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Grief and Loss CHC51712 Diploma of Counselling Module 6

Module 6 grief and loss learning resource 30.4.13

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Page 1: Module 6 grief and loss learning resource 30.4.13

Grief and Loss

CHC51712 Diploma of Counselling Module 6

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Contents Overview ...................................................................................................................... 3

Unit Description ......................................................................................................... 3

Learning Outcomes (Essential Skills) ............................................................................ 3

Content Areas (Essential Knowledge) .......................................................................... 3

Module Duration and Workload ................................................................................... 4

Required underpinning knowledge for this module ........................................................... 5

What is grief? ......................................................................................................... 6

Elisabeth Kubler-Ross (Stages Theory) 1969 ............................................................. 9

J. William Worden (Task Theory) 1982 .................................................................... 10

Margaret Stroebe and Henk Schut (Dual Process Model) 1999 ................................... 11

Steps in providing support and care relating to loss and grief ........................................... 21

1. Identify effects and impact of loss and features of grief ........................................... 21

2. Engage empathically with people who are living with loss ......................................... 30

3. Provide support for individuals who are grieving and identify potential for healing and

growth ..................................................................................................................... 31

4. Identify, inform and refer to appropriate grief and bereavement care services and

resources ................................................................................................................. 34

5. Identify and recognise risks associated with grief and bereavement support .............. 35

6. Access appropriate supervision and debriefing ......................................................... 36

7. Review and evaluate grief and bereavement support provided .................................. 36

READINGS & RESEARCH ............................................................................................... 38

REFERENCES ............................................................................................................... 38

WEBSITES ................................................................................................................... 38

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MODULE 6 Grief and Loss

The unit of competency in this Module is:

CHCCS426B Provide support and care relating to loss and grief.

Overview

Unit Description

CHCCS426B — This unit describes the knowledge and skills required to provide support for

individuals who are experiencing loss, grief and bereavement.

Learning Outcomes (Essential Skills)

At the end of this module of study you will be able to:

1. Recognise expressions of loss, grief, trauma and bereavement

2. Respond appropriately to a range of approaches and responses to loss, grief and

trauma

3. Engage with individuals experiencing loss, grief trauma and bereavement with

empathy, sensitivity, professionalism and courtesy

4. Refer individuals who show some signs of mental illness to appropriate services

5. Apply verbal and non-verbal approaches to dealing with and responding to grieving

individuals

6. Use effective communication skills, including:

o empathic listening skills

o use appropriate communication techniques to respond to individual needs

o provide information clearly and sensitively

o obtain feedback to confirm understanding

7. Maintain documentation as required, including effective use of relevant information

technology in line with work health and safety (WHS) guidelines

Content Areas (Essential Knowledge)

The following areas are the essential knowledge required for this module. These are

discussed in more detail in the following section. Knowledge areas covered are:

Potential impact of specific loss(es) and common features of:

o grief and bereavement at the individual, family and community level

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o trauma at the individual, family and community level

o complex grief at the individual, family and community level

Reactions to loss and associated expressions of grief and bereavement

Awareness of how loss, grief and bereavement can impact on social and emotional

health and well being

Integration of loss

Distinctive social, cultural, ethnic and spiritual differences in loss, grief and

bereavement

Awareness of the context and circumstances prior to loss and their impact on grief

and bereavement

Understanding of a ‘stress vulnerability model’

Awareness of the broad spectrum of loss

Strategies for formal and informal grief and bereavement support

Available grief and bereavement care services and information resources

Module Duration and Workload

This module is 4 months in duration. Learning and assessment should be completed within

this time frame.

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Required underpinning knowledge for this module

The study of grief and loss is an important one for a counsellor. Losses occur for us all every

day in small ways. Fortunately, the larger losses that occur are usually more infrequent, as

to lose someone close to us means a major readjustment in life. The loss of a child, partner

or parent is at the very least incredibly disorientating and at worst can mean that we can

despair to the point that our own life seems meaningless and not worth living. When one

person ends their life others can feel for a time like they too don’t want to go on.

Supporting people to deal with loss is an important skill to learn in counselling. Losses can

range from job loss, moving locations, losing a home, loss of faith, through to separation

and divorce or the loss of friends and family members through death. Fortunately (or

unfortunately) we are all, to some extent, experts for we have all experienced losses. Our

capacity to self-reflect is an important skill in helping others deal with loss as we can identify

the steps and stages that we have gone through on our own grief journeys which are

probably not so different from what others experience as well.

Of course, if someone has a series of losses in their life, it can be extremely hard to find

level ground. Suicides, long drawn-out painful illnesses and other traumatic losses can

require expert attention and the capacity to identify when someone is at risk. It is important

to be able to recognise these risk situations so that we can refer appropriately if someone is

not recovering from a loss.

There is a warning with the study of grief and loss. If you have recently lost someone

precious to you, you could find that this study unit may distress you. It is important to talk

frankly about this with your trainer in order to design strategies to support you through your

study of this vital area.

The following points cover the required knowledge set out in the competencies for this

module.

Potential impact of specific loss(es) and common features of grief

and bereavement at the individual, family and community level

Losing anything is frustrating at the least. You may remember a time when you lost your

wallet or purse. Consider the thoughts, feelings and actions that occurred at the time. If you

found the wallet you would have been relieved and happy as you realised what it would

have meant to have to replace your driver’s licence, credit cards, money etc. If you had lost

that wallet permanently you may have experienced any or all of the following:

Possible thoughts:

I am so stupid, why didn’t I check it?

It’s his fault, if he hadn’t distracted me at that moment!

Where could it be? Maybe I left it in the car.

Maybe one of the kids took it out of my bag.

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This is dreadful, it will mean I can’t get on this flight, and my colleague will be angry

with me.

Possible feelings of:

Agitation

Dread

Anxiety

Anger

Frustration

Sadness

Shock

Disbelief

Possible body sensations:

Sinking feeling

Stomach knot

Palpitations

Tightness in the chest

Shoulder tension

Sweaty palms

Headache

Possible actions:

Frantic searching

Going over and over retracing steps

Anger outbursts

Exclamations

Aggression

Tears

All this over a wallet or purse!

Loss can be disorientating. There is a period where we try very hard to reverse the loss even

if it makes no sense and it is clear that we will never see that thing or person again, that it

is truly over. We may play with thoughts of ‘if only…’ trying to reverse the damage.

What is grief?

The period of adjustment to a loss is called ‘grief’. It is the experience of getting used to the

loss and it is not easy.

In our counselling work we will encounter many, many people who are in the process of

grieving. Many of them won’t realise what they are experiencing is grief. However, as

counsellors, we need to be fully aware of grief in its various forms.

Loss of loved ones through death and divorce, change in location, change or loss of jobs,

loss of pets, equipment or precious possessions, loss of expectations and faith all take their

toll on us. None of us grieve for a loss in exactly the same way — there are vast individual

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differences. There are some commonalities, and we examine three well-known grief theories

below under ‘Reactions to loss and associated expressions of grief and bereavement’.

However, the differences can at times tear families and even whole communities apart as

everyone deals differently with such situations. We can tend to be incredibly judgemental of

others at such times as well. We are not at our best and can consider that others are not

showing appropriate sorrow or sensitivities according to our own standards. This can impact

grieving through lack of support and, even worse, can come at a time when we are quite

vulnerable.

Families need to be reminded that, when we are all grieving in our own way, we may not

have the capacity to help each other terribly well. This may be the time to get outside

support so that one person, or a few people, are not left in the situation of having to be

‘strong’ for everyone else. This naturally would leave this person or persons in a particularly

stressful state and they may ‘go down like a pack of cards’ later when everyone else has

recovered. At that time others may consider that this person is being dramatic or attention

seeking!

Counsellors need to be fully aware of the implications of grieving on family relationships and

in close-knit communities and understand the power of strong painful emotions that come

from a loss.

Potential impact of specific loss(es) and common features of trauma

at the individual, family and community level

Loss can also involve trauma. The shock of a loss from car accidents, murders, rape,

robbery, suicide and even long-term illness can impact the nervous system and produce

long-term damage. When this occurs it is called Post Traumatic Stress Disorder or

PTSD. Clients may find that they have flashbacks to the traumatic event, nightmares that

persist, strong startle responses, lack of control over strong emotion, including see-sawing

of emotions and depression. In these cases it is important to refer the client on for expert

care, which may be to a doctor, psychologist or a psychiatrist in extreme cases.

Traumatised people in a family or community may in turn pass that trauma on to others.

When parents have been traumatised, their capacity to manage children is reduced

considerably as the usual annoyances can be met with extremely strong emotional reactions

and sometimes physical retribution. In addition, traumatised people, particularly those who

have not been treated and don’t realise that they have been traumatised, may turn to drugs

or alcohol and other means to relieve their agitation and body distress. Children and other

vulnerable people may also be deeply affected simply by living with those who are

traumatised.

We can see how incredibly important it is for counsellors and other mental health

professionals to be available and fully trained and skilled in working in the area of loss.

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Potential impact of specific loss(es) and common features of

complex grief at the individual, family and community level

Without support, individuals, families and communities may experience complex grief, for

example, with multiple losses through suicide. Complex grief may occur for a number of

reasons. These are discussed below.

No answers

When a loss occurs and we can’t find any reasons that make sense we may not be able to

resolve that loss and it means that we continuously replay the loss trying to find meaning.

Multiple losses

Resolving a loss takes time. If we experience another loss before we have recovered from

the initial loss we are doubly impacted. It takes our psyche some time to believe that the

world is a good place. With multiple losses we can despair of life and conclude that there is

no safe place and no good thing in store for us. We may not recover emotionally.

Denial

At times the meaning of the loss to us is so painful we do not move out of a denial stage

where we suspend our emotional suffering by imagining that the loss has not occurred at

all.

Abuse

When grievers are not supported but attacked in their grief this can add to the wound

making it extremely hard to recover. It seems like an open wound is ripped open further.

Healing takes longer and may never happen, as resentment and bitterness can leave the

person ‘changed’ and untrusting forever.

No education

Many people do not understand the grief process and can be disturbed by what is

happening to them. This can make them wonder if they are losing their mind or if there is

something ‘wrong’ with them. This can extend the grieving period as they feel lost in the

process.

Trauma

Trauma, as we have mentioned above, halts the grieving process through shock. This can

stay in the person’s system. It is important for trauma to be treated so that grief processes

can move forward.

Reactions to loss and associated expressions of grief and

bereavement

There are some common features of grief experiences. Some of these have been noted by

famous grief theorists. It is important for counsellors to be fully versed in these concepts as

they can be used to educate clients and help them recognise what is happening for them

and provide encouragement that the process will not last forever.

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Elisabeth Kubler-Ross (Stages Theory) 1969

Elisabeth Kubler-Ross was a Swiss-American psychiatrist and a pioneer in near-death

studies. She is the author of a ground breaking book On Death and Dying. In this work she

first discussed her theory of the Five Stages of Grief outlined below. Kubler-Ross first

applied this theory to those who were dying but later revised this to be applicable to all sorts

of loss experiences. She was an advocate for AIDS victims and set up Hospices for those

who were dying.

1. Denial

"I feel fine."; "This can't be happening, not to me."

Denial is usually only a temporary defence for the individual. This feeling is generally

replaced with heightened awareness of possessions and individuals that will be left behind

after death. Denial can be conscious or unconscious refusal to accept facts, information, or

the reality of the situation. Denial is a defence mechanism and some people can become

locked in this stage.

2. Anger

"Why me? It's not fair!"; "How can this happen to me?"; '"Who is to blame?"

Once in the second stage, the individual recognises that denial cannot continue. Because of

anger, the person is very difficult to care for due to misplaced feelings of rage and envy.

Anger can manifest itself in different ways. People can be angry with themselves, or with

others, and especially those who are close to them. It is important to remain detached and

non-judgmental when dealing with a person experiencing anger from grief.

3. Bargaining

"I'll do anything for a few more years."; "I will give my life savings if..."

The third stage involves the hope that the individual can somehow postpone or delay death.

Usually, the negotiation for an extended life is made with a higher power in exchange for a

reformed lifestyle. Psychologically, the individual is saying, "I understand I will die, but if I

could just do something to buy more time...". People facing other traumatic situations can

bargain or seek to negotiate a compromise. For example "Can we still be friends?" when

facing a break-up. Bargaining rarely provides a sustainable solution, especially if it’s a matter

of life or death. Bargaining can also include guilt, including survivor’s guilt.

4. Depression

"I'm so sad, why bother with anything?"; "I'm going to die soon so what's the point?"; "I

miss my loved one, why go on?"

During the fourth stage, the dying person begins to understand the certainty of death.

Because of this, the individual may become silent, refuse visitors and spend much of the

time crying and grieving. This process allows the dying person to disconnect from love and

affection. It is not recommended to attempt to cheer up an individual who is in this stage. It

is an important time for grieving that must be processed. Depression could be referred to as

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the dress rehearsal for the ‘aftermath’. It is a kind of acceptance with emotional attachment.

It’s natural to feel sadness, regret, fear, and uncertainty when going through this stage.

Feeling these emotions shows that the person has begun to accept the situation.

5. Acceptance

"It's going to be okay."; "I can't fight it, I may as well prepare for it."

In this last stage, individuals begin to come to terms with their mortality, or that of a loved

one, or other tragic event. This stage varies according to the person’s situation. People

dying can enter this stage a long time before the people they leave behind, who must pass

through their own individual stages of dealing with the grief.

The Butterfly

An analogy for Elisabeth Kubler-Ross’s ‘stages’ theory is ‘the butterfly’.

The butterfly starts as a caterpillar and grows in size and then turns itself into a pupa or

chrysalis and finally transforms itself into a butterfly. The butterfly then lays eggs and so the

cycle continues. The main feature of this analogy is that, in life, change occurs and at times

in that change we are in a dark place transforming ourselves, but we can emerge as a

butterfly able to move beyond what we were ever able to do before.

This analogy is hopeful and is not unlike Kubler-Ross’s idea that we go through a change

process that takes us through a dark place but that at the end there is light and hope.

J. William Worden (Task Theory) 1982

Worden, an American psychologist known for his work in Gestalt Therapy, developed a new

theory to explain the process of grieving. This was applied first to those who had suffered a

loss through death but then applied to other forms of grieving as well.

Worden’s Task Theory can be viewed as a more ‘masculine’ approach to loss as it is

framed with ‘tasks’ to complete in order to successfully manage a loss.

Task 1: To accept the reality of the loss

Task 2: To process the pain of grief (or to experience it)

Task 3: To adjust to a world without the deceased (or the thing you have lost)

Task 4: To find an enduring connection with the deceased in the midst of embarking on a

new life (to reinvest emotional energy)

The Seasons

This theory has been used by the Seasons for Growth Program and aligns with another

analogy of dealing with grief, using ‘the seasons’ of the year. This follows the pattern:

Autumn – coming to terms with a loss

Winter – experiencing the pain of grief

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Spring – adjustment and starting to see some new life

Summer – renewal and moving forward again

This analogy can be very helpful as it has a time frame of 12 months. Most people who lose

a loved one can identify with the first year as being the hardest time. Into the second year,

while life is still not where they would like it to be, they are generally moving forward.

Margaret Stroebe and Henk Schut (Dual Process Model) 1999

The third theory of grief that has been well established is the Dual Process Model of

Stroebe and Schut. This theory maintains that in a grief process two things happen

simultaneously — grieving work and avoidance of grief.

They recognised that at the beginning of a loss a person is fully involved in grieving and

feeling the sadness of grief but even so they have to get on with life and so avoid their

grieving for periods in order to function. This movement back and forth lessens over time

with people adjusting to their loss. This model lends itself to another analogy of grief and

that is the ‘broken leg’ analogy.

The Broken Leg

While we favour a broken leg, padding it and protecting it, we still need to get up out of bed

and function. We may have artificial supports for a time, including walking sticks and

wheelchairs, but without movement and normal living the leg wouldn’t heal. It needs to

have blood flow and circulation and when a cast comes off the leg needs to move in order

for the muscles to grow again and to file off the bony protrusions that occur in mending

bones. The muscles actually wear down the new overgrown bones to the shape they were in

the first place before the break.

This miracle of nature in healing is also a great one for assisting people to understand both

the need for care and rest and the need to get up and out again in order to feel better and

heal.

Models of grief

The following article is provided as further discussion of models of grief.

Reading: Grief, Loss and Bereavement

Much of what has been written about how people grieve has focused on individual survivors.

The Victorian belief that grief was a sign of a "broken heart" resulting from the loss of a love

was replaced by the psychodynamic view that grief was painful because it involved letting

go of attachment to the deceased. This "letting go" was viewed as essential for "moving on"

with one's life, eventual recovery from depression, and a return to "normal" (Neimeyer

2001). Theories of grieving later included an emphasis on differences between pathological

(complicated) and normal (uncomplicated) grief reactions (e.g., Lindemann 1944), and an

emphasis on phases, stages, or trajectories of the grieving process. The best-known stage

model was presented in Elisabeth Kubler-Ross's (1969) book On Death and Dying. In

discussing anticipatory grief of terminally ill persons she outlines five stages: shock and

denial, anger, bargaining, depression, and acceptance. These stages were viewed by many

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lay people and professionals as "the" way successful grief is experienced. Many still gravitate

to this model for its simple linear approach, using it as a prescription to measure how grief is

progressing. Since its publication, this stage model has been applied to other losses

including divorce, chronic illness, and infertility.

Although these models have been prominent in the popular media, many scholars have

been critical of them (Attig 1991). Studies have failed to find any discernible sequence of

emotional phases of adaptation to loss, or any clear endpoint to grieving. Rather than a

passive climb up a linear staircase, characteristics of grieving may more closely resemble

unsteady twisting and turning paths requiring adaptation and change, but with no specific

end. In addition, there is no evidence that someone who deviates from those stages is

experiencing pathological grief, so authors have called for a de-emphasis on universal grief

syndromes and a recognition of varied practices of subcultural groups.

There also have been many challenges to the concept of grief work that underlies these

theories— an assumption that one must do cognitive work to confront the loss and that

failure to undergo or complete grief work results in pathological grief. The idea that one

must "work" at dealing with grief is not a universal concept, and probably is reflective of the

broader emphasis in the United States that anything worth having requires hard work.

Newer models of grief tend to focus on context and circumstances of a loss, variability in

individuals' grief experiences, meaning of the loss to individual survivors and their families,

recognition that rather than a withdrawal of attachment from the deceased (or lost object)

there is a continued symbolic bond, and adjusting to the new world that exists after the loss

(including new interpretations one has of the environment, and new elements in one's

identity). The emphasis appears to have shifted from identifying symptoms to the process of

grieving. For example, the Dual Process Model of Coping developed by Margaret Stroebe

and Henk Schut (1999), suggests that active confrontation with loss may not be necessary

for a positive outcome. There may be times when denial and avoidance of reminders are

essential. Most individuals can expect to experience ongoing oscillation between a loss

orientation (coping with loss through grief work, dealing with denial, and avoiding changes)

and a restoration orientation (adjusting to the many changes triggered by loss, changing

routines, and taking time off from grief). This reflects a movement between coping with loss

and moving forward, but the extent to which one needs either of these dimensions differs

for each individual.

Theories about families have been slower to develop elements that address loss and grief.

Family systems theory (with its emphasis on viewing reactions to loss by the family group as

a disruption in the family system's equilibrium and structure requiring reorganization of roles

and functions; and the impact of reactions of one family member on another) appears well

suited for examining loss. However, its emphasis on the present and current interactions

appears to have slowed development along this line. There are a few notable exceptions,

including Monica McGoldrick's (1991) elaboration of Murray Bowen's work on the legacy of

loss. Bowen (1976) suggested that a family's history and experiences with loss influences

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how the family adapts to subsequent losses as well as the legacy of viewing themselves as

either "survivors" or "cursed" (i.e., unable to rise above the losses) that they pass on to

future generations.

Another notable work is that of Ester Shapiro (1994), who integrated individual and family

life-cycle development with systems theory to discuss loss as a crisis of identity and

attachment, in which grief disrupts the family's equilibrium but makes possible development

of new "growth-enhancing stability" … In addressing losses related to chronic illness, John

Rolland (1994) developed the Family Systems-Illness Model to examine the interface of the

individual, family, illness, and health-care team. Rather than focusing on the individual,

Rolland views the family or caregiving system as the central resource affected by and

influencing the course of the illness.

Source: <a href="http://family.jrank.org/pages/750/Grief-Loss-Bereavement-Coping-with-

Loss.html">Loss Grief and Bereavement - Coping With Loss</a>

Awareness of how loss, grief and bereavement can impact on social

and emotional health and wellbeing

Our clients’ bereavement experience can impact on their social and emotional health and

wellbeing. Withdrawal from social connections is very common in grief and this is not always

understood by friends and family. It can at times cause offence. It is important to encourage

clients to express their need for quiet while they sort themselves out and for them to

communicate with friends, colleagues and loved ones about their needs at this time. This

will help others to support them in the way that they need. It seems an obvious point, but

people tend to expect that people should just ‘know’ what is going on inside them.

This withdrawal can mean that people don’t want to move outside their homes. However,

exercise and change of external environment is important and should become a normal part

of daily activity for emotional health and wellbeing. Sights, sounds, smells and sensations all

help to stimulate our senses and can help bring relief to a grieving client. Encouragement to

do this is important and sometimes homework can be given for the client to work on this.

Integration of loss

Integration of loss may include:

Dual process

Meaning reconstruction

Continuing bonds

Disenfranchised grief

Grieving styles

To help clients integrate their loss into their lives in a positive way is important. The

following therapeutic model is provided to assist in this process.

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STORY The Person’s Story of Loss

The counsellor may want to use a LIFE LINE approach to this to help map the story of the loss over

time. Sequencing the story can assist people who have been traumatised to make sense of the

events. Small children may be encouraged to tell the story in pictures, with what happened first,

what happened next and so forth.

You may also like to ask them, when you lost … what else did you lose? These are the MICROLOSSES.

Other ways are simply to let the person tell you their story with input from you as a counsellor

reflecting back to the person their strengths and how normal they are to be experiencing the

emotions they are under the circumstances.

FEELINGS/BELIEFS/BODY SENSATIONS/ACTIONS? What does it make them feel/believe about

themselves because they have lost this person or situation or thing?

You may need to ask the person directly about their thoughts and feelings when these things were

happening, or what they are currently, as they may not have had an opportunity to express this or

make sense of it.

FEELINGS – Find out what feelings the person is experiencing, list a few if they can’t quite find the

words.

BELIEFS – Ask the person what this loss makes them believe about themselves, others, God, life

because of what has happened.

BODY SENSATIONS – Importantly, ask the person to tell you where they feel the sadness, or hurt or

anger now in their body, i.e. sick feeling in the stomach, heavy feeling in the heart etc. (With children

you can use a body map for them to colour in and indicate their feelings.)

ACTIONS – Ask the client what the loss is making them want to DO. What do they find themselves

doing now that they normally wouldn’t do?

EDUCATE & NORMALISE — Explain to your client that they are normal, explain the seasons or the

butterfly or broken leg analogy to them to help them understand grief. If they have had lots of

losses, explain to them ‘numbing’ and other behaviours people may use to deaden the pain of loss

(alcohol, abuse, stealing, drugs, sex, gambling etc.). Let them know that real healing/adjustment and

feeling better is possible in time. Let them know that particular strategies can lessen the distress

now as well.

LETTING GO — What ideas have they had to help let go of the person/situation/thing? Painting,

talking to the person, writing them a letter, special place/memorial, memorial service, candle

lighting, memory book, planting a tree. Ask the person if they would like to create a ceremony as a

way of letting the loss go. If there has been a death and the funeral is already over let them know

that personal goodbyes can happen at any time to help in adjustment and that just because the

funeral is over doesn’t mean that they have finished saying their goodbyes.

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STAYING CONNECTED — What part of the person/situation or thing can they keep close to them?

Ask them about words they would say, memory tokens they can keep with them, new purpose for

life discovered or a feeling of their presence that provides this sense of connection. Ask the person

how they would like to stay connected to the very best part of the person, situation or thing that

they have lost. Even in divorce people may need to have a sense of connection to the best part of

the relationship. It might be that they learned to value themselves and this is what they have taken

from the relationship.

POSITIVE STRATEGIES

Positive thoughts — Help the person find better thoughts to replace bad or negative thoughts, and

get them to practise these new thoughts whenever they can. For example ‘Life will never be the

same’ can be changed to ‘Life has been richer because of this person or situation’.

Making the body feel better — What do they notice makes the bad feeling lessen? Can they use a

body pillow, do more walking, cry, laugh, talk to people, exercise, rock back and forth, engage in a

relaxation strategy.

Making positive plans — What new things will they do in their life they haven’t done before? Join a

club, do some study, start a group, do some craft or gardening, go fishing more, spend more time

with the grandchildren, contact someone they haven’t seen for a long time.

COMMUNITY CONNECTION — Who or what is out there to support them when they feel sad or

lonely? Set them some homework to make a connection with others. Help the person find

organisations or people in the community that they can connect to when they are feeling low or sad.

This is really important to stop suicide or other self-harming behaviours and help create a strong

connection in the community for the person.

Distinctive social, cultural, ethnic and spiritual differences in loss,

grief and bereavement

Understanding other people’s responses to loss and their grief expression can sometimes be

confusing. Some of the different reactions are of course due to the uniqueness of a person’s

own personality, perhaps even partly a hereditary disposition. Other differences are due to

the social situation a person is in, their cultural background, their ethnic group and religion.

Social

Our world is a social world. It is filled with people and the people we relate to on a day-to-

day basis are our ‘social circle’. Social circles have their own rules and values; although very

rarely written or spoken of they are ‘understood’. For example, going to an acquaintance’s

place on 25 December at lunchtime just to ‘pop in’ would be seen as inappropriate in many

social circles. Most people would know the social norm is not to go uninvited to someone’s

house on Christmas day.

Our social circles may dictate certain behaviours around grief and loss. In one group it might

be taboo to talk of a deceased person or the loss of a job, while in another group it may be

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considered necessary to talk of such things. In some workplaces to take a day off for

bereavement leave is seen as acceptable; in others it would be seen as reprehensible.

Cultural

In a similar way culture dictates ‘norms’ when it comes to loss as well. Culture is a broad

term of course. Most people see it as an ethnic/racial consideration but it spans social and

religious areas as well as the associated values. Each of us has a personal culture and is part

of larger groups which have ideals and practices around loss.

Ethnic

In Australia we have had a great mix of people from different ethnic backgrounds. However,

when a group from a particular racial background does not mix with others, their cultural

practices are often based on traditional practices that are part of their ethnic background.

The Greek and Italian tradition of wearing black for a whole year when a loved one dies is

one obvious example of this. There are many other less obvious practices that are based on

culture. For example, in some ethnic groups the practice of self-mutilation is regarded as a

demonstration of love when a loved one dies.

Religious/Spiritual

Ethnic groups may also follow religious practices that are part of their traditional culture.

However religion, or spirituality, is more often seen as a choice of world view and beliefs

around the reasons why things happen. ‘God did it’. ‘Satan did it’. ‘He deserved it’. ’It’s fate.’

‘It’s the Secret’ etc. These beliefs will all have an impact on the way in which someone

‘travels’ through their grief journey. For one person a loss can be seen as ‘sabotage from the

devil’, to another the loss is seen as ‘a miracle from God’. The one individual may experience

frustration and hurt and the other jubilation.

As counsellors, our own faith or non-faith position may influence us in viewing the client’s

responses as ‘acceptable’ or ‘strange’. The mind is quite powerful and thoughts have a huge

impact on emotions. We should be happy if we can see that a person is managing their grief

well within their own religious/spiritual background and preferences, and if they have good

support structures in place. It is when we see people twisted in pain in their grief because of

their beliefs that it requires a more complex approach from us as counsellors. We have to

walk a kind and gentle line in these situations.

Ask the person how their faith may be helping them through their loss – this is congruent

with their perspective – we all choose to stay with a faith perspective presumably because it

is helpful to us after all. Then we may gently ask, ‘what are the hardest things about the

loss?’, and then ‘how is your faith or faith community helping with this part of your loss?’. If

the contribution is negative or non-existent we may suggest other resources or thinking

strategies that may help. Be careful to be supportive of the person’s own faith perspective

even so. While we may personally consider the particular faith perspective to be unhelpful

for emotional health, it is not our place to make such judgements. Our kindness and care in

the middle of grief may well assist this person to consider us as a ‘safe place’ in the event

that they choose to leave their non-helpful beliefs behind and to seek us out to help them

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move their thinking at a later date. Remember, people lean on their culture, beliefs and

traditions in turbulent times and to challenge these beliefs when they are vulnerable is

unethical and lacks real love and care. It can also be psychologically dangerous.

Awareness of the context and circumstances prior to loss and their

impact on grief and bereavement

The context and circumstances prior to loss may include:

Socio-economic circumstances

Age of deceased

Family relationships

Presence of mental illness in the deceased

These circumstances naturally have a significant bearing on how people manage a loss and

the extent of their personal suffering. People’s socio-economic circumstances may mean that

they didn’t have access to the very best care to prevent a painful outcome. This might

include medical care, legal care and even food, shelter and travel capacity. This lack of

financial capacity may contribute to the client thinking ‘if only’ thoughts after the loss. They

may compare themselves to others with access to the supports necessary to prevent the

same kind of loss. Loss of innocence at the unfairness of the world and the loss of justice

may be secondary losses in such cases.

Naturally, when someone dies, age is a factor in the impact of this loss. Losing a baby, child

or young person for example can be harder to accept and understand compared to losing an

elderly relative who has lived a long life and died of natural causes, peacefully in their sleep.

However, it is the relationship that we have with someone or something that determines the

grieving that will be experienced. Relationship connections are sometimes unexpected.

Relationships with animals, with jobs, with family members have emotions attached due to

needs inherent in that connection. One person may be more upset about their dog dying

than their husband leaving them. Someone may be more upset about the loss of their job

than their elderly mother dying. The individual connections of meaning in these relationships

determine the emotion experienced and the duration of the grief experience. Counsellors

need to examine these ‘relationship meanings’ with their clients to help them fully

understand the loss experience and to support them in dealing with their grief.

Another important issue is the impact of loss on the mental health of those experiencing the

loss. For example, if a family member had been mentally unwell prior to a suicide, this may

have been a condition that the family and supporters of this individual have coped with for a

long time. The exhaustion and stress levels of family members in this predicament can

precipitate loss of mental health for them as well.

If someone who previously had a mental illness experiences a significant loss this is likely to

increase stress and could increase symptoms of mental illness. Quality professional help will

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be required to support this individual through this time. It is a case of adding fuel to the fire

and it will need specialist support.

Understanding of a ‘stress vulnerability model’

The following reading is reproduced to give an understanding of the stress vulnerability

model. This reading is also reproduced on the online student portal as ‘Article for Grief and

Loss’ under Learning Resources.

The stress vulnerability model was proposed by Zubin and Spring (1977). It proposes that

an individual has unique biological, psychological and social elements. These elements

include strengths and vulnerabilities for dealing with stress.

The Stress Vulnerability Model

In the diagram above person "a" has a very low vulnerability and consequently can

withstand a huge amount of stress, however solitary confinement may stress the person so

much that they experience psychotic symptoms. This is seen as a "normal" reaction. Person

"b" in the diagram has a higher vulnerability, due to genetic predisposition for example.

Person "c" also has genetic loading but also suffered the loss of mother before the age of 11

and was traumatically abused. Therefore persons "a" and "b" take more stress to become

"ill".

This model is obviously simplistic. However it does unite different approaches to psychosis.

Vulnerability is not a judgmental term but an attempt to understand the variables involved.

Source: <http://www.hearingvoices.org.uk/info_professionals_stress.htm>

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Awareness of the broad spectrum of loss

When one person has a loss, their grief can impact on a great number of people in a

community. Most people can empathise to some extent and imagine what the other person

must be feeling. It can bring up feelings of vulnerability in all of us. We may be particularly

affected if we are similar in some ways to the person who has experienced the loss.

For example, if a young person suicides other families may be fearful for their own child,

particularly if their child has been depressed. If one person is put off in a workplace others

may fear for their security as well. They may feel guilty for still having a job or relieved that

they have been passed by. The effects of a loss ripple out like the widening circles in a pond

when a stone is thrown in.

As well as a broad impact across the community loss itself manifests in many different ways

and covers many situations. People losing friendships, jobs, houses, faith, relationships can

still suffer grief reactions at times as severe as in losing a loved one to death.

Strategies for formal and informal grief and bereavement support

There is a range of strategies to assist people in dealing with their grief. These include more

formal strategies such as counselling and identified grief support groups and extend to other

aspects such as literature or seminars about grief and to the love and care provided by

friends and family.

It is important that people are made aware of the sorts of supports that are out there in the

community. If a person seeks counselling for grief, counsellors should also provide

information on other supports that are available. In the end it may be aspects of all of these

avenues that together assist people to recover well.

Certainly grief groups can help to normalise emotions and experiences as well as provide a

social connection that is meaningful. However, counselling provides a forum for individual

understanding of the grief experience that may not be available elsewhere. Self-awareness

gained through reading material in books, brochures or online and attending seminars can

assist people to take the control of their own wellbeing and that is important in growth.

Friends, colleagues and family can display understanding in accepting an individual’s unique

grief responses without seeking for them to be explained, thus enhancing the grieving

person’s sense of being accepted in the grief experience.

Available grief and bereavement care services and information

resources

Police and coronial procedures

At times police are involved in investigating a death. In suicides this is a routine situation.

This involvement can be traumatic for the family as they are often in shock and disbelief and

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they may be asked questions which give them the feeling that they are a suspect in the

death of their loved one.

In these situations, which may intensify the grief experience for people, you may be

required to provide debriefing about this whole situation. Naturally in our communities we

want justice and protection for people. Police provide this for us by taking routine measures

to enquire about the nature of a death to ensure that it was either natural causes or

accidental rather than something deliberate. However as counsellors we should be aware

that this process may be extremely traumatic for the loved ones involved in this sort of

investigation.

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Steps in providing support and care relating to loss and grief

The following steps reflect Elements and Performance Criteria from:

CHCCS426B Provide support and care relating to loss and grief.

These skills apply to work in the industry in both general and in specialist areas of

counselling.

1. Identify effects and impact of loss and features of grief We have all experienced loss in our life and are familiar with the term. Losses can include

loss of people, things, situations, beliefs, health, careers, animals etc.

Loss may include the following, which are explained in more detail below:

Primary losses

Secondary losses:

o losses of the internal world, such as loss of cognitive or sensory capacity

o interaction losses

o losses of the external world, such as material or personal losses

Cumulative losses

Primary losses

A primary loss is an obvious loss.

For example: ‘My husband died, and I miss my husband.’

‘I lost my ring and I am missing my ring.’

Secondary losses

A secondary loss relates to the other things we may lose as a result of a primary loss.

For example: ‘I lost my job, so I also lost income, I lost the activity each day, I lost my

position in society, AND I lost my self-esteem.’

‘I lost my husband and I lost the person who takes me shopping, who

cleans the windows, and provides the income for me.’

Another way of describing secondary losses is ‘micro-losses’.

Losses of the internal world

Losses can relate to the internal world of the client, such as loss of cognitive or sensory

capacity. This may include loss of ideas, beliefs, attitudes, hopes, faith etc. We all have an

internal world; it is the reason why people will react differently to the same type of loss. We

have different thoughts.

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For example: ‘I lost my mother to death – I’m glad it is over, she was in great pain, she

suffered for years, I’m glad she is not suffering anymore, she is with God

now and the angels...it’s OK’.

Or

‘I lost my mother to death – this is dreadful, she had a dreadful end and I

hated to see her suffering, it seems so horrible that such a good person

had such pain. Once you are dead you are dead, there is nothing after

this. The world sucks because there is no justice, some really horrible

people just die in their sleep, why couldn’t my mum!’

Both individuals above have suffered an external loss which is similar, the loss of their

mother, but their internal loss is very different and particular to them. Our internal world can

mean that our loss can be extremely painful or not very, although we may have lost the

same thing and valued the thing we lost in exactly the same way.

When we speak about internal losses we generally consider these losses as the unseen

things that we lose.

For example: ‘I lost my faith when the pastor I respected and looked up to lost his

temper with me when I didn’t agree with him. It made me doubt the

reality of my beliefs. If, after more than 20 years practising his religion, he

is still deep down not a good person what hope is there for me?’

Another type of loss of the internal world is one that cannot be shared publically.

For example: ‘I aborted my baby, I am missing my baby, what have I done? I didn’t

know what else to do and I can’t tell anyone as I am ashamed.’

This is called disenfranchised grief — when people can’t express their grief due to stigma

or shame.

Interaction losses

Interaction losses refer to losses in relationships between people or situations.

Interaction losses also have secondary or internal world losses. You may imagine that the

loss of a partner and the interaction would be the primary loss for a person, yet when

talking to them, they are more concerned about yet another ‘bad’ thing happening for them.

In this case it is the loss of hope for a good world that is the internal world loss, not the

interaction between husband and wife.

Loss presents a complex landscape – but with simple questioning we can hit the mark of the

significant losses for our clients. They will value us if we can ‘get’ them, especially if they

can’t get themselves and why they are acting as they are.

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When people get a glimpse of the complex map of primary and secondary losses and

meanings for themselves they are grateful and are on their way to making sense of their

emotions and caring for themselves as they should. This is of course critical to successful

recovery from a loss.

Losses of the external world

Losses of the external world are the obvious losses, which everyone will see and

understand. Loss of job, loss of house, loss of a limb etc. are all examples of an external

loss – they are visible. In some ways primary losses and external losses are related and

secondary losses and losses of the internal world are related, but not in every case.

For example: June and Greg got a new house with a big mortgage. They could afford it

at the time. However the interest rates went up and June lost her job.

They have to sell their dream home. For both of them their external loss is

the house, however their internal losses are quite different.

For Greg, his internal loss is lost pride because his parents always said he

was a ‘nobody’ and only people who could save and buy a house had

‘made it’.

For June, her internal loss was that she had plans for a nursery in that

house as she was desperate for a child. She could see the child care centre

from her front veranda and the primary school was just over the hill. There

was a beach nearby where she imagined herself playing with her child in

the future.

Their primary loss was not actually losing the house, it was the losses of

their internal world that were the most powerful losses for both of them.

The secondary loss for both of them was the actual bricks and mortar of

the new home.

As counsellors it is important not to assume we know what a person is grieving for most. We

have to find out from them what the most difficult thing is in their loss. This will put you in

contact with their internal world of priorities, which is what we need to work with in order to

successfully help someone. Misunderstandings about this can cause people more grief.

For example: Alice’s daughter had a stillborn baby. June her friend is angry at her that

she is grieving and won’t come to bowls and is locking herself away in the

house. She says to their shared friend Marg that she thinks she is trying

for the sympathy vote. She’s never found out that Alice herself fell

pregnant when she was 15 and was shamed terribly by her family. She

finally gave birth at 16 but the baby was stillborn. She felt that God was

punishing her and that her family, who were staunch Catholics, thought so

too. The pain of this news for her daughter had brought her past up

painfully.

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Cumulative losses

Losses can build over time. The young woman whose mother died when she was 10 may

experience a build-up of grief over time when she loses her first boyfriend, her girlfriend

moves away and then she loses her children in a custody battle. Cumulative loss is also

multiple losses. However multiple losses may be viewed as a number of losses experienced

in a relatively short time. The sadness of these losses is that in many cases the person has

not been able to integrate or resolve the losses that they have experienced and life itself

becomes the stage of a personal tragedy where pain and grief fill the landscape.

How do we help to identify secondary losses?

Most losses inlcude both primary and secondary losses. As counsellors, it is important to

search out the secondary losses the person may be coping with, as most friends and

relatives will provide acknowledgement of the obvious loss a person may experience. The

individual themselves may or may not have identified the secondary losses, but this is

necessary for a client to understand and validate why they are feeling as they do. It also

helps to work out ways to deal with the loss.

Ask the simple question

How can we identify these secondary losses? The best way is to ask, for example:

‘When you lost your job Harold, tell me what other things did you lose as well?’

Or

‘Alice it’s been a hard road hasn’t it losing Bert, he was everything to you wasn’t he?

I’m wondering Alice about all the things Bert was to you, the things he did for you

and gave to you and provided for you? I bet it is a long list.’

In asking these questions we acknowledge both the primary and the secondary losses a

person may be coping with.

Discovering secondary (or micro-losses) is a way to help the person build their future and

take some of the pain of the primary loss away. Helping Harold or Alice above, for example,

to find how to deal in other ways with the list of smaller micro-losses can help make life

bearable for them.

For example Alice may have lost the person who helped her sweep the floors or clean the

bath when she lost Bert. As a counsellor you may be able to refer her to home help or a

government agency that will provide this support to her if she is elderly and wants to stay in

her own home.

Harold may have lost his self-esteem in helping others within his workplace. You may find

out that he has been a supporter of cricket with kids for a long time but has never

volunteered to be the coach. Encouraging him in this area may well provide a sense of pride

and involvement that may have been taken away when he lost his job.

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It is important that we don’t guess the secondary losses, but actually ask. Sometimes you

may have to prompt the person. This is because it can be incredibly surprising the sorts of

answers people give you. It may be outside of your guess work completely.

For example: Alf is 68 and has had three failed relationships, the last one with a 40-

year-old woman. In checking for Alf’s micro-losses you find out that he is

actually more upset about losing the chance to be a dad. He liked his last

wife, but he was actually hanging out for her to get pregnant for five

years. This secondary loss was actually his primary loss (secretly). Without

asking you may never know.

Features of grief

Grief is the reaction we have to a loss. Features of grief may include:

Sadness

Longing

Somatic complaints

Integration

In understanding the grief experience it is probably helpful for us to see the grief response

in four domains:

Emotions/feelings

Thoughts (cognitions)

Body sensations/somatic complaints

Behaviours

Emotions

What are some of the emotions or feelings that people may experience in a loss?

Anger

Anxiety

Depression

Despair

Helplessness

Hopelessness

Loneliness

Longing

Guilt and remorse

Sadness

Shock

Relief

Thoughts

What are some of the thoughts that people may experience in a loss?

Confusion – ‘I don’t understand’

Fear of going mad – ‘I must be losing my mind’, ‘I’m going mad’

Feeling unable to cope – ‘I’m not strong enough for this’, ‘I’m going to break in two’

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Questioning of values and beliefs – ‘Nothing makes sense anymore – how can there

be a God?’, ‘There is no meaning to this’

Drop in self-esteem – ‘I’m a dreadful person, this is all my fault’, ‘If only I had loved

him more’

Shock and disbelief –‘ How could this happen?’

Trauma – ‘I’m destroyed’, ‘I can’t heal from this, it is impossible’

Blame – ‘They took away my world when they fired me, I hate them’

Change in worldview –- ‘No more Mr Nice Guy, it doesn’t get you anywhere, I’m

going to be a real bastard, maybe that is the way you keep a woman’

Body sensations

What are some of the body sensations (somatic complaints) people may experience when

grieving?

Headaches

Chest tightness

Stomach pain/knot

Shoulder tension

Dizziness

Dry mouth

Confused feeling in the head

Heavy heart

Heavy legs

Tingles in the hands and feet

Dread sensation

Jumpy/nervy

Behaviour

What are some of the behaviours that people may engage in when suffering grief?

Withdrawal

Reckless behaviour

Nastiness

Selfishness

Distraction

Blame

Overcompensation – giving

Talking about the loss repetitively

Not talking about the loss – avoidance

Crying

Sleeplessness

Over-eating

Under-eating

No interest in sex or trying to feel better through sex

Spending/shopping

Gambling

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Alcohol

Drug use

Suicide

Of course these are not exhaustive lists but it does help us understand some of the

individual differences that occur.

It is mostly the behaviour of grieving people which is obvious as this is externally

demonstrated. Some of the behaviours can be a way to feel better, to have momentary

relief in a sad world, for example withdrawal, over-talking, over-eating, gambling, drugs and

alcohol, shopping etc. Other behaviour can be self-punitive in order to gain some kind of

justice in the world, for example reckless driving, over-giving and even suicide. Other

behaviours can be a form of punishing others including blame, nastiness, resentment and

selfishness etc. Other behaviours are just part and parcel of depression – these would

include under-eating, sleeplessness, crying, loss of interest in sex etc. It may be important

to explore with your client what the behaviours they are engaging in are achieving for them.

It is important to do this in a non-judgemental way so that they can reflect on whether their

behaviour is useful or whether there is another way to act to help them feel better.

1.1 Clarify the impact of specific loss(es) and common features of grief and trauma and

their interplay at the individual, family and community level

Of course grief is not just an individually experienced thing. Even if other members of the

family have not lost something in common they may also grieve on behalf of their family

member. For example a son who fails university experiences this loss personally however

parents may also ‘feel’ for him and grieve this loss as well. Often family members who have

lost a loved one grieve together but of course each person has an internal loss which may

be different and inexplicable. When a child dies a whole community may be caught up in

this loss and imagine the pain of the parents and identify strongly with this loss. Suicide can

have an impact on a whole community and affect a wide range of people associated with

the person who has suicided in powerful ways.

In Indigenous communities the loss of a loved one on top of other losses that may not have

had resolution can have an impact on community members who connect closely at a very

deep level.

1.2 Recognise common but also distinctive expressions of grief and complex grief

We have discussed above some of the more common expressions of grief, and looked at

some of the features of complex grief in the previous section. Complex grief is experienced

when the grief doesn’t follow ‘normal’ patterns.

Complex grief may present as a fixed denial where the client cannot come to terms with

the reality of the loss. For example the elderly gentleman who accidently puts his foot on

the accelerator instead of the brake and kills his wife of 45 years and who persists in

believing that she is coming back from the shops and is just late. Or the mother whose son

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went missing and had been previously suicidal who believes that he has just gone off but

will return soon and may just be trying to teach them a lesson. People for whom the reality

is extremely painful may stay fixed in denial.

At times people may feel a numbness in the face of an extreme loss and not have any

emotions around the loss. This may also be a way to prevent strong undesirable painful

emotions from descending. It may be that internally the person believes that they would die

from such a shock.

At times grief may erupt into violence for people that normally wouldn’t be prone to this

type of behaviour. The violence may then be seen as an expression of extreme emotional

self-preservation as the self-destruction, guilt and despair of allowing the pain of the loss

to register may be overwhelming. For example, this might be so for a father who accidently

runs over his toddler when backing out of the driveway.

Suicide as a response to dealing with grief can also be seen as a complex grief reaction.

Inability to recover from grief is also seen as a complex grief reaction. There are

generally subconscious blocks to recovery which may require expert psychological

assistance.

Other examples of extreme complex reactions to grief include: hysterical laughter,

uncontrolled compulsive purchasing, running away by moving or travelling and not returning

home.

1.3 Take into account distinctive social, cultural, ethnic and spiritual differences in loss

and grief

Social, cultural, ethnic and spiritual differences in loss, grief and bereavement may include:

Reactions to loss

Individual expressions of grief and bereavement

Cultural expressions of grief and bereavement

Spiritual and religious beliefs relating to loss, grief and bereavement

Coping strategies

Some of the individual experiences that people have in coping with a loss have to do with

their internal world but what contributes to that internal world? We can put this down to

personality and some of the aspects of the person’s world that have shaped their thinking,

values, behaviours and so forth.

For example one family may not talk about loss or feelings but keep these feelings private

and quiet and prefer to act as if all is normal. Another family shaped by cultural expectations

and modelling will have a more overt response to loss and be extremely expressive in

emotions.

Outward symbols of grief may also be displayed in many different ways, for example by

wearing black or attending to certain rituals. Typically, cultural and religious beliefs have

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developed over time to ‘help’ in the grieving process. Sometimes however an individual’s

needs and unique thoughts and experiences don’t fit the model and they may feel

unsupported by their religion or culture at the most difficult time in their life. People often

re-evaluate their beliefs and values at times of great loss and redefine who they are and

what they want to believe and how they will behave in future.

All people, regardless of heritage, culture or religious beliefs, have in common the ability to

choose how to express grief. We can choose to think about loss in a positive way and hope

to have adequate support and self-care through the process. As counsellors we need to look

for these features and check that individuals have these supports in place whatever culture,

religion, community or family surrounds them.

1.4 Recognise the elevated risk of developing negative impacts on health and wellbeing

after a loss

There is an elevated risk to health and wellbeing after a loss. Without expression and

resolution and without support for a loss the individual may be traumatised, may not adjust

to the loss and/or may have negative thinking leading to poor mental health. They may also

adopt unhelpful behaviours as discussed above, limiting their healthy integration of the loss.

Grief that is not supported or treated may well provide the start of a more serious mental

illness. Grief is not recognised as a mental illness although depression is very much part of a

normal grief experience and depression is identified as a mental illness. Sometimes it is a

fine line. We have to consider that people need time to recover from loss and that feeling

down is part of that. The fact is that if someone stays depressed for too long, six months or

more, and displays other symptoms such as loss or increase of appetite, weight gain or loss,

lack of desire for sex, lack of desire for socialisation, low self-worth, suicidal thoughts,

heaviness in the chest, legs or body etc. then they would certainly be diagnosed as having a

Major Depressive Episode. The shock of severe losses as well can impact the nervous

system resulting in panic attacks and nervousness. The diagnosis of this may be Generalised

Anxiety Disorder or Panic Disorder if it is persistent. Too much stress for too long can

mean that someone can develop Post Traumatic Stress Disorder.

1.5 Recognise and understand disenfranchised grief

We have looked at the concept of disenfranchised grief above. This is when a loss cannot be

shared publically and the grief is unexpressed because of stigma or shame. It is important

that we recognise how disenfranchised grief works in our counselling practice. To do this we

need to understand typical situations where our society may attribute blame in experiencing

a loss.

For example if someone chooses a path but then grieves as a result of the change that has

occurred the person may feel inclined to hide their pain, believing they may be judged or

judge themselves for the action. To show the grief is to make themselves vulnerable to

others. Examples include abortion, breaking up with a husband or wife, adopting out a child,

quitting a job, moving away from family voluntarily etc.

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We need to comfort individuals about the fact that the grief is real despite our sense of a

decision being right or wrong. This is because change requires adjustment and longing for

the familiar, or for something that has worth even symbolically, and it can be a bitter pill to

swallow. Whether the outcome of the change is seen as ‘good’ or ‘bad’ doesn’t negate the

grief experience.

1.6 Identify and demonstrate understanding and respect for specific approaches and

responses of individuals, families and communities to grief

The ways in which people negotiate their losses and go through their grieving will be

extremely different. Our job as counsellors is to show respect and to grow in our

understanding through observation, gentle questioning and testing strategies that bring

relief to individuals, families and communities.

1.7 Demonstrate understanding of integration of loss

Loss is a normal part of life and needs to be integrated into our thinking and our lives. We

need to understand that losses are normal (as is failure) and that none of us, no matter how

clever or avoidant, will be able to live without experiencing a loss. We need to normalise loss

for our clients.

Self-blame for loss is quite common. It is always important to explain to clients that blame

and refusal to forgive yourself or others will not help. Typically the thinking behind this is

that people ‘should be good, and if possible perfect’. We need to observe individuals and

families and support them in positive ways of managing the grief experience and encourage

helpful thought processes.

Dealing with a loss caused by another person can be incredibly hurtful. We can explain to

clients confronting this scenario that the people responsible have had experiences which

have caused them to act in the way they have. To understand this is better than holding

onto a grudge. To forgive themselves as an imperfect human being who is on a learning

curve is also better than to sit in guilt.

2. Engage empathically with people who are living with loss

2.1 Interact with individuals with empathy, sensitivity, professionalism and courtesy

This may include:

Empathic listening

Identifying and affirming the grieving person's strengths and opportunities

Helping manage overwhelming feelings to facilitate coping

Using questions and concreteness to focus on identifying immediate needs and

concerns

Facilitating informed choices by the grieving person

Unconditional positive regard for the grieving person

Non-judgemental approach

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Genuineness of response

2.2 Identify and respect social, cultural, ethnic and spiritual differences which may affect

grief and bereavement responses

Again, while we may recognise the different ways that people grieve and their various

bereavement responses, to respect these can be incredibly difficult. It is all too easy to

judge, especially around emotionally charged issues and situations. We need to practise

what we preach and this is not always easy.

It may be that you see a woman dressed all in black for a year and you feel that this is not

helping her. It may be that you believe that it is better to speak about the deceased but the

person won’t. You may worry that someone may be repressing their feelings and will suffer

later because their faith expects them to be cheery about the death of their loved one who

is now ‘in heaven’. Respecting other people’s beliefs will assist us to help other people. The

tools to help can be found through understanding the individual’s own culture.

2.3 Apply, within culturally appropriate boundaries, verbal and non-verbal approaches to

dealing with and responding to grieving individuals

Appropriate verbal and non-verbal approaches may include:

Verbal approaches that support empathy, sensitivity, professionalism and courtesy

Facial expressions, gestures, eye contact and personal space that support empathy,

sensitivity, professionalism and courtesy

2.4 Apply, within culturally appropriate boundaries, empathic listening skills

Empathic listening skills may include:

Appropriate brief encouragers which help the grieving person relate their story and

concerns

Reflection of feelings/thoughts, behaviours and experience (content)

Hearing the grieving person’s concerns

Paraphrasing (reflection of content)

Using open and closed questions to expand or clarify understanding

Understanding the grieving person's context

Recognising when higher levels of care may be indicated

Balancing the frequency of questions

Summarising and closure

Application of listening skills within culturally-appropriate boundaries

3. Provide support for individuals who are grieving and identify

potential for healing and growth

3.1 Recognise common reactions to loss and the range of grief responses

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As mentioned above our capacity to recognise common reactions to loss and the whole

range of grief responses will be the first step in assisting people. Dealing with young people

facing grief poses additional problems however.

In teenagers grief responses may be more difficult to detect. Even under normal

circumstances adults have difficulty interpreting teenage behaviour. Young people who are

grieving may become involved in drug taking and other risky behaviour. They may oscillate

between withdrawal and excessive socialisation and in extreme situations contemplate

suicide. Being aware of teenagers’ verbal and written expression, their music choices and

unusual behaviours is important, especially after experiencing a loss. It is useful to enlist the

support of peers after a significant loss for a young person to watch them and report any

disturbing behaviours.

Grieving children may oscillate between normal play and distraction behaviours and

feelings of helplessness and sadness. Like adults this movement between grieving and

avoidance of grieving is important for the adjustment process. Assisting younger children to

express their feelings can bring security and relief to the child. This can be done through

drawing and play (for instance with sand tray therapy) and helping them to normalise what

is happening through bibliotherapy (the reading of books for therapeutic purpose). Ensuring

that children do not take on blame for a loss event is also critical. Children are ego-centric

and tend to believe that bad things that happen around them must be linked to their own

behaviour.

3.2 Recognise common reactions to trauma and the range of responses

Trauma responses should also be recognised. Nightmares which don’t stop, flash backs,

hyper vigilance, significant startle responses, inability to manage emotional responses etc.

may indicate that the person has been traumatised by the loss. In these cases it is

important to refer to an experienced psychologist.

The reactions to a traumatic loss can be substantially different to a loss which is anticipated

or expected, for example the sudden loss of a child in a car accident compared to the death

of an elderly parent who has been ill for some time. This does not mean that an anticipated

loss is not traumatic however. Loss experiences are individual and trauma may be

experienced in some seemingly innocuous situations.

3.3 Identify individuals experiencing difficulty in coping with grief and trauma and link

them with options for further help as needed

Difficulty in coping with grief and trauma may include:

Symptoms of separation distress

Symptoms of traumatic distress/stress

Complex grieving

Suicidal ideation

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In dealing with all of these situations the counsellor will need to assess whether these

difficulties mean that the client needs referral to other specialist services for additional

support or treatment.

3.4 Demonstrate understanding of the role of complex grief reactions

We have looked at the features of complex grief in previous sections. When grief doesn’t

end or doesn’t begin or won’t move beyond a certain stage there are reasons for this.

Typically a halting of the grief process has to do with protection of the client’s psyche from

what it fears is ‘worse’ emotional pain. It is important to refer clients experiencing complex

grief for specialist treatment.

3.5 Identify and assess an individual’s suicide risk and where necessary refer to

appropriate services

Suicide risk can be assessed by observation of body language and by listening to the client’s

expression (either in writing or verbally) for signs which indicate loss of connection or

meaning or overwhelming emotional pain. When the client has the means of harm at their

disposal and no one to watch them the potential risk is magnified. If a client has had

thoughts of overdosing, for example, and they have access to tablets and live alone, a

suicide attempt is a very real possibility if they have been thinking about the

meaninglessness of life, the pain of life, or their own worthlessness etc.

Again, referral for appropriate specialist treatment is essential in such cases.

3.6 Use, within culturally appropriate boundaries, communication techniques to respond

to each individual’s needs in relation to their grief and bereavement

As mentioned above the client’s own culture will give us clues in responding to their needs.

If we ask people what they have found helpful or what they need directly this can provide

some useful guidance.

The need to tailor communication techniques to suit the client applies as in any counselling

scenario. The skill of the counsellor is in being able to assess what techniques will be

appropriate for each individual.

3.7 Identify, suggest or use strategies for formal and informal grief and bereavement

support

Grief and bereavement support strategies and grief and bereavement care services may

include:

Aboriginal health services

Coronial services

Emergency services

Empathic listening

General practitioners

Group grief counselling

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Health services

Individual grief counselling

Palliative care services and teams

Practical support

Psychological services

Spiritual and faith care services

Support group

Telephone counselling services

3.8 Maintain confidentiality in line with organisation practices

Confidentiality provides clients with the sense that they have a space of safety and trust.

However if you sense that a client is suicidal or may do something illegal which will hurt

other people you may need to call the police if you are not able to satisfy yourself that they

are completely safe.

4. Identify, inform and refer to appropriate grief and bereavement

care services and resources

4.1 Identify grief and bereavement care services available in the community

Some general support services were listed above. The type of specific support services

available will depend on the community. In larger cities specialists of all descriptions are

available, including for grief support. Sometimes there can be problems in accessing these

services as they may be at a great distance from the client. Finding these services can also

be a challenge with a number of organisations vying for attention through advertising.

Internet searching can refine this task considerably. We typically think that a smaller

community has limited services for grief support, however on the other hand it may be

easier to review each of the possibilities more quickly.

Lifeline telephone counselling is a nationwide service which is particularly useful for grieving

people as they can access it at all times of the night or day and talk to someone

confidentially who is trained to identify suicidal ideation and can also provide ideas on

further bereavement support within the client’s area.

4.2 Identify referral procedures in accordance with organisation policies and procedures

Referral procedures may include:

Referral information

Referral databases

Referral protocols

4.3 Identify and make accessible general grief and bereavement care information

resources

Grief and bereavement care information resources may include:

Internet resources

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Fact sheets

Information packs

Books

4.4 Fully inform individual about grief and bereavement care service options

In supporting your client it is important to consider what kinds of supports they may prefer.

Some people find reading particularly helpful as they don’t want to go out of their homes

more than necessary. Other people are more inclined to connect with an ‘expert’ to assist

them. Still others may appreciate a help group like ‘Seasons for Growth’ where they can

meet with others who have experienced a loss and form a support network. Find out from

your client what they would prefer.

4.5 Obtain feedback from individual to determine whether options are clearly understood

Don’t forget that a grieving person may have a limited capacity to remember information

and digest it. Ensure you find out that they clearly understand their options by asking for

feedback. You might also provide information on a hand out.

5. Identify and recognise risks associated with grief and

bereavement support Risks associated with grief and bereavement support may include:

Compassion fatigue

Vicarious traumatisation

Burnout

Lack of adequate supervision

Lack of access to external expertise

Grief is a very sad area to work in for the counsellor. Stories of loss can easily trigger our

own fear of losing a loved one or a valued situation. As counsellors we focus on our capacity

to be empathetic but this can also be our own undoing. It is extremely important to have

good supervision and have a place to ‘empty’ our own sadness in hearing a great number of

loss stories. We may be especially vulnerable if the story has some connections to our own

life experience. For example we may have a sick mother and a client’s mother has just died

of cancer. Their painful story may make it difficult for us to adequately support them as our

mind is focused on our own situation. In these cases it may be important to refer the client

to someone else. The way you do this must be gentle and caring and should provide the

client with ‘reasons’ so that they do not feel abandoned.

5.1 Identify and recognise a range of risks associated with grief and bereavement

support

As a mental health professional it will be important that you don’t take this role in

bereavement support lightly. Keep regular supervision in place and reflect regularly on your

own wellbeing and capacity rather than continuing regardless and ignoring your own self-

care.

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5.2 Develop and implement appropriate strategies to minimise risks associated with grief

and bereavement support

Strategies to minimise risks associated with grief and bereavement support may include:

Self-care

Supervision

Debriefing

Back-up support

External networks and expertise

6. Access appropriate supervision and debriefing

6.1, 6.2 Identify the need to access appropriate supervision and debriefing

This may include:

Duty of care to clients

Self-care

As noted above, there are many risks associated with grief and bereavement support work.

Counsellors need to be self-aware in identifying the need for supervision support and

debriefing, as discussed below.

6.3 Develop and implement appropriate strategies to access supervision and debriefing

Various agencies have different rulings around supervision and debriefing and some do not

have anything in place at all. Whatever supervision practices your organisation follows,

when it comes to support you need to initiate this when you need it. New counsellors may

feel awkward about initiating supervision and debriefing outside of ‘regular’ times, however

it is very important that this occurs on a needs basis.

7. Review and evaluate grief and bereavement support provided

7.1 Reflect on outcomes during and after support is provided

It is important to consider how effective your support has been to the client. Ways to do this

include a feedback form, observation of your client’s progress and direct verbal feedback.

One great way to identify value is through use of a ‘scale’, as written or verbal responses

can be hard to evaluate objectively. You might ask the client whether they could rate how

helpful the counselling has been on a scale of 1-10 where 10 has been ‘incredibly helpful’

and 1 ‘not helpful at all’. It is important that you don’t take this feedback personally. Grief is

not an issue which is ‘over’ in one session but takes its own time.

You can also find out from the client what things help them the most and encourage them

to do more of that. We always hope that our help is incredibly useful. However some

grieving clients might find that nothing much can take away the pain and sadness of loss,

especially very early on in the process. If this is the case keep contact with the client as they

will need continued support.

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7.2 Identify where further support is required

You may encourage other supports concurrently with your counselling sessions or refer to a

specialist psychologist or grief counsellor or other service provider afterwards if the need still

exists.

7.3 Review practices for continuous improvement

As with any therapeutic intervention it is important to constantly review counselling practices

to see where there is room for improvement. None of us can hope to be immediately

effective in all counselling sessions with clients but we can grow in our capacity. It is usually

our own clients that teach us the most.

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READINGS & RESEARCH Review readings on the online student portal on the following under Learning Resources:

Stress Vulnerability Model (Article on Grief and Loss)

Loss, Grief and Bereavement - Coping With Loss

The Coronial Process

Grief Recovery Checklist

REFERENCES Kubler-Ross, E. 1969, On Death and Dying, Simon & Schuster/Touchstone

Marriage and Family Encyclopedia, available at <family.jrank.org>, accessed April 2013

Stroebe M. and Schut H. 1999, ‘The Dual Process Model of Coping with Bereavement:

Rationale and Description’) in Death Studies, Vol 23(3), April-May

Worden, JW. 1982, Grief Counselling and Grief Therapy, Springer Publishing Co., New York

Zubin and Spring. 1977, The Stress Vulnerability Model,

http://www.hearingvoices.org.uk/info_professionals_stress.htm, accessed April 2013

WEBSITES The following websites provide support material for grief and loss.

National Association for Loss and Grief (NSW) www.nalag.org.au

Australian Centre for Grief and Bereavement www.grief.org.au

Australian Child and Adolescent Trauma, Loss

and Grief Network

www.earlytraumagrief.anu.edu.au

National Association of Loss and Grief

(Victoria)

www.nalagvic.org.au

Compassionate Friends www.compassionatefriendsvictoria.

org.au

SIDS and KIDS www.sidsandkids.org

Lifeline www.lifeline.org.au

Email to heaven emailtoheaven.org/