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