In this essay I will discuss what grief is and the kind of grief a client could experience. We will move onto attachment theory and its link as to why we grieve. I will then look at what tools are available for counsellors to support their clients through a normal or abnormal grieving process.
Grief, Loss and Change
A grief process can be kicked off by anything that signals an ending or change in someone’s life. We tend to think of this as the death or loss of someone loved. However, it can also be an ending of other sorts. Below is a mind map I created to consider some of these things. The list is not exhaustive, but instead gives an understanding of the extensive subjects to which the grieving process may apply:
Diagram 1: Types of Loss that may lead to grief (via Coggle Tool)
An example may be a teenager who has extreme acne and as a result their skin or face has changed permanently. This may lead to a grieving process for how they looked or expected to look
Timelines may also not necessarily fit within a ‘social’ expectation. For example, whilst the grief may indeed be related to the death of a partner, it may be that if the death was expected due to a terminal illness that part of the grieving process has been processed. This may lead to surprise by others when a partner finds they are move on to a new relationship earlier that others expect. Of course, this grieving process also applies to the person who is ill – grieving for the part of their life that they will not live. Grief comes in many forms.
The loss of an ‘attachment’ suggests a connection in the first instance. Attachment Theory has developed in support of this – suggesting that we learn to make attachments through childhood and this development affects our adult relationships. ‘Bowlby (1977) developed his attachment theory based on research in many areas (cognitive, control theory, neuropsychology, biological), but concluded that the main basis was not biological but due to a need for trust, safety and security. This attachment is distinct from feeding and sexual behaviour’ (Worden, 1991). This need for trust, safety and security directs us straight to Maslow’s Hierarchy of Needs model.
Worden goes on to suggest that Bowlby’s theory has a correlation with Erikson’s Psychosocial Theory of child development ‘through good parenting, the individual sees himself as being both able to help himself and worthy of being helped should difficulties arise (Erikson, 1950).’ Worden also says that conversely, pathological aberrations can develop in this pattern, abnormal situations and/or parenting during development can lead to abnormal attachments.
There are four main styles of attachment (Ainsworth & Bell, 1971):
Secure AttachmentCan leave attachment situation and return without extreme emotional response. Positive outlook of attachment, trusting, seeking support and comfort when necessary from relationship. Able to share feelings. Dismissive-AvoidantAvoids attachment situations and intimacy. Avoids sharing emotions socially or romantically. Tend to suppress and hide feelings. Appears to show little emotional preference between attachments and strangers. Deals with rejection by distancing themselves. Anxious-PreoccupiedExhibiting high levels of emotional expressiveness, worry and impulsiveness in relationships. Worries that they are not loved. Difficult to relieve worry with comfort. Reluctant to form initial bonds through distrust.
An additional category was added by Ainsworth’s colleague, Mary Main (1988):
Disorganised-DisorientedShows avoidant and resistant behaviours. Seeming dazed, confused or apprehensive. Contradictory interactions with those close to them. Observed in children during Main’s ‘Strange Situation’ study.
It must be noted at this point there are strong links between these attachment categories and development theories. I think it’s’ worth briefly exploring these as it may affect understanding of how our client is thinking:
BehaviouralConditioning by parent or those in roles of influence during the development years. Influencing security, insecurity, trust, mistrust, etc. PsychosocialAs referenced above via Worden. Various development stages whether Erikson, Piaget others with potential for conflict during these periods with changing the nature of attachment to others. PersonalityIntrovert/extrovert, emotional stability/neuroticism/etc. Specific research surrounding personality and its effect on normal or abnormal grief. Suggesting that certain personality types are more prone to abnormal grief (Prosser-Dodds) Transactional AnalysisI’m okay, you’re okay would suggest security, I’m okay, you’re not okay being would suggest insecure avoidant, etc and the resultant regression states.
The logical view around attachment suggests then that an individual losing that attachment may then go through a process of grieving.
The Grief Curve, Circles and Waves
Many will have heard of the ‘grief curve’. Some may have heard of similar models such as the Change Curve ‘S.A.R.A.H’ (Shock, Anger, Revenge, Acceptance and Help). The stages outlined below were originally identified by Dr Elizabeth Kübler-Ross. Her involvement in bereavement and hospice care led to her creating this theory (businessballs.com). The Kubler-Ross model is seen as something that can be applied for any process of change helping those regain the feeling of ‘control’ and creating an understanding of their experience.
Figure 2: From Focus Mediation Website – Adapted from Kubler-Ross model
There are alternative views to that of a time oriented theory. Debbie Messer Zlatin, also working with terminally ill patients suggested that individuals look to interpret their own identity during such periods. Lisa Prosser-Dodds (2013) discusses both ‘linear’ and ‘circular’ grieving processes that are under discussion within the profession. She includes the suggestion of “waves of acutely painful emotions” being more of an ongoing process in grief.
Grief has also been likened to a temporary depression; although some grief may lead to ongoing depression. A counsellor must be understand where grief ends and longer term depression is now seated with the client. If someone is grieving, anti-depressants may simply slow the journey through the grief curve. Similarly, if someone is suffering from depression and it’s clear the symptoms have been exacerbated by grief, it may be important to ensure a GP referral to have supporting medication.
With all of these different perspectives, it’s important to keep in mind that any research and theory done through observation extends our professional knowledge and undending. Rather than considering theories as ‘competitive’, surely all observations are useful in understanding the varying experience of both client and counsellor. Prosser-Dodds (2013) also notes that Kubler-Ross’s last written words in 2005 stated “I am so much more than five
stages. And so are you. It is not just about knowing the stages. It is not just about the life lost but also about the life lived.”
What does grief ‘Feel’ like?
One of the things that Kubler-Ross identified were the ‘feelings’ behind grief. The ending of any kind of attachment can result in the feelings of grief. Anyone who has experienced grief will appreciate the feelings and sensations are multi-faceted. If we take Freud’s three elements that make up ‘human existence’ we can show some examples of these varying experiences of grief.
Same Symptoms as Loss
Lack of Communication
Reason for Loss (Accepable)
Duration of Grief
Execution of Wills
Rituals (Funeral, Saying Goodbye)
Seeing the body
Short on Breath
Whilst the lists are not exhaustive they gives an idea of how the physical, emotional, cognitive, behavioural and social affect our experience of grief.
Complications of Grief Issues
When does grief go beyond the ‘normal’? It’s suggested that a ‘normal’ grieving process is 18months to 2 years. When does the trauma of grief create a long lasting depression? Solomon (2001) suggests ‘Grief is depression in proportion to circumstance; depression is grief out of proportion of circumstance.’ He quotes The New England Journal of Medicine as saying ‘Since normal bereavement can lead to major depression, grieving patients who have symptoms of depression lasting longer than two months should be offered antidepressant therapy.’
Further examples of complications to grief:
Cumulative GriefPersonal issues surrounding previous losses, similarities, types of relationship, multiple losses Inability to resolve grief and feeling overwhelmed Nature of RelationshipDifficult relationship, abnormal relationship, loss where individual deemed too young, i.e. loss ‘before time’. Nature of Death/LossHow the person died or was lost in relation to person grieving, such as unexpected death. Denial/DelayedLack of emotional response, ridding of anything to do with them. Avoiding reminders of the dead or lost. Too busy to grieve. Media AttentionDealing with additional factors such as media attention around the loss or individual(s) involved. SocialIncomplete grief when others believe ‘it’s time to move on’. Affecting job, relationships, loss of status.
Children get into trouble at school. Attempting to fulfil the role of the lost. Family conflicts. MummificationKeeping a room the same, not changing routines that should involve that person. Putting that person on a pedestal or idealizing them. InformationNew knowledge of the person after the loss that may change original perception by those grieving. Such as sexual orientation, debt, affair. HealthDue to severity of grief. Also same symptoms to those of lost if lost through ill health. Over/under-eating as per depressive style symptoms. Self-medicationOngoing use of alcohol or drugs.
Therapeutic Approach to Grief
When would someone consider additional support when the ‘flags’ shown above are not immediately obvious? The NHS (2014) suggests the following:
•You don’t feel able to cope with overwhelming emotions or daily life.
•The intense emotions aren’t subsiding.
•You’re not sleeping.
•You have symptoms of depression or anxiety.
•Your relationships are suffering.
•You’re having sexual problems.
•You’re becoming accident-prone.
•You’re caring for someone who isn’t coping well.
Worden (1991) steps away from any grief curve or circle and talks about ‘principles’ can be worked through with a client in order to facilitate the grieving process to a conclusion:
1. ‘Actualisation’ of the loss: Helping the client discuss the loss, the circumstances. Help the client explore and recognize the reality of the loss. 2. Explore feelings and emotions: Considering the thoughts and how these are effecting them. Awareness of the emotions that drive a feelings of being ‘out of control’. Identifying associated ‘phenomenon’ such as seeing the lost person, hearing them. Still feeling a leg that has been amputated. To normalizing (See below). 3. Adjusting to living without: Identifying specific issues that are preventing the client from progressing to a life ‘adjusted’ to this loss. Worden suggests that at this point, clients should be discouraged from making major life changes – for example selling a property, rather take time to allow yourself to work through your grief in familiar surroundings. Whilst I agree, in part, where there has been major trauma – making such a change may in fact be a necessity for some.
4. ‘Emotional Relocation of the Deceased’: Remembering or reconciling. Adjusting to the new life without the person or situation and how this new life looks to them. Discovering the joy of remembering and the coping strategies moving forward. What would the client like the future to ‘look like’? What would they envisage for themselves? 5. Ongoing space to remember and grieve: This is Worden’s nod, I think, to the cyclical models of grief. Being aware of waves of emotion that may return via a trigger; be it a smell, anniversary or a familiar face. What would the client like to do at key times – when they are reminded, how would they like to reconcile such an experience? What would they like to do on the anniversary of the death of a loved one or their birthday?
6. Normalising: Understanding it’s normal to feel the emotions or feeling of ‘going mad’. Of course, awareness of prior psychosis is key as well as looking for cues symptomatic of any disorder. 7. Individual Differences: Understanding and accepting the wide variety of responses, behaviours, personalities, expectations and methods of grieving. 8. Continuing Support: Worden suggests that grief counselling should not be contracted to a specific number of sessions but available ongoing should the client require. Of course, the counsellor needs to be aware of when the sessions become a crutch instead. 9. Coping Mechanisms: Positive or negative. Working with client to identify coping mechanisms as positive action and identifying any that may ultimately become a self-defeating behaviour. 10. Referral: When does a client need to be referred? I have discussed this below.
It may become clear that there are longer term complications either around the grief or secondary to the grief that requires additional support and may need GP referral. Prolonged Grief Disorder would fall into this category. However, it is difficult to diagnose and not particularly well researched. There are also many assessments for grief and understanding the severity of grief. One such is called ‘PG-13’ which assesses all the symptoms of grief and is designed to identify Prolonged Greif Disorder.
Additional Tools to Support Clients
Empty ChairClient either imagines the person in the chair or being the person in the chair. So the client can either talk to the person they have lost or be that person (counsellor asks questions). Evocative LanguageUsing language to bring forward the reality of the loss, example, using word ‘death’ instead of ‘lost’. Cognitions/BehaviourRecognising hot thoughts/cognitions and behaviours. Understanding how the client would like to change these. Items or SymbolsClient brings items or symbols to a session to discuss and remember. WritingTo the deceased or about the loss.
Memory Book/AlbumCreating a book with memories, letters, photos to look at and to return to during difficult ‘waves’. Similarly could be a box of memories/items. Role-playWhen someone needs to do something that perhaps was done by the person they lost. A safe place to try. The same can be said for other major changes such as retirement. In MemorandumA trip, a tree, a bench in memory.
Group CounsellingWhen the loss is specific to something such as cancer or a natural event. Talking to others who have similar experience. DrawingWhat does the grief look like to the client? Or if they were to draw how they feel? Conclusions
Grief is entirely dependent on the client’s attachments, perspective, beliefs, personality and/or their modality. Chapman (businessballs.com) suggests ‘One person’s despair (a job-change, or exposure to risk or phobia, etc) is to another person not threatening at all.’
A great deal is written on grief theory, with many different conclusions reached; some suggesting a linear process, some a cyclical, perhaps even unending process. Some suggest that grief counselling may cause more damage than benefit.
I believe from what I have read, all of the above is true. Counselling isn’t always appropriate, some people will never fully resolve their grief. However, with the tools available, those who are ‘stuck’ in some way due to grief have a strong tool available in counselling to explore, understand and identify changes or coping mechanisms to feel safe, create new attachments and be a part of everyday life again. Counsellors need to ensure they are well trained for grief counselling and well supported through supervision to understand their own health around such a familiar issue.
Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1971) Individual differences in strange- situation behavior of one-year-olds. In H. R. Schaffer (Ed.) The origins of human social relations. London and New York: Academic Press.
Chapman, Alan – Business Balls: Elisabeth Kübler-Ross – Five Stages of Grief [Online] Available from: http://www.businessballs.com/elisabeth_kubler_ross_five_stages_of_grief.htm [Accessed: 10th February 2015]
Focus Mediation – The Grieving Cycle and Relationship Breakdown [Online – Diagram Only] Available from: http://blog.focus-mediation.co.uk/2013/12/10/the_grieving_cycle_and_relationship_break_down/ [Accessed 13th February 2015]
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M.T. Greenberg, D. Cicchetti & E.M. Cummings (Eds.), Attachment in the Preschool Years. Chicago, University of Chicago Press.
Maslow, A.H . (1943) Hierarchy of Needs [Online] Available from: http://figur8.net/baby/2014/11/06/maslows-hierarchy-of-needs-and-how-it-relates-to-your-childs-education/ [Accessed: 13th February 2015]
NHS Choices: Dealing with Loss [Online]
Available from: http://www.nhs.uk/Livewell/emotionalhealth/Pages/Dealingwithloss.aspx [Accessed: 20th February 2015]
Prosser-Dodds, L. (2013) THE RELATIONSHIP BETWEEN GRIEF AND PERSONALITY – A QUANTITATIVE STUDY [Online]
Available from: http://www.researchgate.net/profile/Lisa_Prosser-Dodds2/publication/260081247_THE_RELATIONSHIP_BETWEEN_GRIEF_AND_PERSONALITY__A_QUANTITATIVE_STUDY/links/0deec52f5e83729ef8000000.pdf [Accessed: 13th February 2015]
Solomon, A (2001) The Noonday Demon: An Anatomy of Depression. London: Chatto and Windus