Working with grief

Grief is the response we get to any kind of loss. Although it is often linked strongly with bereavement, there are a number of different griefs that you might need to help clients come to terms with.

These might include feelings triggered by changes in relationships, life-style or identity beliefs, or the client's environment. Let's look at each of these in a bit more detail.

• Relationship losses are those following a miscarriage or termination, the ending of a marriage or other relationship, and the loss of friendships or social support following changes in lifestyle. Bereavement would also be a relationship loss, whether the death has already occurred, or is something the client is anticipating.
• Life Cycle or Personal Identity losses happen around changes such as ageing, health issues such as severe or long-term illness, or an inability to conceive, 'empty-nest syndrome', job loss, career change or retirement, the realisation that a cherished dream will never come true, family changes
• Environmental losses occur when geographically relocating, after experiencing natural or man-made disasters, or even losing a treasured object, belonging or opportunity

Despite this, most of the better-known studies that have been carried out on loss do seem to focus on how we deal with death.

The Grief Curve

Psychiatrist Elisabeth Kübler-Ross was interested in the ways that hospitals dealt with terminally ill patients, and published a book in 1969 (On Death and Dying) in which she suggested that there were five stages of grief. These are:

1. denial - a refusal to accept the truth, used as a defence mechanism
2. anger – which comes along with the realisation that denial isn't realistic, the anger can be directed at themselves or others, or at the general 'unfairness' of the situation
3. bargaining - an attempt to reshape the situation to postpone or mitigate the grief, so at the end of a relationship someone might say 'can we still be friends?' or, if faced with a terminal illness, they might offer reformed behaviour to their deity in return for more time
4. depression - a period of sadness, regret, fear, and uncertainty as the person accepts the reality of the situation, and perhaps begins to disconnect emotionally from it
5. acceptance - a final coming to terms with the situation

This is often shown as a line graph (hence the name ‘The Grief Curve’).

However, although Kübler-Ross suggest that most people experienced most of the stages, she also said they did not occur in a defined sequence, so this might be a more useful representation.

As we mentioned above, Kübler-Ross was talking about individuals who are terminally ill, but the model has been generalised and used in all kinds of situations including business change analysis and staff management.  Used in this way, it’s generally represented as a graph, and called the ‘Change Curve’.
  

Therapists who use the Kübler-Ross Model of grief sometimes suggest that problems arise when people become 'stuck' in one stage or the other - this has been called complicated grief. Unfortunately, as each person works through their issues differently and needs different lengths of time in order to do so, it can sometimes be hard to define when this has happened.
  

The Kübler-Ross model is still widely used today but not everyone accepts the basic concept of progressing through ‘stages’ of grief. A study conducted at Yale University from 2000 -2003, for example, found that although some people seem to follow through the stages, others do not.
  

Alternatives to the Grief Curve

George Bonanno of Columbia University studied people grieving in a variety of extreme stress situations such as war, terrorism, terminal illness, death and abuse and concluded that most have a natural resilience which helps them cope. Not everyone who goes through one of these experiences develops long-term problems.

There also seem to be differences related to culture and the cause of the grief. For example, many pet owners find it difficult to mourn properly over the loss of a dog or cat, because their feelings are not taken seriously by others. (If you have a client with this specific grief, try referring them to the Rainbow Bridge website where there are plenty of resources, support and helpful ideas, including a world-wide pet-loss candle ceremony.)
  

Berger[1] looked at how people came to terms with loss and he identified five main coping strategies.

These are:

• Nomads, who have not yet resolved their grief and don’t often understand how their loss has affected their lives
• Memorialists, who are committed to preserving the memory of their loved ones by creating concrete memorials and rituals to honour them
• Normalizers, who are committed to re-creating a sense of family and community
• Activists, who focus on helping other people who are dealing with the same disease or issues that caused their loved one’s death
• Seekers, who adopt religious, philosophical, or spiritual beliefs to create meaning in their lives

Again, most of Berger's initial work was done with one limited group - the recently bereaved - but just like Kübler-Ross's model, it has been generalised into other situations of grief, mourning and loss.

The two approaches are not mutually exclusive. One could suggest that Berger's strategies outline the ways in which people reach acceptance within the Kübler-Ross model, for example. We suggest you bear them both in mind as a theoretical grounding, take from them whatever seems useful to your client and set aside the rest. As always listening to your specific client and responding to their individual needs is the most important thing you can do.

Working with grieving clients

Remember that grief may not be your client’s presenting issue. For example, someone grieving following a relationship break-up may use words like 'obsessed' or 'unable to let go' or may present with another problem such as 'loss of confidence'. I had a client whose public speaking phobia was a result of losing her Dad in traumatic circumstances many years before, who had simply not connected the two things in her conscious mind. It’s up to you to listen for what is being said, and left unsaid, and (as always) work with what the client gives you.
  

Clients may ask you to 'make them forget' which, even if possible or ethical, would not be a healthy resolution. However, there are things you can do to help. 

To begin with, offer relaxation and an uncritical forum in which to express any emotions the person does not feel it’s safe or appropriate to express elsewhere. In general terms, you can also allow them to

• Face their actual emotions, rather than trying to experience what they (or others) think they should be feeling
• Express their feelings in a tangible or creative way (e.g. keeping a journal, using the empty chair or inner advisor technique for unresolved issues) 
• Work with parts, to explore if the grief is serving a positive purpose, and whether the client is ready to release all or some of it
• Consider Berger's coping strategies outlined above to see if one of them might help (e.g. creating a memorial of some kind)
• Have realistic expectations of themselves
• Look after their physical health, especially including elements of stress management and being aware of increased dependency on tobacco or alcohol.
• Plan ahead to cope with grief 'triggers' like anniversaries, holidays, and milestones
• If there has been trauma with the loss (e.g. death in an accident, an emotional or public break-up scene) consider using the rewind, swish or other desensitising techniques on the bad times, whilst reconnecting the client to the good times
• Reframing may be appropriate in some circumstances e.g. at the end of a relationship helping the client to see that they are mourning what they hoped the relationship was going to be rather than what it actually was. 
• Some clients may also need help with getting in touch with positive feelings like self-esteem or confidence, though you should never 'jolly' them through the grief process which can be insensitive or dismissive of their feelings. 

As in all areas, how the client wants to feel and what their solutions are should come from them and not you.

You can encourage the client to find support (family and friends, support group) and at every stage consider whether it’s necessary to refer them on to a specialist grief/relationship counsellor or GP.

Reference: 
[1] Berger, S. A. (2009). The Five Ways We Grieve: Finding Your Personal Path to Healing After the Loss of a Loved One. Boston : Shambhala Publications, Inc
[2] Grief curve image from U3173699 [CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)]


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Author: Debbie Waller is an experienced hypnotherapist and hypnotherapy trainer. She is the author of Their Worlds, Your Words and has co-written the Hypnotherapy Handbook, both of which are available from Amazon.
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