Discuss the psychological and physical effects of loss and grief: How might an ethical therapist incorporate this knowledge into his/her work? Base your answer of the theories and models presented in Module 7. It is a fact of life that every individual will experience loss and grief at some point in their lives but in certain circumstances they may be unaware of it. Loss can come in many disguises from the easily recognisable bereavement, to redundancy, children leaving home, divorce, relocation, disfigurement, chronic illness, miscarriage, loss of a close pet, abortion and others. When a client presents for Counselling, it is vital to be alert for losses, both recent and historical, to check if there are unresolved issues because grief can be easily missed or misinterpreted.
Chrysalis (2012) states that there are two ways in which a therapist will encounter the need to work with loss and grief. These are: 1) When a client presents with a recent loss and their goal is to work through the process and understand it, reaching a satisfactory conclusion. 2) When a client presents with other symptoms which you then uncover as being a grief reaction. In this case the person may not recognise that their problems are related to grief or unresolved grief in the past. For the purposes of this assignment, loss and grief will be focus primarily on bereavement.
Worden (2009) states “that the overall goal of grief counselling is to help the survivor adapt to the loss of a loved one and adapt to a new reality without him or her”. He goes on to explain that there must be four adjustments: increasing the reality of the loss, dealing with behavioural pain, and helping the client maintain a bond with the deceased while being comfortable with the new reality. I will now examine the psychological and physical aspects of grief and how a therapist may use grief models and theories in the therapy room and take into consideration social and ethical factors.
The Physical and Psychological effects of Grief.
Before exploring the theories and models of grief, it is important to be aware of the psychological and physical issues which accompany the grieving process. It is possible indeed common that a client may present for Counselling on an unrelated issue and on closer examination by the therapist; it becomes apparent that the client is in the grief process, and is in fact stuck at a certain stage in this process, or has failed to grieve in the past. There are feelings, cognitive processes, behaviours and physical symptoms which manifest not only in grief but in other psychological issues. It is the job of the Counsellor to make the link between the presenting issue with the unresolved past grief and loss. Many people will assume that the over-riding feeling associated with grief is sadness and if sadness is not being experienced then the issue is not grief. This is most definitely not the case. There is often a ray of emotions that individuals experience, such as anger, frustration, sometimes and a sense of relief.
This is not uncommon after the deceased has been ill for months or years or if there was a difficult relationship between the deceased and the client. There are several stages to the grief process and each of these stages has distinct range of emotions and feelings. Common feelings surrounding grief are shock, numbness, denial, fear, sense of abandonment, anxiety, anger, guilt, loneliness, pining, relief, tiredness and freedom. The same is true for cognitive processes and behaviours which can be frightening and confusing to the client. They include obsessive thoughts, hallucinations or visions of the deceased, denial that the deceased has died or even sensing that the deceased is in the room with the client.
Behaviours can be disturbed sleep, loss or a gain in appetite, forgetfulness, or lack of interest in life, withdrawal from the client’s normal network of friends and family, crying, avoidance, restlessness, a idealisation of the deceased and the treasuring of the deceased objects. The bereaved can also experience a range of physical symptoms which can be disturbing and frightening and may exacerbate any feelings of anxiety being experienced by the client. These can include tightness in the chest, hollowness in the stomach, sensitivity to noise, shortness of breath, increased sighting or yawning, feelings that they are going to collapse, a sense of disconnectedness from others and the external world.
In such cases, it is important as a Counsellor that the client is encourage to visit their G.P. if theIR symptoms become serious or a cause for concern. Sometimes clients need reassurance that their symptoms are normal reactions to the grieving process and that the physical symptoms will pass in time. The physical symptoms of grief can mimic depression but there is a difference. Freud believed that in grief the world looks poor and empty to the client, where’s in depression the person feels poor and empty themselves.
The Theories and Models used in Therapy.
These have been numerous theories and models proposed by psychologists over the years, these include works by Bowlby, Worden, Murray Parkes and Kubler Ross among others. Bowlby (1907 to 1990) believed that in psychoanalysis the therapist is too interested in fantasy and not sufficiently interested in the present environment and events of the client’s current life. Bowlby tried to understand the human tendency to attach to others. He went on to study the reaction of infants when they are separated from their mother and what occurs when this bond is threatened or broken, (he went on in the 1950’s he published his Attachment Theory). His ideas on separation response could be said to be the underpinning theory of bereavement. Chryslais (2012) explains the three stages of separation response:
1) Protest (related to separation anxiety)
2) Despair (relating to grief and mourning)
3) Detachment or denial (related to defence).
The models and theories used by psychologists present grief as a curve and that the grieving process (sometimes expressed as phrases or stages) must be worked through. Worden explains that he chooses to use the word “tasks” because he finds it more useful for the clinician; phrases or stages imply certain passivity, something that the mourner must pass through. The tasks concept on the other hand, can give the mourner a sense of leverage and hope that there is something that he or she can actively do to adapt to the death of a loved one. As there are a lot of similarities between the theories on grief, I will focus on Worden’s tasks of mourning. He describes four tasks through which the bereaved must work through:
1) To accept the reality of the loss (that the deceased will not return). 2) To process the pain of grief, the pain associated with the grief must be worked through. If there is avoidance or suppression then this will be carried through life to surface at a later date. 3) To adjust to a world without the deceased. This will differ from client to client depending on the type of loss and what the deceased provided for the bereaved. Parkes (1972), explains, it is seldom clear exactly what is lost. A loss of partner may or may not mean the loss of a sexual partner, companion, accountant, gardener, someone to help with the children; this will obviously depend on the particular roles normally performed by their deceased partner. There are also the financial consequences of losing a partner which can cause a lot of worry and anxiety for the client which also create further change in the client’s lifestyle.
4) To find an enduring connection with the deceased in the midst of embarking on a new life, the Counsellors role is not to help the bereaved give up their relationship with the deceased but to help them find an appropriate place for the person they have lost in their emotional lives, a place that will enable them to go on living effectively in the world. I have discussed already that some people who present for therapy may be unaware that they are experiencing a grief reaction at all. Others, who have suffered a recent loss may not understand the grief process, particularly if this is the first time grief has been experienced. It is appropriate to ask the client this during the therapy, to determine how grief will be handled and whether there is previous grief that is unresolved, which could signify “complex grief” as being a problem. To help the client understand the grieving process, the grief curve is a visual tool which can be employed in the therapy room and given to the client to take home with them.
The therapist can ask the client if explaining to them about the grieving process would be useful. The curve plots the emotions over the time which the client can expect to experience following bereavement and confirms to the client that the feelings and reactions they are experiencing are entirely normal. The disadvantage of actually showing the client an illustration of the grief curve is that the client may start to put pressure on themselves where they feel they ‘should be at this stage of the grieving process! The curve begins at the time the loss was first experienced and then continues until the point of resolution. That is to say, when Worden’s fourth task has been completed and the mourner is able to reminisce and remember the deceased while forging a new life for themselves. This process does not have a time limit, Chrysalis (2012), explains that the time it takes for a person to complete the process will depend on the situation, the client’s previous experience of grief and the environment they are living in.
Worden (2009) states in order to understand how somebody is going to grieve, you need to know if he or she has had previous losses and the circumstances they were grieved. Did they grieve adequately or does the individual bring to the new loss a lack of resolution from a previous loss! The grieving process is not linear and the client is likely to move forwards and backwards through the emotions depicted on the loss curve. This can be very confusing and frustrating for the client, who may believe that they beginning to move forward only to take a backward step. This can be explained to the client as a perfectly normal and expected part of the grieving process and although it may seem frustrating and challenging at times, the overall motion is one towards resolution, even if it is two steps forward and one step back.
As previously mentioned the grief curve plots the emotions the client is likely to experience during the process. It can be very useful to ask the name of the emotion that they are feeling in order to bring it to the client’s full awareness. Worden’s first task of mourning is to actualise the loss because the process cannot start without full realisation and confrontation of this fact. He states, the first task is to come to a more complete awareness that the loss actually occurred and the person is dead and will not return. Survivors must accept this reality before they can deal with the emotional impact of the loss. He goes on to say on occasions the Counsellor needs to use language that reminds the client that the deceased has died. This language can help clients with reality issues surrounding the loss and stimulate some of the painful feelings that need to be felt.
As can be observed in Appendix 1, the emotions on the curve begin with shock. According to Chrysalis (2012) shock is an emotional defence mechanism which allows the situation to dip slowly into the bereaved awareness in order to protect them from emotional overload. It is a very difficult time and in reality it is not until this stage is over that people usually present for Counselling, unless they have become stuck here. The second stage is separation and pain, during which time there will be periods of very deep darkness and periods of easier times. The client may report dreams and hallucinations of the deceased and exhibit searching behaviours.
The next stage is despair, during which the client, may experience many feelings and emotions to understand. It can be accompanied by depression and lack of concentration or inability to focus on everyday tasks. People in this despair stage may feel unable to function and may say things like “I can see no way ahead and no way out of this”. Acceptance comes next on the curve and is the beginning of the upward slope towards resolution. Chrysalis (2012) explains that it is important to note that the client will often reach intellectual acceptance before emotional acceptance and can experience mood swings and depressions associated with despair at times. At this point, the client may feel able to begin to adjust to a new life, but may feel guilty and need reassurance and permission from the Counsellor.
The final stage is resolution during which time the client will be able to make plans for the future and has found a place for the deceased to be remembered with happiness. The above is a representation of a normal grief process (although it is widely accepted that there is no norm), but there can be obstacles which can complicate the process and this is known as Complex Grief. Clients may have unresolved issues from their past which may be affecting the grieving process or stopping it altogether. This is why the therapist must check for unresolved grief in the past. According to Chrysalis (2012) the factors which should be taken into account are: 1) The nature of the attachment (is there an ambivalent attachment or conflict with the deceased). 2) Method of death (including socially unacceptable deaths such as suicide, violent deaths, missing persons and in other dramatic circumstances). 3) Historical unresolved grief.
4) Personality, how easily does the client assimilate change! 5) Social variables, how is grief handled in the client’s culture or faith! 6) Concurrent stresses (is the bereavement around the same time as other major life stresses such as relationship breakdown, loss of work, a close relative has a chronic ill and the client is the main carer giver, moving house). 7) What support system (friends and family) does the bereaved have!
There are four types of complex grief these are:
1) Chronic grief, where the client is unable to find resolution 2) Delayed grief, the client has unresolved grief from the past and a present loss triggers the grieving process. 3) Exaggerated grief, the client may use maladaptive behaviours such as drugs and alcohol, suffer general chronic anxiety, clinical depression. If a client is struggling to cope with difficult emotions then they may find outlets to help them manage. 4) Masked grief, the client does not link the symptoms to the grieving process. This is why the Counsellor must check when working with a client that their presenting issue is not masking unresolved grief. Ethical Factors
It is widely accepted that a Person Centred Counselling approach is required when working with grief. The process cannot be hurried and each person will take their own time to work through the curve. All that may be necessary is the holding of the client and allowing them to work through the process. This means allowing the client to take their own time, to create a safe space for the client to explore their emotions, to reassure the client that what they are feeling is “normal” and to be a non-judgemental listener.
Inventions however, must be carefully planned and only used towards the end of the grieving process when the client is nearing resolution and has the strength to take them on board. It is important to recognise that clients may display displacement activities or using defence mechanisms. In a normal therapeutic session this behaviour would often be challenged but in this instance it is often advisable to continue to support the client without challenging their behaviour, as the client may not have the reserve or strength to confront them at the current time.
Grief and loss is something that will be experienced by everyone at some point in their lives. Counsellors and psychologists generally agree that grief is a process and generally follows a curve. It can take approximately two years to work through (for someone close to the client) but obviously varies for each individual and this does not include complex grief. A variety of emotions will be experienced by the bereaved. The curve is organic, meaning that the bereaved is likely to move forwards and backwards through these until resolution is reached.
The way grief is handled depends on a variety of factors unique to the individual. Grief can be “normal” or described as “complex”. Factors associated with complex grief I have mentioned previously in this assignment, such as the circumstances of the deceased’s death, the importance of the relationship between the deceased and the client, the depth of the attachment between the two, how stressed was the client prior to this loss! Another important factor does the bereaved have the opportunity to express their grief or do they feel pressured to supress their emotions. An example of this, would be a mother who has lost their partner and has dependent children and feels that in order to appear strong, that she must soldier on without the opportunity to express her own emotions around the loss.
There are four types of complex grief, chronic, delayed, exaggerated and masked, the therapist must use their skills to determine whether the client who presents for an unrelated issue actually has an unresolved grief issue in their past. Tools can be used in the therapy room to aid the process. These could include asking the client to draw their own grief curve or ask them to write to the deceased. A person centred approach is necessary to give the client space and time to process the loss in safety. Interventions can be kept to minimum unless near resolution and the client has progressed along the grief curve and has the strength to handle them.