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Grief – Therapeutic interventions to ease suffering in the face of loss.

Jenny Sanbrook 

Accredited Mental Health Social Worker.

BSW, MSW Couple and Fam Ther.

Certified Gottman Therapist

NB: Details of case examples have been changed to protect and respect the privacy of clients who have shared their journey with me in therapy.

Thinking about death is never easy and working with clients in this space can seem daunting, evoking powerful feelings such as helplessness, sadness, anxiety within the therapist.  In a recent case of a young man whose father died suddenly of a heart attack after having been hospitalised with Covid-19 some months prior, I felt I had to tread carefully, the death had happened three weeks prior to him coming to see me.  A previous case involved a parent whose child suffered Cystic Fibrosis and died at age 22. I also have been a part of the journey for a father who suffered the loss of a young adult son in a case of mental health and physical illness.   By coincidence as I started this article the news of Shane Warne’s death came to light, his public memorial and state funeral to be held.  There has also been countless scenarios of death and tragedy played out in the media; the war in the Ukraine and floods here in Northern NSW.  Needless to say, loss is around us whether personally or professionally.  This article provides a brief overview of theory and some ideas for working with grief both creatively and with compassion.

A Developmental Model of Grief

Over the years grief has been described by some as stages (Kubler Ross, 1969), or by others as phases and tasks (Worden, 2009).  As a whole, there is consensus that grief is a process and differs for each person.  In my reading on this topic I was drawn to work by Robert Neimeyer (2016) who described three “periods” of grief – Reacting, Reconstructing and Reorienting.  Each period has a crisis to resolve between two polarised tensions.  He bases the theory on Erikson’s 1968 developmental model of the resolution of a series of crises (such as trust vs mistrust, autonomy vs shame) in order for “successful” development through the life span. I have outlined this below including the role of the therapist.

“It may be easier in this period to withdraw to protect oneself from well-intentioned but unhelpful others.. most often mourners will seek out others whose stories mirror their own to seek similarity and validation of their emotional state” (Niemeyer 2016: 6).

Period of Early Grief – “Reacting” (Crisis:  connection vs isolation – weeks after the loss)

The earliest period of time after a profound loss is characterised by a sense that part of the self has been ripped away.  The person will likely oscillate in and out of reality in a suspended state of disbelief.  There is a sense that their unique loss has cast them out of the normal world of relationships shared by others thus a struggle of connection vs isolation from the world.  As the emotional anaesthesia wanes the person will begin to feel the full weight of the grief and pain which is unbearable.  The person may have difficulty with such things as self care, relationships, cognition, spirituality.  Psychological needs include listening, identification and compassion.  Therapy involves emotion regulation and containment.  Finding mutual support groups can be a way to find connection with others experiencing similar losses.  Therapy at this point should provide a high degree of “presence”, a “holding environment” and “containment” with the goal of promoting self capacity towards re-connection and self regulation.  

Period of Middle grief – “Reconstructing” (Crisis: Security vs Insecurity – months after the loss)At this time there is a focus on the “back story” of the relationship as opposed to the “event story” of the death.

During this period the person is coming to terms with the permanence of the loss and a sense of emptiness.  Parallel to Bowlby’s formulation of attachment, during this time “the mourner may find themselves cut adrift from the secure mooring previously afforded by their bond with a living loved one” (Niemeyer 2016: 8).  This may create hyper-vigilance and restlessness as a person tries to locate the person that represented a secure attachment.   This period can be managed by validation for the loved ones importance and ongoing presence in the mourners life.  Permission to reconstruct rather than relinquish a connection in a sustainable form is also useful.  In practice this means a person have permission to talk about the deceased person and find inspiration in their story. This may also look like symbolic correspondence via letters, imagined conversations with the deceased or creative practices or public memorialisation.

Period of Later Grief – “Reorienting”  (Crisis: Meaning vs Meaninglessness – years after the loss)

After the time of a number of months and into years, the mourner is finding new meaning around who they are without the loved one in their life.  There is a revising of the self-narrative.  There may be a re-ordering of priorities and a reinventing of life goals.  There may be a searching for meaning around the loss, a turning towards compassionate helping of others in similar situations. During this time families struck by tragedy may set up or affiliate themselves with a charity or campaign to raise awareness and to maintain a connection with their loved one in a meaningful way.  An example that came to mind was the tragic death of Thomas Kelly in 2012 in an unprovoked one punch attack in Kings Cross – The family response to this and then the tragic death of his brother Stuart 4 years later.  See https://www.staykind.org or “One Punch Can Kill Campaign” is one example of many others.  Or in a personal example a good friend who is raising money for the Children’s Cancer Institute after the death of a close friend’s young girl from brain cancer 4 years ago – walking 86Kms Walk for a Cure (86kms for 86 kids diagnosed each month with cancer) see ccia.org.au

Summary Table: Developmental Model of Grief (Excerpt from Niemeyer, R 2016) .

Period of Grief CrisisClient Experience Therapeutic and psychological needs
Early Grief – Reacting Isolation vs ConnectionOscillation in and out of reality in a suspended state of disbelief.  A sense that their unique loss has cast them out of the normal world of relationships shared by others thus a struggle of connection vs isolation from the world.Emotion regulation, ContainmentListening Identification Compassion 
Middle Grief – ReconstructingSecurity vs InsecurityContending with the permanence of the loss.  Restlessness, hyper-vigilance, anxiety  due to loss of attachment bonds. Focus on the back story not the event story of the death.Permission to reconstruct the bond rather than relinquish the bond.Audience for stories – (permission for ongoing presence of person in the mourners life) Imaginal/creative work, memorialization, symbolic correspondence.
Later Grief – Reorienting Meaning vs MeaninglessnessExploring the meaning of suffering, altruism, search for meaning about the loss, renewed life priorities. Permission to discover new strengths, revise time honoured commitments, reinventing a sense of coherence of self without the loved one.

Managing the Turbulence – The Dual Process Model of Coping.

It is one thing to understand theoretically what is happening in the grief process but another to walk with a person through the grief.  One of the unique challenges of grief work is the oscillation that occurs between managing day to day life and the experience of strong feelings of despair.  Helping clients manage these changes flexibly is an important part of the work.  

Stroebe and Schut (2010) have put forward the idea of the Dual Process Model of Coping with Bereavement.  This describes an oscillation between Loss Oriented (LO) stressors and Restoration Oriented (RO) stressors.  LO stressors relate to situations that force the person to confront the loss – eg conversations, events and memories.  It involves feelings of intense yearning and uncontrollable emotion.  RO relates to coping with secondary stressors that are related to consequences of the bereavement such as financial changes, responsibilities, and identity changes.  Clients mainly focussed on Loss Oriented stressors can experience chronic persistent grief whereas clients primarily focussed on Restoration Oriented stressors experience little or no sign of grieving.

Clients will shift between confrontation and avoidant strategies to manage these stressors.  Goals of therapy can be to help clients face these stressors rather than fully avoid them or being overly reactive to them.  Stroebe and Schut point out that clients will have times of “resting and coping”, “confronting- avoiding”, “continuing-relinquishing the bond”. Thus therapy needs to be person centred, dynamic, “here and now” work, tailored to the client, occurring within a secure attachment style relationship with the therapist. 

Creative Ways of Working with Grief.

Lastly, to tie together theory with practice, I have listed some ways to work creatively with clients  Below are 5 ideas that I have used – however there are many more worth attention.  I have found these strategies have helped to deepen the conversation and facilitate the safe expression of emotion during the session.

  1. A Grief Drawer:  This technique can introduce a way to face emotion while also having limits to intensity and duration of the emotion.  It is documented that avoidance of grief with the intention to regulate or avoid the confronting reality of the loss can be impairing.  Conversely, an over engagement with the emotion can also be debilitating.  The grief drawer involves gathering together objects, written material, music, pictures and other reminders of the person.   Find a way to keep an awareness of time in a subtle way such as a music track, small tea light candle or subtle phone timer.  The items are placed in the drawer which is closed.  The client can set aside a specific time each day to enter into their grief.  Emphasis is placed on the idea that the timing signals the end of the process with all items placed back in the drawer.  There may be a transition or closing ritual that signifies re-entry into everyday responsibilities. (See Harris, Darcy in Neimeyer 2016).
  • The Grief River:  Metaphors often deepen the therapeutic encounter, making thoughts and emotions more accessible through imagination.  As an alternative to the idea of “stages of grief”, this metaphor likens grief to a river.  Rivers are dynamic and always changing.  Building on the wave idea used to describe the emotional experience of loss – the grief river is made up of the following phases:  Headwaters (pre-existing issues that shape the loss eg values, cultural norms, attachment), rapids (acute phase/reactivity), run (smooth water, attention directed to the scenery around), delta (meaning making about mortality) and rejoining the sea (opportunities to explore ideas of afterlife and existential questions).  (See Dennis, 2009 in Niemeyer 2016) Also: griefriver.com  It is also possible to bring in photos of each phase of the river and use these as a visual prompt for clients to describe where they are in the process. 
  • Letters To Self:   Expressive writing can open a way for expression of pain by self reflection as opposed to words alone.   This technique is best used once the initial phase of grief has eased. The following steps can be followed: Step 1:  Letter from Adult to Child: What do you want to tell your “child” so that you are prepared for your future life?  What do you wish you had known that would have prepared you for your life ahead?  Step 2:  Letter from Child to Teen (written in non-dominant hand)  Have your innocent “inner child” write a letter to the “teenage you” who may have become serious, discouraged, or self conscious.  What would the child remind the teen that the adolescent might be forgetting?  What does your “child” want you to hold on to that could get lost in adolescence?  Step 3:  Writing from the Present to Future Self.  What are your biggest fears of this “new beginning” as you face death and loss?  What is your biggest excitement as you take new risks? What are you hoping to change in the future?   My experience of this technique has been noticing clients connect with their emotional state rather than their thoughts and cognitions.  There is often a period of quiet reflection as the client reads the questions and thinks about what they might write – I invite clients to take the questions home and complete the task at home if they prefer or they can do this in session.  They may bring the letters back to the next session.  (See Rollo-Carlson in Neimeyer, 2016)
  • Who am I ?

 This is a technique for adults wanting to process struggles with their identity after a loss. (Lichtenthal and Breitbart (2015).  These are not considered appropriate for clients who have longstanding identity or personality disturbance. 

  1. Think about a time before your loved one became ill – Write down four answers to the question:  “Who was I before my loved one became ill?” Based on how you viewed yourself then.   These can be positive or negative and may include, personality characteristics, values, beliefs things you did, roles you held, relationships with people you knew etc.  Eg.. answers might start with “I was someone who….(was passionate, optimistic, organised, worried a lot..) or I was a …..(homemaker, entrepreneur, sister, brother, mother, father). 
  2. Next write four answers to the question, “who was I while my loved one was ill?”  These can once again be positive or negative responses, and include personality characteristics, beliefs, values, things you did, roles you held, relationships with people you knew.
  3. Next, write four answers to the question “Who am I now”?  These can once again be positive or negative responses and include personality characteristics, beliefs, values, things you did, roles you held, relationships with people you knew etc. Take some time to think about how your loss has affected your answers and your sense of identity.  How has what you’ve been through affected who you are, what you value and the things that are out meaningful to you? 
  4. Finally write down four answers to the question, “Who do I want to be?” Consider the person you would like to be in the future.  Your responses may include characteristics, values or roles, you already listed or some towards which you hope to work.

5.   Client Self Assessment Exercise:  This brief tool is a helpful way to encourage conversation around where the client feels they are at with their grieving (Jeffreys, S 2011 in Niemeyer 2016).  This tool asks the client to rate on a scale of 0-100 where they see themselves on the “tasks of mourning” a term used by Worden (2009).   The questions asked are as follows:

How would you assess your degree of activity/movement for each of the four tasks of mourning with regard to your most painful loss? 

Task 1 – Still mostly unreal – very real

Task 2 – Little or no feelings expressed – many feelings expressed

Task 3 – Not used to life without the deceased – pretty used to life without the deceased

Task 4 – Can’t let go of him/her unable to have new interests – my connection continued with the deceased as a new spiritual bond and this fits with my new life. 

I have used this with clients later in the grieving process – in one case a number of years after the loss as a checkpoint to facilitate conversation about progress.

In summary – working with grief requires flexibility and compassion, and an understanding of the ways it may present at different times and how best to help clients at that time.  Theoretical background of the stressors clients face will assist the therapist to be client centred and help them move between confronting and avoiding the grief.  Our role as therapists is to provide containment along with facilitating emotional expression.  The overall aim being to help clients integrate the loss into their lives and return to a place of peace and equilibrium with acceptance of a new identity, purpose and growth.

References:

Kubler-Ross, E (1969) On Death and Dying.  Macmillan Publishing NY

Lichtenthal, W and Breitbart W (2015) The central role of meaning in adjustment to the loss of a child to cancer. Implications for development of meaning centred grief therapy.  Current Opinion in Supportive and Palliative Care 9 (1) 46-51.

McKissock, M and D (1985) Coping with Grief.  ABC Corporation Australia.

Neimeyer R (2016) Techniques of Grief Therapy:  Assessment and Intervention.  Rutledge NY.

Stroebe M and Schut H (2010).  Continuing Bonds in Adaptation to Bereavement.  Toward Theoretical Integration in Clinical Psychology Review 30 (2) 259-268.

Worden W J (2009) Grief Counselling and Grief Therapy. Taylor and Francis. Britain.

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