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Ann Marie T. Sullivan, M.D., Commissioner
Governor Andrew M. Cuomo

Grief Counseling Resource Guide
A Field Manual

Download Guide in Adobe Acrobat Format | Download Adobe Acrobat Reader

New York State Office of Mental Health
Sharon Carpinello, RN, Ph.D.
Comissioner

Bureau of Education and Workforce Development
Deborah Wagoner
Director

Joe LeViness
Project Director

Authors
Susan Wheeler-Roy, Ed.D.
Bernard A. Amyot, MS, M.A.

Special Thanks To:
Gail Meehan
Ann Cohan

Copyright © 2004 by New York State Office of Mental Health. All rights reserved.

Table of Contents

Introduction
Section 1 Bereavement Counseling – A Framework
Section 2 Helping Skills for the Outreach Worker
Section 3 Personal Impact of Grief
Section 4 Sudden Death Loss Issues
Section 5 Secondary Loss Issues/Adaptation Strategies
Section 6 Rituals
Section 7 Gender Issues in Bereavement
Section 8 Care for the Caregivers
Bibliography

Introduction

This manual has been developed as a guide for those who encounter individuals reacting to trauma related grief reactions in the course of their outreach work. It is hoped that this document will be helpful for both licensed mental health practitioners with limited experience working with individuals who are grieving as well as for paraprofessionals and outreach workers. Whenever a person is encountered who is experiencing severe reactions or complicating conditions for which the worker feels unqualified to address, consultation with an appropriate mental health professional and an appropriate referral for more formal services should be made.

Section 1 Bereavement Counseling – A Framework

Elizabeth Kubler-Ross has taught us that we must see the bereaved people we serve and counsel as our teachers. We need to allow them to teach us what their experience is, rather than constructing some set of goals and expectations that we expect them to meet and achieve. In Zen Mind, Beginner’s Mind, Shunryu Suzuki wrote, “In the beginner’s mind there are many possibilities. In the expert’s mind there are few.” We are not the experts on anyone’s grief. As bereavement workers we must meet the grieving without expectations about what should happen or what they should be feeling. There are no experts in this work.

John Welshons, in his fine book entitled Awakening from Grief, states:

“So there is no way to apply systems, rules or emotional road maps. Our job is to be a presence, rather than a savior. A companion, rather than a leader. A friend, rather than a teacher.” (p 159)

The Companioning Model of Bereavement caregiving developed by Dr. Alan D. Wolfelt is one in which we as bereavement caregivers help people to integrate life’s losses by being present to them and observing them—companioning. He tells us that observance comes to us from ritual. It means not only “to watch out for,” but “to keep and honor, to bear witness.” Wolfelt elaborates on the companioning idea:

Utilizing this model of bereavement caregiving, the helper:

The heart of grief counseling, according to Dr. Ken Doka, writer and lecturer in grief and loss, is validation. Grieving individuals need reassurance that what they are experiencing is normal. Counselors can help people understand and identify the ways they are reacting. Some people grieve through their expression of feelings. Others grieve through problem-solving, thinking, and activities. Doka, in a recent presentation (2002), maintains that there are many different ways in which individuals experience, express and adapt to loss.

Section 2, Helping Skills for the Outreach Worker

These skills are ways to show people that you are paying close attention, that you care, and that you are actively listening. The better the helper listens, the more the individual may share. This is a caring relationship and develops through mutual respect.

Eye Contact and Facial Expression:

Body Language:

Vocal Style:

Verbal Following:

Verbal Skills/Interventions:

Open Questions:

Paraphrasing:

Reflecting Feelings:

In reflecting feelings, the following steps are most essential:

  1. The feeling must be named. This may be through the actual words of the individual or through observation of non-verbal communication (eyes, facial expression, posture, voice tone).

  2. Use the leads: “You seem to feel...,” “Sounds like you feel...,” “I sense you are feeling....” Then ask: “Is that close?” “Is that right?”

    Examples:
    "Sounds like that makes you angry." "You feel very discouraged right now."
    "I sense some feelings of confusion." "You are feeling really sad at the moment."

Additional helpful comments/phrasing:

Non-Supportive Behaviors

Verbal Behaviors:

Non-Verbal Behaviors:

Section 3, Personal Impact of Grief

The grief experience impacts all aspects of the being of the individual. The manifestations listed are more intensified when there has been a sudden, unanticipated death. With the intensification, the period of time to process the reactions will often be longer. It is important to remember there is no timetable for processing. Grief reconciliation depends on many other factors confronting the individual in his/her life. People are not only grieving, they are also participating in life and those stressors will affect the journey of adaptation.

An individual may not experience all reactions that are listed. Reactions may change over time. What needs to be noted is that the reactions follow the loss event; it is then that a grief reaction is considered.

Physical Reactions:

As part of the individual’s way of handling the stress and anxiety of his/her loss experience, the following are possible physical reactions:

Changes in appetite:

Sleep disturbances:

Exaggeration of other physical situations:

Note: All are often triggered by poor eating and sleeping habits, thereby affecting the immune system and the body’s ability to maintain a healthy balance.

Behavioral Reactions

Because the loss event changes the individual, behaviors, whether while alone or in social settings, also reflect the change the individual is experiencing.

Cognitive Reactions

Emotional Reactions

Spiritual/Philosophical Reactions

The experience of grief and the mourning process involves many changes in the life of the individual. It is a period of adaptation and transitions in all aspects of the individual’s life. Therefore, it is the whole person that faces this forced change. Individuals seek support and encouragement as they find their way through this maze. Adapting takes as long at it needs to take. An individual’s circumstances in life, coping mechanisms, and spiritual/philosophical beliefs will all contribute to the outcome.

Learning to accept that we do not get over a loss, but learn to live with the loss experience, can assist individuals in accepting their grief response as a journey—as a part of their own life experience—and not see this merely as tasks to be accomplished to “get better.” The loss experience is part of the individual’s life journey in all aspects listed above—physical, behavioral, cognitive, emotional and spiritual.

Section 4, Sudden Death Loss Issues

As described in Section 3, some of the possible reactions involved in the “normal” processing of a death loss are more intensified with a sudden death loss, and tend to take much longer to process due to the overwhelming disbelief that impacts the individual. Some issues that lead to complications in reconciling the loss include the following.

Section 5, Secondary Loss Issues/ Adaptation Strategies

During the mourning period, the grieving individual not only focuses energy toward the deceased, but must adapt the self to changes and continue life incorporating the loss —the good and bad—of the relationship. What is truly lost is examined; what roles, expectations, opportunities and hopes must be given up; and what personal adjustments must be made all comprise the transitional aspects of the grieving process.

The personal experience of grief must be processed through the eyes of the grieving individual as he/she sees his/her loss and its ramifications. Each secondary loss perceived requires its own grief response.

The following is a list of some identified aspects of the loss that may be perceived as part of the unique process.

One can see there are many issues that may be part of any loss, but are often an immediate aspect of sudden death loss. The world in all its day-to-day intricacies is impacted. Awareness of the perceptions of the one in grief is important in providing emotional support and in companioning this individual through the intense response to a reconciliation of the loss. There is often intense yearning for what was as well as much frustration and anger for the way life IS. Those counseling or assisting in any way must be aware of the normalcy of the protest. This is part of the struggle; this is part of the emotional pain of letting go of a way of life as they simultaneously are forced to create something new that they really don’t want. It is often during this change into the new normal that survivors feel they will forget the loved one. They need reassurance that forgetting need not happen as they continue on their life journey. Developing a balanced view of the individual—their strengths and weaknesses—is important. Good memories can be surfaced and become a part of the survivor’s journey never to be forgotten. We are a product of our experiences and these need not die when a participant in that event dies. Grieving individuals may need to be encouraged to:

All of the above are intended to reinforce that the loved one has become a part of us due to the relationship experienced. It is this that is grieved—the connection—the need for the individual and the need by him/her for us. This is intensified in sudden death because there was no time to plan for this change; the individual is forced into many adaptive processes at once causing an “overwhelming” aspect to the grief reaction.

Section 6, Rituals

Rituals provide us with acts to engage in for the purpose of meaning-making (Neimeyer). Dr. Kenneth Doka discusses ritual as giving extraordinary meaning to the commonplace. Ritual provides symbolic connection to the lost persons. For example, on Thanksgiving a woman makes her deceased mother’s recipe for cranberry relish. Only a few people in the family enjoy this dish but she continues to prepare it because during the preparation she feels connected to her mother and feels her mother is within her and thus, present at the holiday.

Dr. Kenneth Doka has identified four functions of ritual that may help in a variety of situations:

Rituals must fit the story. They must be planned ahead and thoroughly processed after completion.

Certain dates are particularly troubling and anxiety producing for the bereaved. These include birthdays, anniversaries, holidays, religious celebrations, Valentines Day, anniversary of the death and other specific family markers.

The goal is to plan ahead a remembrance ritual in order to acknowledge the day both cognitively and symbolically. Utilizing any of the above mentioned rituals will help acknowledge in some personal way the relationship and life that was shared. The day is best confronted and dealt with through ritual rather than avoided. Following is a list of rituals.

Rituals To Commemorate

Rituals are effective and meaningful when they have significance to the deceased and to the survivor. The following are merely suggestions and might be altered and enhanced to appropriately accommodate the relationship involved.

Section 7, Gender Issues in Bereavement

There is literature on the market focusing on gender differences in processing a loss event. These may be helpful, but often give a stereotyped view of gender in the grief process. We must recognize the uniqueness of each individual and therefore his/her personal style may be a blend of often stated gender patterns. Some of the items listed may be more “feminine” in style; others may seem more “masculine” in style. There is no right or wrong way to grieve. There is the individual’s way; whatever works for him or her is what is important. Helping individuals find successful methods can be part of the companioning model previously explained.

Beliefs:

Because some individuals choose not to talk about their feelings does not mean they do not feel; but rather they don’t have the words to express their feeling in the face of the tragedy or don’t have the need to do so. For some the event is beyond words or expression and is felt deeply. This must not be misconstrued as cold or unfeeling. The person may not be ready to live with the reality once it is expressed openly. In their recent work Kenneth Doka and Terry Martin talk of “transcending gender stereotypes” and describe two main styles of grieving—the “intuitive griever” and the “instrumental griever.” They present a third, the “blended style griever.” Below represents the two components that comprise the “blended” style:

Intuitive Griever:

Instrumental Griever:

Patterns, according to Doka, occur along a continuum. Those grievers/responders near the center who demonstrate a blending of the two styles experience a variety of both patterns. One pattern may be more pronounced than another depending upon the loss and the personal connection to that loss. This pattern suggests a need for even more choices among adaptive strategies than for the griever who is more fixed in either strategy mentioned above.

Gender may contribute to a particular style due to socialization rather than gender itself. One needs to carefully consider the style of the individual and support it. Accordingly, know there is not a right or wrong way—just the way this individual must process this particular loss. Some individuals have never dealt with a sudden death, so the way to grieve and adapt to the loss is unfamiliar to them. Patience is important; support and encouragement for where the individual is at any particular time after the loss is important

Personality and style are important—some people are less verbal than others; others think things through before reacting. Some go right into a task and take control of a situation, while others react emotionally first then gather themselves for action. Both genders may represent the “blended” pattern.

Section 8, Care for the Caregivers

Burnout occurs in any helping situation when there is too much work and too little support for the caregivers. If burnout is to be avoided, support must be available to the helpers through regular supervision and through sharing their work with other helpers. Group support is nurturing and can renew commitment to loss and bereavement work. Keeping a personal journal of the helper’s work and feelings and reactions can help. Stories of grieving individuals’ resiliency serve as powerful reminders that healing does occur.

Each worker must find what works best to help him or her keep in touch with self. Walks, family and free time, prayer, meditation, exercise, cooking, gardening, and yoga can serve as opportunities for a breathing spell from work.

Daily rituals and routines can help to ground helpers for the work ahead each day. Lighting a candle daily before beginning work, meditating, or reading a particularly meaningful passage can help center us. Keeping fresh flowers nearby and caring for one’s workspace in a way that makes for an atmosphere of comfort and security can help. Even when one does not have choice or control over workspace, personalizing the space in some small way can create a caring and safe atmosphere for oneself and one’s clients. Perhaps bringing a few pillows or lighting a small candle can be enough to support a sense of solidness and centeredness.

Following are a few suggestions for preventing burnout of caregivers (Corey 2001):

Bibliography

Attig, Thomas. The Heart of Grief: Death and the Search for Lasting Love. Oxford
University Press. NY. 2000.

Boss, Pauline. Ambiguous Loss: Learning to Live with Unresolved Grief. Harvard
University Press. MA. 1999.

Collins, Bonnie. “Expect Miracles,” Psychotherapy Networker. V.26, No. 5, Sept/Oct
2001, pp. 23–24.

Corey, Gerald. Theory and Practice of Counseling and Psychotherapy, 6th Edition,
Belmont CA: Wadsworth, 2001, pp.39–40.

Doka, Kenneth, ed. Disenfranchised Grief: New Directions, Challenges, and Strategies for
Practice
. Research Press. II 2002.

Doka, Kenneth. Second Annual Bereavement Conference, The Sage Colleges, Albany,
NY. Oct 4, 2002.

Dyer, Wayne. There’s a Spiritual Solution to Every Problem. Harper Collins. NY. 2001.

Figley, C., Bride, B., and Mazza, N. eds. The Traumatology of Grieving. Taylor and
Francis. Washington DC. 1997.

Golden, Thomas. The Gift of the Masculine Side of Healing. Golden Healing
Publications. MD. 1996.

Ivey, A., et al. Basic Attending Skills, 3rd Edition, Microtraining Associates, Amherst, MA.
1992.

Kauffman, J. ed. Loss of the Assumptive World: A Theory of Traumatic Loss. Brunner-
Routledse. NY. 2002.

Klass, D., Silverman, P. and Nickman, S. eds. Continuing Bonds: A New Understanding
of Grief
. Taylor and Francis. Washington, DC. 1996.

Kubler-Ross, E. and Kessler, D. Life Lessons. Scribner. NY. 2000.

Martin, T. and Doka, K. Men Don’t Cry... Women Do: Transcending Gender Stereotypes
of Grief
. Brunner and Mazel PA. 2000.

Neimeyer, R. Lessons of Loss. Center for the Study of Loss and Transition, Memphis,
TN. 2000.

Pread, A. D. Transcending Loss: Understanding the Lifelong Impact of Grief and How to
Make it Meaningful
. Berkley Books. NY. 1997.

Rando, Therese. How To Go On Living When Someone You Love Dies. Bantam Books.
NY. 1988.

Rando, Therese. Treatment of Complicated Mourning. Research Press. Chicago, IL 1993.

Rich, Phil. The Healing Journey Through Grief: Your Journal for Reflection and Recovery.
John Wiley & Sons. NY. 1998.

Suzuki, S. Zen Mind, Beginner’s Mind. Weatherhill. NY. 1999.

Welshons, J. Awakening from Grief. Open Heart Publications. NJ. 2002.

Wolfelt, Alan D. “Companioning vs. Treating: Beyond the Medical Model of
Bereavement Caregiving– Part 1.” The Forum Newsletter. Association of Death Education
and Counseling. July/Aug1998.

Wolfelt, Alan D. “Companioning vs. Treating: Beyond the Medical Model of
Bereavement Caregiving– Part 2.” The Forum Newsletter. Association of Death Education
and Counseling. Sept/Oct 1998.

Wolfelt, Alan D. “Companioning vs. Treating: Beyond the Medical Model of
Bereavement Caregiving– Part 3.” The Forum Newsletter. Association of Death Education
and Counseling. Nov/Dec 1998.

Produced by
OMH Bureau of Education
and Workforce Development
518-474-2578
Deborah Wagoner
Director