Dealing with loss of a loved one can have a devastating effect on anyone. In this article I will explore grief and some of the psychological theories surrounding it. I will then continue to explore some of my approaches towards working with clients experiencing grief and provide some insight to how clients can begin to move on when ready.
Grief could be described as a natural and intense response to losing someone or something that is important to you. For example, losing a loved one or breaking up a relationship can all produce grief. Loss could be described as similar to grief and is the act or process of losing someone of something. Some of the theories of grief and loss that we could consider, are Bowlby’s theory of attachment. (1961). Bowlby believed that attachment often starts in infancy between a child and its carer. Bowlby proposed that grief is a natural response to separation. When attachments are broken or lost, individuals may experience emotions such as anxiety, crying and anger. Bowlby (1961) identified four phases of mourning: ‘Numbing’; The first phase where the loss may seem unreal and impossible to accept. The sheer impact of the loss may result in symptoms and behaviours such as; numbness, lack of concentration, loss of appetite and insomnia. Feelings of loneliness, anxiety, anger and fear may also be experienced by the client who is grieving. E.g. fear that they are alone and/or anger at being left alone. ‘Yearning and searching’ is the second stage that follows and where the bereaved client may become aware of the loss. The client may try to find reminders of the loss and find ways of feeling closer to the loss. Bowlby (1961) believed that if the client may not be able to work through this phase than they may spend the rest of their lives trying to fulfil this void in some way. The third stage; ‘disorganisation’ is where there is an acceptance by the client that the loss has happened and that it will not be the same. The client may feel angry and start questioning the loss and may also be consumed by other emotions. If client’s do not proceed through this stage than according to Bowlby and Parkes (1961) we will continue to experience these negative emotions. The fourth stage; ‘Re-organisation’, involves recovery. So slowly the client may begin to recover and get back to normality and may start to rebuild their goals. (Bowlby 1961)
Alternatively, we can consider the dual process model of grief. (Strobe and Schut 1995, 1996) According to this model, there is emphasise that avoiding grief- may be helpful- and even problematic- depending on the situation. Whilst Bowlby’s (1961) process of grief places emphasise on loss and how its importance to overcome each stage, this model acknowledges that expressing your emotions but also containing them may also be important for the client. This model proposed that there is an alternation between the client focusing on the loss (loss orientation) and avoiding the loss (restoration orientation). (Strobe and Schut 1999). Both these stages are essential in dealing with and overcoming loss but each approach will obviously depend on the circumstances and the personality and individual differences of the client dealing with the loss.
Whilst Bowlby’s model of grief and loss may be focused on a process-and how we must overcome each process in order to move on, the dual theory model also takes into account the need to not just deal with the loss, but also how ‘avoiding’ the loss at the time may help people to cope and deal with other issues e.g. arranging the funerals, mortgage payments etc.
We could also consider Kubler- Ross’s (1969) model of grief which was initially used as a part of her research with dying people. According to this model, people experience five stages of grief which involve Denial, Anger, Bargaining, Depression and acceptance. The first stage ‘Denial’, would be the refusal to accept the death of a loved on. The second stage ‘Anger’ could be the anger that the bereaved is experiencing at themselves or others. The third stage, ‘Bargaining’ may involve the client trying to reach a compromise with themselves or with ‘God’ and may show that they have started to accept the loss. ‘Depression’ may also follow where the client may be experiencing grief for the loss of the loved one. Finally ‘acceptance’, where there is the acknowledgement that the loved one has gone and therefore normality begins to return. Kubler- Rose (1969) also acknowledge that people may revisit parts of the stages which is important, as grief is often rarely just a consecutive process.
. In my opinion there is no correct way of working with client’s experience grief and loss. It is about utilising a person centred approach that consists of warmth, empathy and positive regards and utilising the appropriate techniques and models according to the client’s needs. Each client is different and will deal with the loss in different ways. Therefore I may utilise kubler’s model of grief as a framework to which to work with. I would start by adopting a person centred approach- allowing the client to just talk about their loss, utilising skills such as empathy, congruence and positive self-regard. This will also give me some idea as to what stage of their grief they may be at. It’s important to allow client’s to just talk about their loss as much as possible as it might be the first time they have been able to express themselves. I would then follow on to explore the client’s emotions and any symptoms that they may be experiencing- if they are experiencing any anger, sadness etc. in particular guilt. Client’s may feel guilty about not doing the things they were planning on doing or saying and this can cause client’s to carry a lot of guilt. I would encourage the client to think about what their loved one would have wanted them to do- continue feeling guilty or to just continue living their lives? I would also focus on any behavioural issues the client may be experiencing, due to the the loss e.g. insomnia, loss of appetite etc. and encourage the client to ensure that they are looking after themselves- eating and to rest where appropriate as going through such emotional upheavals can be exhausting. Perhaps gently reminding the client that they may even grieve better if they start to also rest from the grief at times, o that they can then remember that person even better once they are thinking more clearly after resting and eating etc.
Depending on where the client is during Kubler’s stages of grief (perhaps during bargaining/depression) client’s may be focused on irrational thinking and negative self-doubt. .e.g. ‘I’m all alone, no one will love me’. I will work when appropriate, with the client with identifying these thoughts and challenging them with more realistic one. . (Reeves 2013) Its important to note that such tasks may only be done once the client is feeling less emotional and more able to focus
One major ethical consideration to consider when working with a client experiencing loss/grief, is to ensure that we are not re-traumatising clients when they are talking about the loss of a loved one. E.g. asking them to recall in detail what happened. This could lead to traumatising our clients unnecessarily and potentially triggering further depression and anxiety or making the depression worse. In addition, it’s important to distinguish if clients may be suffering from post-traumatic stress disorder as a result of their loss. In which case we may need to refer such client’s on to a specialist if we feel that the issue is beyond our depth of knowledge and experience.
Finally, it is essential that counsellors have dealt with their own issues of bereavement and loss before they start counselling others in this area. This is because of the risk of transference and the possibility of the counsellor becoming too emotionally involved with the client’s own loss and (potentially) reminding the counsellor of their own loss.
Another ethical consideration to consider is when client’s present with pathological grief. A client who may be presenting with unresolved grief that may have happened many years ago may be experiencing a variety of symptoms. E.g. insomnia, a loss of appetite, depression etc. which is why it is essential that any physical illnesses are ruled out and ensuring the client has seen their doctor with regards to theirs symptoms.
Some of the therapeutic considerations of working with client’s facing loss and grief; Its important that the counsellor considers blind spots- no matter how well meaning they want to be. For example, a counsellor may be seeing a couple over the death of their new-born due to birth complications. Sessions are going well and the couple as a means of thanking the counsellor invite the counsellor to dinner- the counsellor agrees- however then realising his or her mistake, declines politely- ‘dampening’ the good therapeutic relationship that they had built up with the couple. Grief and loss can often bring people closer together- including counsellors and clients- therefore it’s imperative that counsellors are attending regular supervision and counselling themselves so that they are working through their own issues as well as the emotional influences of the bereaved client/s. (Louis and Ritter 2009)
It is also important to allow client’s to mourn individually, without placing undue necessary reliance on the models. Grief and loss are very subjective experiences- and not all clients will experience them similarly. Therefore, individual differences must be taking into amount-Respecting the client’s choices and values. It’s also imperative to consider religious differences in belief that could impact the therapeutic relationship. For example, Hindu’s will often cremate the death of a loved one and a hindu client may be talking about this to the counsellor. Internally, a counsellor may not agree with the spiritual beliefs of a client’s- therefore its essential that the client continues to remain non-judgemental and to be mindful of any internal conflicts that they may have themselves and to work through these.
To conclude, ethics and therapeutic considerations of working with client’s experiencing grief and loss are varied and there is no ‘right’ way of working with a client. Above all, in my opinion, it’s imperative that, counsellors working with bereaving clients should consider a person centred mixed model approach so that the client can talk at their own pace, with an empathetic counsellor. It is also important to consider the cultural difference in counselling bereaved clients. Not all clients will be experiencing grief in the same manner- it’s important to consider that the models and stages of grief described are based on western outlooks of grief and loss and cannot necessarily be applied as a standard framework for other cultures.