following:

"Say his name." The name of the loved one may be loaded with sadness and remains unspoken until you invite it.

"Talk about a happy memory." The happy memory brings up a sense of loss and sadness.

"Talk about the last time you saw him." The last memory may be of the death or of regrets and sadness about this.

"What do you see as your talk? It's as if you are looking at something." Tapping into mental images may be associated with sadness because the past is being re-lived in the present.

"You will never see his face again." The realization about the finality of the death is often very sad but true.

"Have you said good-bye to him?" This brings up sadness about the finality of the loss and can be key to letting go.

While observing the client's emotional response, take note of keywords and phrases immediately preceding the sadness, then repeat these words at an opportune time to facilitate grief. For example, a client grieves when describing how her son was killed by a "power truck." Later, I simply said, "There was a power truck," and the client cried.

Remember to always process the process after a client has finished crying, by saying, "What's its like talking about this and feeling these things? Is it OK to cry?" And if she says it hurts so much say, "It's normal to feel that with what you've been through. You loved him."

Guilt

Guilt is one of the primary reasons that people develop very maladaptive behaviours. A person who feels very guilty doesn't believe that he deserves happiness, and so what does he think he think he deserves? Punishment. Punishment goes with guilt, so I may want to explore with the person how much guilt he feels? Maybe a little bit, a lot? This is the same technique I may use exploring any feeling. How much anger do you feel? A little bit, a lot, a medium amount? I want to gauge how much of that feeling they are aware of inside.

If they feel a lot of guilt, or they identify a feeling of guilt I'm going to say, "I wonder if you're aware of how you may be punishing yourself."

And then I'll say what some people do. "Sometimes when people feel guilty they won't let themselves be happy, they'll be depressed, they'll be stuck in their life. They won't let themselves get on with their life. They won't let themselves experience enjoyment, they won't let themselves be close to people, they won't let themselves really welcome the challenges and opportunities that life has to offer. And I wonder if you're aware of how you may be punishing yourself in some small way?"

A helpful approach is to use exaggeration: "I wonder if you will give yourself a life sentence." When the client considers this, they have a chance to realize what he may have done and decide to let go of the self-punishment. "What will you do differently? Can you let go of that?" and "What would (your loved one) say?"

Use of minimizing and exaggeration

So again use that minimizing technique, because it's easier for people to think of small ways sometimes and then that opens up other areas of awareness. So a person will choose and then I'll say, "I wonder if you're going to give yourself a life sentence?" That's making use of exaggeration. In other words, take that metaphor to its ultimate conclusion, or to it's extreme, which could be something like a life sentence of punishment by means of depression. For example, I had a client who lived a rebellious life, and then his mother suddenly died of a heart attack. He blamed himself for his mother's death and he became chronically depressed after that for a number of years. When I saw him in treatment I explored the guilt with him, and I said, "I wonder how you may punish yourself? I wonder if maybe depression is a way you may do that?" And he acknowledged it. And he went on saying that he didn't deserve to be happy. He felt that his life style was a cause of his mother's death. And so I said, "I wonder if you're going to give yourself a life sentence?" And he stopped and the wheels were turning and he made a new decision. He pulled back from the guilt.

With the extreme conclusion or exaggeration intervention, a person will pull back from the exaggerated possibility. He'll say, "No, I'm not going to take it to that extent." This client started making real changes, real improvements in his direction. When people feel really guilty, they won't allow themselves to get on with their grieving. They'll remain stuck in it, and that's their unconscious form of punishment.

Hanging on or letting go

Sometimes people won't let themselves work through their sadness and their anger, or other painful feelings, because hanging on to the guilt is a way of hanging on to the person who died. Sometimes I'll put it to a client that way. I'll say, "I wonder if hanging on to that guilt may be a way of hanging on to Mom?" And some times they don't realize it, they haven't thought of it in those terms. When you put it that way it helps them to decide not to hang on.

I've heard clients say that: "I don't want to hang on any more." That implies letting go of the guilt. You can use that with anger: "I wonder if hanging on to that anger is a way of hanging on to the man you divorced? Hanging on to the fight may be a way of hanging on to your ex-husband. Hanging on to the fight may be a way of hanging on to Dad."

You can move people forward by saying, "It's not easy to let go. It's not something you need to hurry." What you often hear is, "How do you let go?" and I say, "By doing exactly what you're doing today. Talking about your feelings, putting it into words, by doing exactly what you're doing and I encourage you to keep doing that. What's it like doing that today, talking about your pain?" And they'll say, "It's tough."

I mentioned earlier that some people use anger to cover sadness and others use sadness to cover anger. So sadness is not necessarily the core feeling, although often for the person who's very angry, it's important for him to get to his sadness.

For the person who's very sad, especially if he appears to be stuck in sadness over a long period of time, weeks, months, or maybe years, maybe it's because it's because he hasn't dealt with the anger, or he hasn't dealt with the guilt, or both.

Emptiness

So then we come to emptiness. Emptiness is something a person may feel constantly. But sometimes a person will fill the emptiness, or attempt to fill that empty feeling or that void with the other painful feelings. It's easier to feel anger than that agonizing emptiness or that sense of the void, that abandonment, that loneliness.

Sometimes, early on in grief counseling, that person may identify feeling empty, and the way I may work with that is to say, "What goes into that emptiness? Would it be empty sad, empty angry, empty frightened, empty guilty, empty what?" I'll associate another feeling with the emptiness.

And I may work with the emptiness on its own, and just invite the person to talk about the emptiness. She may talk about a loved one she lost, who had been in her life at the dinner table, or in bed beside her if it's a partner, a spouse. The spouse came to the door at the same time on schedule for so many years, and now that person is gone and so there are empty spaces at the table, in the bedroom, at the door.

When a child dies there is tremendous emptiness because that child has occupied so much of the parents' time, and has contributed so much to the noise level. The child leaves a deafening silence that's very agonizing. We need to help a person identify what the emptiness is about and then validate that.

Now the emptiness may become more apparent to a person as she gets support and is able to put these other painful feelings, the anger or sadness, into words. As she's letting go of that anger or sadness, the emptiness may still be there and it may be even more obvious to the person. And most especially, I find that clients report feeling empty when I invite them to talk about letting go or saying goodbye to the loved one.

For example, I sometimes use the empty chair to invite a person to talk to a loved one about saying goodbye, and I then explore the feelings that he's left with. I say, "What's it like, what are you feeling inside as you say goodbye and as you talk about saying goodbye to your father or your child? What feelings come up? Fear, anger, guilt, emptiness, despair?" And nine times out of ten they choose emptiness because that's what's left if you're going to say goodbye to somebody.

Now if a person has done a fair amount of grieving, I'll work with that emptiness in a therapeutic way by saying, "Maybe you're at a kind of crossroads in your grief. You can either fill that emptiness with the old pain, your old ways of being stuck and not getting on with your life, not letting yourself be close to other people, or you can begin to fill that emptiness with the challenges that life has to offer, taking risks to get close, allowing yourself to enjoy pleasurable experiences in life. Which way do you think you'll go on this crossroad?"

That's a cognitive technique that allows clients to make a conscious decision about what they're going to do or which way they're going to go. This is transition toward reconstruction of life and saying hello to new people and experiences.

Seeing the hidden loss

If there was emotional distance, a loss of bonding, or if the lost person was experienced as angry, the grief may be buried and be more about the loss of closeness when the person was alive or prior to the loss.

A woman married a man who disclosed to her after two or three years of marriage that he was homosexual, and then he ended the relationship. She didn't appear to go through any grieving process at all when it actually ended. She went back to work the next day and two months later she met another man. She got married and had kids, and I'm not aware of her going through much grief. Why? Because the marriage was the loss not the ending of the marriage. She grieved when she first learned he was gay; she was angry, sad; felt guilt, low self-worth, emptiness.

Grief will only be experienced as an intense kind of experience if there's been bonding. If there hasn't been significant emotional bonding, it's not as much of a loss. If he was homosexual it's understandable that there may not have been much intimacy, or closeness, or bonding. It may have been some other kind of relationship, more like a brother and sister rather than husband and wife. So it has to do with how much is invested.

A woman came up to me after a talk I had given and said that when her mother died she didn't grieve. And she wanted to know why, because other people grieve. She wondered why she wasn't upset. I asked her, "Were you close to your mother?" and she said "No." She had never been close all those years. And I said, "I wonder what feelings come up inside you when you think about all those years of not being close to your mother?" That's when the tears welled up in her eyes. That's what her grief was about. It wasn't about her mother's death. It was about the loss of closeness during her lifetime.

Low self-worth

A person may feel low self-worth, especially if he is experiencing feelings of guilt, because when a person feels very guilty he doesn't feel worthwhile, he doesn't feel he deserves to go on living.

A person may also experience low self-worth if he comes from a dysfunctional family and now has experienced a tragic death of a loved one. He may feel as though he didn't really deserve to have that person be alive for him. Low self-worth sometimes happens when people bargain, for example with God, over the life of the person who died. So you may hear about a person saying, "I'm really the one who should die. Don't let that child die. Take me, God." So in that kind of bargaining the implied message is, "I'm not as worthwhile as the child." A person may then become very depressed, and isolate or deprive himself of enjoyment in life because he doesn't feel worthwhile or deserving.

In cases of sexual abuse, low self-worth is connected to shame or to feeling dirty. What do you do with something if it's dirty or worthless? You throw it away. That's another kind of loss that we haven't yet talked about. Sexual abuse and assault is a very significant loss. Feeling dirty or feeling shame is closely related to that and leads to self-abuse by choosing unhealthy relationships and lifestyle or behaviours that distance from others, such as obesity or aggression.

Despair

Despair and hopelessness are the sum total of these other painful feelings, and as a person is engaging in the grief process and getting support and validation, often that despair will diminish. The despair may appear early on along with fear, but as the safety of the counseling relationship increases and the therapeutic alliance improves, despair sometimes diminishes along with the fear.

Despair often goes with confusion. A person may have a lot of painful feelings inside that he hasn't identified, especially early in the grief process. He feels despair because he has the intensity of all that pain but he hasn't been able to sort it out. So as you work with him throughout the process and identify the distinct feelings and help him work through them, the confusion and the despair diminish.

Prior loss affecting a current loss

If a person has suffered significant losses throughout her lifetime, is the coping process easier for her? It depends on how she has dealt with those previous losses. If she has coped with her previous losses in an unhealthy way by burying feelings, or by dumping feelings, or by distancing herself from others, that can become a pattern.

For example, some people won't say goodbye; they'll just leave and you'll wonder where they went. And it may be that that's related to their style of hanging on or their style of dealing with loss and separation from an earlier experience in life. Sometimes when a person experiences a tragic loss it will bring up their previous losses. And if there seems to be difficulty establishing and maintaining intimate relationships and getting on with life goals, it may be due to unfinished business with a previous loss.