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Module 6 grief and loss learning resource 30.4.13

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Module 6 grief and loss learning resource 30.4.13

  1. 1. Grief and LossCHC51712 Diploma of CounsellingModule 6
  2. 2. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2ContentsOverview...................................................................................................................... 3Unit Description......................................................................................................... 3Learning Outcomes (Essential Skills)............................................................................ 3Content Areas (Essential Knowledge) .......................................................................... 3Module Duration and Workload................................................................................... 4Required underpinning knowledge for this module........................................................... 5What is grief?......................................................................................................... 6Elisabeth Kubler-Ross (Stages Theory) 1969............................................................. 9J. William Worden (Task Theory) 1982....................................................................10Margaret Stroebe and Henk Schut (Dual Process Model) 1999...................................11Steps in providing support and care relating to loss and grief...........................................211. Identify effects and impact of loss and features of grief ...........................................212. Engage empathically with people who are living with loss.........................................303. Provide support for individuals who are grieving and identify potential for healing andgrowth.....................................................................................................................314. Identify, inform and refer to appropriate grief and bereavement care services andresources.................................................................................................................345. Identify and recognise risks associated with grief and bereavement support ..............356. Access appropriate supervision and debriefing.........................................................367. Review and evaluate grief and bereavement support provided..................................36READINGS & RESEARCH...............................................................................................38REFERENCES...............................................................................................................38WEBSITES...................................................................................................................38
  3. 3. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3MODULE 6 Grief and LossThe unit of competency in this Module is:CHCCS426B Provide support and care relating to loss and grief.OverviewUnit DescriptionCHCCS426B — This unit describes the knowledge and skills required to provide support forindividuals 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 bereavement2. Respond appropriately to a range of approaches and responses to loss, grief andtrauma3. Engage with individuals experiencing loss, grief trauma and bereavement withempathy, sensitivity, professionalism and courtesy4. Refer individuals who show some signs of mental illness to appropriate services5. Apply verbal and non-verbal approaches to dealing with and responding to grievingindividuals6. Use effective communication skills, including:o empathic listening skillso use appropriate communication techniques to respond to individual needso provide information clearly and sensitivelyo obtain feedback to confirm understanding7. Maintain documentation as required, including effective use of relevant informationtechnology in line with work health and safety (WHS) guidelinesContent Areas (Essential Knowledge)The following areas are the essential knowledge required for this module. These arediscussed 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
  4. 4. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 4o trauma at the individual, family and community levelo 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 emotionalhealth and well being Integration of loss Distinctive social, cultural, ethnic and spiritual differences in loss, grief andbereavement Awareness of the context and circumstances prior to loss and their impact on griefand 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 resourcesModule Duration and WorkloadThis module is 4 months in duration. Learning and assessment should be completed withinthis time frame.
  5. 5. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 5Required underpinning knowledge for this moduleThe study of grief and loss is an important one for a counsellor. Losses occur for us all everyday in small ways. Fortunately, the larger losses that occur are usually more infrequent, asto lose someone close to us means a major readjustment in life. The loss of a child, partneror parent is at the very least incredibly disorientating and at worst can mean that we candespair to the point that our own life seems meaningless and not worth living. When oneperson 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 canrange from job loss, moving locations, losing a home, loss of faith, through to separationand divorce or the loss of friends and family members through death. Fortunately (orunfortunately) we are all, to some extent, experts for we have all experienced losses. Ourcapacity to self-reflect is an important skill in helping others deal with loss as we can identifythe steps and stages that we have gone through on our own grief journeys which areprobably 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 findlevel ground. Suicides, long drawn-out painful illnesses and other traumatic losses canrequire expert attention and the capacity to identify when someone is at risk. It is importantto be able to recognise these risk situations so that we can refer appropriately if someone isnot recovering from a loss.There is a warning with the study of grief and loss. If you have recently lost someoneprecious to you, you could find that this study unit may distress you. It is important to talkfrankly about this with your trainer in order to design strategies to support you through yourstudy of this vital area.The following points cover the required knowledge set out in the competencies for thismodule.Potential impact of specific loss(es) and common features of griefand bereavement at the individual, family and community levelLosing anything is frustrating at the least. You may remember a time when you lost yourwallet or purse. Consider the thoughts, feelings and actions that occurred at the time. If youfound the wallet you would have been relieved and happy as you realised what it wouldhave meant to have to replace your driver’s licence, credit cards, money etc. If you had lostthat 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.
  6. 6. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 6 This is dreadful, it will mean I can’t get on this flight, and my colleague will be angrywith me.Possible feelings of: Agitation Dread Anxiety Anger Frustration Sadness Shock DisbeliefPossible body sensations: Sinking feeling Stomach knot Palpitations Tightness in the chest Shoulder tension Sweaty palms HeadachePossible actions: Frantic searching Going over and over retracing steps Anger outbursts Exclamations Aggression TearsAll this over a wallet or purse!Loss can be disorientating. There is a period where we try very hard to reverse the loss evenif it makes no sense and it is clear that we will never see that thing or person again, that itis 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 theloss and it is not easy.In our counselling work we will encounter many, many people who are in the process ofgrieving. Many of them won’t realise what they are experiencing is grief. However, ascounsellors, 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 theirtoll on us. None of us grieve for a loss in exactly the same way — there are vast individual
  7. 7. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 7differences. There are some commonalities, and we examine three well-known grief theoriesbelow under ‘Reactions to loss and associated expressions of grief and bereavement’.However, the differences can at times tear families and even whole communities apart aseveryone deals differently with such situations. We can tend to be incredibly judgemental ofothers at such times as well. We are not at our best and can consider that others are notshowing appropriate sorrow or sensitivities according to our own standards. This can impactgrieving through lack of support and, even worse, can come at a time when we are quitevulnerable.Families need to be reminded that, when we are all grieving in our own way, we may nothave the capacity to help each other terribly well. This may be the time to get outsidesupport 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 particularlystressful state and they may ‘go down like a pack of cards’ later when everyone else hasrecovered. At that time others may consider that this person is being dramatic or attentionseeking!Counsellors need to be fully aware of the implications of grieving on family relationships andin close-knit communities and understand the power of strong painful emotions that comefrom a loss.Potential impact of specific loss(es) and common features of traumaat the individual, family and community levelLoss 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 producelong-term damage. When this occurs it is called Post Traumatic Stress Disorder orPTSD. Clients may find that they have flashbacks to the traumatic event, nightmares thatpersist, strong startle responses, lack of control over strong emotion, including see-sawingof emotions and depression. In these cases it is important to refer the client on for expertcare, 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 reducedconsiderably as the usual annoyances can be met with extremely strong emotional reactionsand sometimes physical retribution. In addition, traumatised people, particularly those whohave not been treated and don’t realise that they have been traumatised, may turn to drugsor alcohol and other means to relieve their agitation and body distress. Children and othervulnerable people may also be deeply affected simply by living with those who aretraumatised.We can see how incredibly important it is for counsellors and other mental healthprofessionals to be available and fully trained and skilled in working in the area of loss.
  8. 8. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 8Potential impact of specific loss(es) and common features ofcomplex grief at the individual, family and community levelWithout support, individuals, families and communities may experience complex grief, forexample, with multiple losses through suicide. Complex grief may occur for a number ofreasons. These are discussed below.No answersWhen a loss occurs and we can’t find any reasons that make sense we may not be able toresolve that loss and it means that we continuously replay the loss trying to find meaning.Multiple lossesResolving a loss takes time. If we experience another loss before we have recovered fromthe initial loss we are doubly impacted. It takes our psyche some time to believe that theworld is a good place. With multiple losses we can despair of life and conclude that there isno safe place and no good thing in store for us. We may not recover emotionally.DenialAt times the meaning of the loss to us is so painful we do not move out of a denial stagewhere we suspend our emotional suffering by imagining that the loss has not occurred atall.AbuseWhen grievers are not supported but attacked in their grief this can add to the woundmaking 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 theperson ‘changed’ and untrusting forever.No educationMany people do not understand the grief process and can be disturbed by what ishappening to them. This can make them wonder if they are losing their mind or if there issomething ‘wrong’ with them. This can extend the grieving period as they feel lost in theprocess.TraumaTrauma, as we have mentioned above, halts the grieving process through shock. This canstay in the person’s system. It is important for trauma to be treated so that grief processescan move forward.Reactions to loss and associated expressions of grief andbereavementThere are some common features of grief experiences. Some of these have been noted byfamous grief theorists. It is important for counsellors to be fully versed in these concepts asthey can be used to educate clients and help them recognise what is happening for themand provide encouragement that the process will not last forever.
  9. 9. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 9Elisabeth Kubler-Ross (Stages Theory) 1969Elisabeth Kubler-Ross was a Swiss-American psychiatrist and a pioneer in near-deathstudies. She is the author of a ground breaking book On Death and Dying. In this work shefirst discussed her theory of the Five Stages of Grief outlined below. Kubler-Ross firstapplied this theory to those who were dying but later revised this to be applicable to all sortsof loss experiences. She was an advocate for AIDS victims and set up Hospices for thosewho were dying.1. Denial"I feel fine."; "This cant be happening, not to me."Denial is usually only a temporary defence for the individual. This feeling is generallyreplaced with heightened awareness of possessions and individuals that will be left behindafter death. Denial can be conscious or unconscious refusal to accept facts, information, orthe reality of the situation. Denial is a defence mechanism and some people can becomelocked in this stage.2. Anger"Why me? Its 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 ofanger, 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 withothers, and especially those who are close to them. It is important to remain detached andnon-judgmental when dealing with a person experiencing anger from grief.3. Bargaining"Ill 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 areformed lifestyle. Psychologically, the individual is saying, "I understand I will die, but if Icould just do something to buy more time...". People facing other traumatic situations canbargain or seek to negotiate a compromise. For example "Can we still be friends?" whenfacing a break-up. Bargaining rarely provides a sustainable solution, especially if it’s a matterof life or death. Bargaining can also include guilt, including survivor’s guilt.4. Depression"Im so sad, why bother with anything?"; "Im going to die soon so whats the point?"; "Imiss 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 thetime crying and grieving. This process allows the dying person to disconnect from love andaffection. It is not recommended to attempt to cheer up an individual who is in this stage. Itis an important time for grieving that must be processed. Depression could be referred to as
  10. 10. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 0the 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"Its going to be okay."; "I cant 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 lovedone, or other tragic event. This stage varies according to the person’s situation. Peopledying can enter this stage a long time before the people they leave behind, who must passthrough their own individual stages of dealing with the grief.The ButterflyAn 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 orchrysalis and finally transforms itself into a butterfly. The butterfly then lays eggs and so thecycle continues. The main feature of this analogy is that, in life, change occurs and at timesin that change we are in a dark place transforming ourselves, but we can emerge as abutterfly 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 changeprocess that takes us through a dark place but that at the end there is light and hope.J. William Worden (Task Theory) 1982Worden, an American psychologist known for his work in Gestalt Therapy, developed a newtheory to explain the process of grieving. This was applied first to those who had suffered aloss 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 isframed with ‘tasks’ to complete in order to successfully manage a loss.Task 1: To accept the reality of the lossTask 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 anew life (to reinvest emotional energy)The SeasonsThis theory has been used by the Seasons for Growth Program and aligns with anotheranalogy 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
  11. 11. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 1 Spring – adjustment and starting to see some new life Summer – renewal and moving forward againThis analogy can be very helpful as it has a time frame of 12 months. Most people who losea 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) 1999The third theory of grief that has been well established is the Dual Process Model ofStroebe and Schut. This theory maintains that in a grief process two things happensimultaneously — grieving work and avoidance of grief.They recognised that at the beginning of a loss a person is fully involved in grieving andfeeling the sadness of grief but even so they have to get on with life and so avoid theirgrieving for periods in order to function. This movement back and forth lessens over timewith people adjusting to their loss. This model lends itself to another analogy of grief andthat is the ‘broken leg’ analogy.The Broken LegWhile we favour a broken leg, padding it and protecting it, we still need to get up out of bedand function. We may have artificial supports for a time, including walking sticks andwheelchairs, but without movement and normal living the leg wouldn’t heal. It needs tohave blood flow and circulation and when a cast comes off the leg needs to move in orderfor the muscles to grow again and to file off the bony protrusions that occur in mendingbones. The muscles actually wear down the new overgrown bones to the shape they were inthe first place before the break.This miracle of nature in healing is also a great one for assisting people to understand boththe need for care and rest and the need to get up and out again in order to feel better andheal.Models of griefThe following article is provided as further discussion of models of grief.Reading: Grief, Loss and BereavementMuch 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 lovewas replaced by the psychodynamic view that grief was painful because it involved lettinggo of attachment to the deceased. This "letting go" was viewed as essential for "moving on"with ones life, eventual recovery from depression, and a return to "normal" (Neimeyer2001). Theories of grieving later included an emphasis on differences between pathological(complicated) and normal (uncomplicated) grief reactions (e.g., Lindemann 1944), and anemphasis on phases, stages, or trajectories of the grieving process. The best-known stagemodel was presented in Elisabeth Kubler-Rosss (1969) book On Death and Dying. Indiscussing anticipatory grief of terminally ill persons she outlines five stages: shock anddenial, anger, bargaining, depression, and acceptance. These stages were viewed by many
  12. 12. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 2lay people and professionals as "the" way successful grief is experienced. Many still gravitateto this model for its simple linear approach, using it as a prescription to measure how grief isprogressing. Since its publication, this stage model has been applied to other lossesincluding divorce, chronic illness, and infertility.Although these models have been prominent in the popular media, many scholars havebeen critical of them (Attig 1991). Studies have failed to find any discernible sequence ofemotional phases of adaptation to loss, or any clear endpoint to grieving. Rather than apassive climb up a linear staircase, characteristics of grieving may more closely resembleunsteady twisting and turning paths requiring adaptation and change, but with no specificend. In addition, there is no evidence that someone who deviates from those stages isexperiencing pathological grief, so authors have called for a de-emphasis on universal griefsyndromes and a recognition of varied practices of subcultural groups.There also have been many challenges to the concept of grief work that underlies thesetheories— an assumption that one must do cognitive work to confront the loss and thatfailure to undergo or complete grief work results in pathological grief. The idea that onemust "work" at dealing with grief is not a universal concept, and probably is reflective of thebroader 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 inindividuals 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 onesidentity). The emphasis appears to have shifted from identifying symptoms to the process ofgrieving. For example, the Dual Process Model of Coping developed by Margaret Stroebeand Henk Schut (1999), suggests that active confrontation with loss may not be necessaryfor a positive outcome. There may be times when denial and avoidance of reminders areessential. Most individuals can expect to experience ongoing oscillation between a lossorientation (coping with loss through grief work, dealing with denial, and avoiding changes)and a restoration orientation (adjusting to the many changes triggered by loss, changingroutines, and taking time off from grief). This reflects a movement between coping with lossand moving forward, but the extent to which one needs either of these dimensions differsfor 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 asa disruption in the family systems equilibrium and structure requiring reorganization of rolesand functions; and the impact of reactions of one family member on another) appears wellsuited for examining loss. However, its emphasis on the present and current interactionsappears to have slowed development along this line. There are a few notable exceptions,including Monica McGoldricks (1991) elaboration of Murray Bowens work on the legacy ofloss. Bowen (1976) suggested that a familys history and experiences with loss influences
  13. 13. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 3how the family adapts to subsequent losses as well as the legacy of viewing themselves aseither "survivors" or "cursed" (i.e., unable to rise above the losses) that they pass on tofuture generations.Another notable work is that of Ester Shapiro (1994), who integrated individual and familylife-cycle development with systems theory to discuss loss as a crisis of identity andattachment, in which grief disrupts the familys equilibrium but makes possible developmentof new "growth-enhancing stability" … In addressing losses related to chronic illness, JohnRolland (1994) developed the Family Systems-Illness Model to examine the interface of theindividual, 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 andinfluencing 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 socialand emotional health and wellbeingOur clients’ bereavement experience can impact on their social and emotional health andwellbeing. Withdrawal from social connections is very common in grief and this is not alwaysunderstood by friends and family. It can at times cause offence. It is important to encourageclients to express their need for quiet while they sort themselves out and for them tocommunicate with friends, colleagues and loved ones about their needs at this time. Thiswill help others to support them in the way that they need. It seems an obvious point, butpeople 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 partof daily activity for emotional health and wellbeing. Sights, sounds, smells and sensations allhelp to stimulate our senses and can help bring relief to a grieving client. Encouragement todo this is important and sometimes homework can be given for the client to work on this.Integration of lossIntegration of loss may include: Dual process Meaning reconstruction Continuing bonds Disenfranchised grief Grieving stylesTo help clients integrate their loss into their lives in a positive way is important. Thefollowing therapeutic model is provided to assist in this process.
  14. 14. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 4STORY The Person’s Story of LossThe counsellor may want to use a LIFE LINE approach to this to help map the story of the loss overtime. Sequencing the story can assist people who have been traumatised to make sense of theevents. 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 counsellorreflecting back to the person their strengths and how normal they are to be experiencing theemotions they are under the circumstances.FEELINGS/BELIEFS/BODY SENSATIONS/ACTIONS? What does it make them feel/believe aboutthemselves 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 werehappening, or what they are currently, as they may not have had an opportunity to express this ormake sense of it.FEELINGS – Find out what feelings the person is experiencing, list a few if they can’t quite find thewords.BELIEFS – Ask the person what this loss makes them believe about themselves, others, God, lifebecause of what has happened.BODY SENSATIONS – Importantly, ask the person to tell you where they feel the sadness, or hurt oranger now in their body, i.e. sick feeling in the stomach, heavy feeling in the heart etc. (With childrenyou 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 themselvesdoing now that they normally wouldn’t do?EDUCATE & NORMALISE — Explain to your client that they are normal, explain the seasons or thebutterfly or broken leg analogy to them to help them understand grief. If they have had lots oflosses, 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 andfeeling better is possible in time. Let them know that particular strategies can lessen the distressnow 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, candlelighting, memory book, planting a tree. Ask the person if they would like to create a ceremony as away of letting the loss go. If there has been a death and the funeral is already over let them knowthat personal goodbyes can happen at any time to help in adjustment and that just because thefuneral is over doesn’t mean that they have finished saying their goodbyes.
  15. 15. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 5STAYING 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 forlife discovered or a feeling of their presence that provides this sense of connection. Ask the personhow they would like to stay connected to the very best part of the person, situation or thing thatthey have lost. Even in divorce people may need to have a sense of connection to the best part ofthe relationship. It might be that they learned to value themselves and this is what they have takenfrom the relationship.POSITIVE STRATEGIESPositive thoughts — Help the person find better thoughts to replace bad or negative thoughts, andget them to practise these new thoughts whenever they can. For example ‘Life will never be thesame’ 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 abody pillow, do more walking, cry, laugh, talk to people, exercise, rock back and forth, engage in arelaxation strategy.Making positive plans — What new things will they do in their life they haven’t done before? Join aclub, do some study, start a group, do some craft or gardening, go fishing more, spend more timewith 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 orlonely? Set them some homework to make a connection with others. Help the person findorganisations 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 strongconnection in the community for the person.Distinctive social, cultural, ethnic and spiritual differences in loss,grief and bereavementUnderstanding other people’s responses to loss and their grief expression can sometimes beconfusing. Some of the different reactions are of course due to the uniqueness of a person’sown personality, perhaps even partly a hereditary disposition. Other differences are due tothe social situation a person is in, their cultural background, their ethnic group and religion.SocialOur 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 veryrarely written or spoken of they are ‘understood’. For example, going to an acquaintance’splace on 25 December at lunchtime just to ‘pop in’ would be seen as inappropriate in manysocial circles. Most people would know the social norm is not to go uninvited to someone’shouse on Christmas day.Our social circles may dictate certain behaviours around grief and loss. In one group it mightbe taboo to talk of a deceased person or the loss of a job, while in another group it may be
  16. 16. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 6considered necessary to talk of such things. In some workplaces to take a day off forbereavement leave is seen as acceptable; in others it would be seen as reprehensible.CulturalIn a similar way culture dictates ‘norms’ when it comes to loss as well. Culture is a broadterm of course. Most people see it as an ethnic/racial consideration but it spans social andreligious areas as well as the associated values. Each of us has a personal culture and is partof larger groups which have ideals and practices around loss.EthnicIn 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 culturalpractices 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 isone obvious example of this. There are many other less obvious practices that are based onculture. For example, in some ethnic groups the practice of self-mutilation is regarded as ademonstration of love when a loved one dies.Religious/SpiritualEthnic 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 beliefsaround 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 thedevil’, to another the loss is seen as ‘a miracle from God’. The one individual may experiencefrustration and hurt and the other jubilation.As counsellors, our own faith or non-faith position may influence us in viewing the client’sresponses as ‘acceptable’ or ‘strange’. The mind is quite powerful and thoughts have a hugeimpact on emotions. We should be happy if we can see that a person is managing their griefwell within their own religious/spiritual background and preferences, and if they have goodsupport structures in place. It is when we see people twisted in pain in their grief because oftheir beliefs that it requires a more complex approach from us as counsellors. We have towalk a kind and gentle line in these situations.Ask the person how their faith may be helping them through their loss – this is congruentwith their perspective – we all choose to stay with a faith perspective presumably because itis helpful to us after all. Then we may gently ask, ‘what are the hardest things about theloss?’, and then ‘how is your faith or faith community helping with this part of your loss?’. Ifthe contribution is negative or non-existent we may suggest other resources or thinkingstrategies that may help. Be careful to be supportive of the person’s own faith perspectiveeven so. While we may personally consider the particular faith perspective to be unhelpfulfor emotional health, it is not our place to make such judgements. Our kindness and care inthe middle of grief may well assist this person to consider us as a ‘safe place’ in the eventthat they choose to leave their non-helpful beliefs behind and to seek us out to help them
  17. 17. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 7move their thinking at a later date. Remember, people lean on their culture, beliefs andtraditions in turbulent times and to challenge these beliefs when they are vulnerable isunethical and lacks real love and care. It can also be psychologically dangerous.Awareness of the context and circumstances prior to loss and theirimpact on grief and bereavementThe context and circumstances prior to loss may include: Socio-economic circumstances Age of deceased Family relationships Presence of mental illness in the deceasedThese circumstances naturally have a significant bearing on how people manage a loss andthe extent of their personal suffering. People’s socio-economic circumstances may mean thatthey didn’t have access to the very best care to prevent a painful outcome. This mightinclude medical care, legal care and even food, shelter and travel capacity. This lack offinancial capacity may contribute to the client thinking ‘if only’ thoughts after the loss. Theymay compare themselves to others with access to the supports necessary to prevent thesame kind of loss. Loss of innocence at the unfairness of the world and the loss of justicemay be secondary losses in such cases.Naturally, when someone dies, age is a factor in the impact of this loss. Losing a baby, childor young person for example can be harder to accept and understand compared to losing anelderly 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 thegrieving that will be experienced. Relationship connections are sometimes unexpected.Relationships with animals, with jobs, with family members have emotions attached due toneeds inherent in that connection. One person may be more upset about their dog dyingthan their husband leaving them. Someone may be more upset about the loss of their jobthan their elderly mother dying. The individual connections of meaning in these relationshipsdetermine the emotion experienced and the duration of the grief experience. Counsellorsneed to examine these ‘relationship meanings’ with their clients to help them fullyunderstand 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 theloss. For example, if a family member had been mentally unwell prior to a suicide, this mayhave been a condition that the family and supporters of this individual have coped with for along time. The exhaustion and stress levels of family members in this predicament canprecipitate loss of mental health for them as well.If someone who previously had a mental illness experiences a significant loss this is likely toincrease stress and could increase symptoms of mental illness. Quality professional help will
  18. 18. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 8be required to support this individual through this time. It is a case of adding fuel to the fireand it will need specialist support.Understanding of a ‘stress vulnerability model’The following reading is reproduced to give an understanding of the stress vulnerabilitymodel. This reading is also reproduced on the online student portal as ‘Article for Grief andLoss’ under Learning Resources.The stress vulnerability model was proposed by Zubin and Spring (1977). It proposes thatan individual has unique biological, psychological and social elements. These elementsinclude strengths and vulnerabilities for dealing with stress.The Stress Vulnerability ModelIn the diagram above person "a" has a very low vulnerability and consequently canwithstand a huge amount of stress, however solitary confinement may stress the person somuch 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 11and 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>
  19. 19. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 1 9Awareness of the broad spectrum of lossWhen one person has a loss, their grief can impact on a great number of people in acommunity. Most people can empathise to some extent and imagine what the other personmust be feeling. It can bring up feelings of vulnerability in all of us. We may be particularlyaffected 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 othersmay fear for their security as well. They may feel guilty for still having a job or relieved thatthey have been passed by. The effects of a loss ripple out like the widening circles in a pondwhen a stone is thrown in.As well as a broad impact across the community loss itself manifests in many different waysand covers many situations. People losing friendships, jobs, houses, faith, relationships canstill suffer grief reactions at times as severe as in losing a loved one to death.Strategies for formal and informal grief and bereavement supportThere is a range of strategies to assist people in dealing with their grief. These include moreformal strategies such as counselling and identified grief support groups and extend to otheraspects such as literature or seminars about grief and to the love and care provided byfriends and family.It is important that people are made aware of the sorts of supports that are out there in thecommunity. If a person seeks counselling for grief, counsellors should also provideinformation on other supports that are available. In the end it may be aspects of all of theseavenues that together assist people to recover well.Certainly grief groups can help to normalise emotions and experiences as well as provide asocial connection that is meaningful. However, counselling provides a forum for individualunderstanding of the grief experience that may not be available elsewhere. Self-awarenessgained through reading material in books, brochures or online and attending seminars canassist 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 uniquegrief responses without seeking for them to be explained, thus enhancing the grievingperson’s sense of being accepted in the grief experience.Available grief and bereavement care services and informationresourcesPolice and coronial proceduresAt 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
  20. 20. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 0they may be asked questions which give them the feeling that they are a suspect in thedeath of their loved one.In these situations, which may intensify the grief experience for people, you may berequired to provide debriefing about this whole situation. Naturally in our communities wewant justice and protection for people. Police provide this for us by taking routine measuresto enquire about the nature of a death to ensure that it was either natural causes oraccidental rather than something deliberate. However as counsellors we should be awarethat this process may be extremely traumatic for the loved ones involved in this sort ofinvestigation.
  21. 21. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 1Steps in providing support and care relating toloss and griefThe 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 ofcounselling.1. Identify effects and impact of loss and features of griefWe have all experienced loss in our life and are familiar with the term. Losses can includeloss 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 capacityo interaction losseso losses of the external world, such as material or personal losses Cumulative lossesPrimary lossesA 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 lossesA 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 myposition in society, AND I lost my self-esteem.’‘I lost my husband and I lost the person who takes me shopping, whocleans the windows, and provides the income for me.’Another way of describing secondary losses is ‘micro-losses’.Losses of the internal worldLosses can relate to the internal world of the client, such as loss of cognitive or sensorycapacity. This may include loss of ideas, beliefs, attitudes, hopes, faith etc. We all have aninternal world; it is the reason why people will react differently to the same type of loss. Wehave different thoughts.
  22. 22. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 2For example: ‘I lost my mother to death – I’m glad it is over, she was in great pain, shesuffered for years, I’m glad she is not suffering anymore, she is with Godnow and the angels...it’s OK’.Or‘I lost my mother to death – this is dreadful, she had a dreadful end and Ihated to see her suffering, it seems so horrible that such a good personhad such pain. Once you are dead you are dead, there is nothing afterthis. The world sucks because there is no justice, some really horriblepeople just die in their sleep, why couldn’t my mum!’Both individuals above have suffered an external loss which is similar, the loss of theirmother, but their internal loss is very different and particular to them. Our internal world canmean that our loss can be extremely painful or not very, although we may have lost thesame 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 unseenthings that we lose.For example: ‘I lost my faith when the pastor I respected and looked up to lost histemper with me when I didn’t agree with him. It made me doubt thereality of my beliefs. If, after more than 20 years practising his religion, heis 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’tknow 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 stigmaor shame.Interaction lossesInteraction losses refer to losses in relationships between people or situations.Interaction losses also have secondary or internal world losses. You may imagine that theloss of a partner and the interaction would be the primary loss for a person, yet whentalking 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 theinteraction between husband and wife.Loss presents a complex landscape – but with simple questioning we can hit the mark of thesignificant losses for our clients. They will value us if we can ‘get’ them, especially if theycan’t get themselves and why they are acting as they are.
  23. 23. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 3When people get a glimpse of the complex map of primary and secondary losses andmeanings for themselves they are grateful and are on their way to making sense of theiremotions and caring for themselves as they should. This is of course critical to successfulrecovery from a loss.Losses of the external worldLosses of the external world are the obvious losses, which everyone will see andunderstand. Loss of job, loss of house, loss of a limb etc. are all examples of an externalloss – they are visible. In some ways primary losses and external losses are related andsecondary 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 itat 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 isthe house, however their internal losses are quite different.For Greg, his internal loss is lost pride because his parents always said hewas 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 thathouse as she was desperate for a child. She could see the child care centrefrom her front veranda and the primary school was just over the hill. Therewas a beach nearby where she imagined herself playing with her child inthe future.Their primary loss was not actually losing the house, it was the losses oftheir 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 ofthe new home.As counsellors it is important not to assume we know what a person is grieving for most. Wehave to find out from them what the most difficult thing is in their loss. This will put you incontact with their internal world of priorities, which is what we need to work with in order tosuccessfully 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 thatshe is grieving and won’t come to bowls and is locking herself away in thehouse. She says to their shared friend Marg that she thinks she is tryingfor the sympathy vote. She’s never found out that Alice herself fellpregnant when she was 15 and was shamed terribly by her family. Shefinally gave birth at 16 but the baby was stillborn. She felt that God waspunishing her and that her family, who were staunch Catholics, thought sotoo. The pain of this news for her daughter had brought her past uppainfully.
  24. 24. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 4Cumulative lossesLosses can build over time. The young woman whose mother died when she was 10 mayexperience a build-up of grief over time when she loses her first boyfriend, her girlfriendmoves away and then she loses her children in a custody battle. Cumulative loss is alsomultiple losses. However multiple losses may be viewed as a number of losses experiencedin a relatively short time. The sadness of these losses is that in many cases the person hasnot been able to integrate or resolve the losses that they have experienced and life itselfbecomes 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 tosearch out the secondary losses the person may be coping with, as most friends andrelatives will provide acknowledgement of the obvious loss a person may experience. Theindividual themselves may or may not have identified the secondary losses, but this isnecessary for a client to understand and validate why they are feeling as they do. It alsohelps to work out ways to deal with the loss.Ask the simple questionHow 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 youand 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 aperson may be coping with.Discovering secondary (or micro-losses) is a way to help the person build their future andtake 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 lifebearable for them.For example Alice may have lost the person who helped her sweep the floors or clean thebath when she lost Bert. As a counsellor you may be able to refer her to home help or agovernment agency that will provide this support to her if she is elderly and wants to stay inher own home.Harold may have lost his self-esteem in helping others within his workplace. You may findout that he has been a supporter of cricket with kids for a long time but has nevervolunteered to be the coach. Encouraging him in this area may well provide a sense of prideand involvement that may have been taken away when he lost his job.
  25. 25. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 5It is important that we don’t guess the secondary losses, but actually ask. Sometimes youmay have to prompt the person. This is because it can be incredibly surprising the sorts ofanswers 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 isactually more upset about losing the chance to be a dad. He liked his lastwife, but he was actually hanging out for her to get pregnant for fiveyears. This secondary loss was actually his primary loss (secretly). Withoutasking you may never know.Features of griefGrief is the reaction we have to a loss. Features of grief may include: Sadness Longing Somatic complaints IntegrationIn understanding the grief experience it is probably helpful for us to see the grief responsein four domains: Emotions/feelings Thoughts (cognitions) Body sensations/somatic complaints BehavioursEmotionsWhat 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 ReliefThoughtsWhat 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’
  26. 26. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 6 Questioning of values and beliefs – ‘Nothing makes sense anymore – how can therebe 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 lovedhim 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’mgoing to be a real bastard, maybe that is the way you keep a woman’Body sensationsWhat are some of the body sensations (somatic complaints) people may experience whengrieving? 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/nervyBehaviourWhat 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
  27. 27. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 7 Alcohol Drug use SuicideOf course these are not exhaustive lists but it does help us understand some of theindividual differences that occur.It is mostly the behaviour of grieving people which is obvious as this is externallydemonstrated. Some of the behaviours can be a way to feel better, to have momentaryrelief in a sad world, for example withdrawal, over-talking, over-eating, gambling, drugs andalcohol, shopping etc. Other behaviour can be self-punitive in order to gain some kind ofjustice in the world, for example reckless driving, over-giving and even suicide. Otherbehaviours can be a form of punishing others including blame, nastiness, resentment andselfishness etc. Other behaviours are just part and parcel of depression – these wouldinclude under-eating, sleeplessness, crying, loss of interest in sex etc. It may be importantto 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 theirbehaviour 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 andtheir interplay at the individual, family and community levelOf course grief is not just an individually experienced thing. Even if other members of thefamily have not lost something in common they may also grieve on behalf of their familymember. For example a son who fails university experiences this loss personally howeverparents may also ‘feel’ for him and grieve this loss as well. Often family members who havelost a loved one grieve together but of course each person has an internal loss which maybe different and inexplicable. When a child dies a whole community may be caught up inthis loss and imagine the pain of the parents and identify strongly with this loss. Suicide canhave an impact on a whole community and affect a wide range of people associated withthe person who has suicided in powerful ways.In Indigenous communities the loss of a loved one on top of other losses that may not havehad resolution can have an impact on community members who connect closely at a verydeep level.1.2 Recognise common but also distinctive expressions of grief and complex griefWe have discussed above some of the more common expressions of grief, and looked atsome of the features of complex grief in the previous section. Complex grief is experiencedwhen the grief doesn’t follow ‘normal’ patterns.Complex grief may present as a fixed denial where the client cannot come to terms withthe reality of the loss. For example the elderly gentleman who accidently puts his foot onthe accelerator instead of the brake and kills his wife of 45 years and who persists inbelieving that she is coming back from the shops and is just late. Or the mother whose son
  28. 28. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 8went missing and had been previously suicidal who believes that he has just gone off butwill return soon and may just be trying to teach them a lesson. People for whom the realityis extremely painful may stay fixed in denial.At times people may feel a numbness in the face of an extreme loss and not have anyemotions around the loss. This may also be a way to prevent strong undesirable painfulemotions from descending. It may be that internally the person believes that they would diefrom such a shock.At times grief may erupt into violence for people that normally wouldn’t be prone to thistype of behaviour. The violence may then be seen as an expression of extreme emotionalself-preservation as the self-destruction, guilt and despair of allowing the pain of the lossto register may be overwhelming. For example, this might be so for a father who accidentlyruns 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 aregenerally subconscious blocks to recovery which may require expert psychologicalassistance.Other examples of extreme complex reactions to grief include: hysterical laughter,uncontrolled compulsive purchasing, running away by moving or travelling and not returninghome.1.3 Take into account distinctive social, cultural, ethnic and spiritual differences in lossand griefSocial, 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 strategiesSome of the individual experiences that people have in coping with a loss have to do withtheir internal world but what contributes to that internal world? We can put this down topersonality 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 privateand quiet and prefer to act as if all is normal. Another family shaped by cultural expectationsand modelling will have a more overt response to loss and be extremely expressive inemotions.Outward symbols of grief may also be displayed in many different ways, for example bywearing black or attending to certain rituals. Typically, cultural and religious beliefs have
  29. 29. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 2 9developed over time to ‘help’ in the grieving process. Sometimes however an individual’sneeds and unique thoughts and experiences don’t fit the model and they may feelunsupported by their religion or culture at the most difficult time in their life. People oftenre-evaluate their beliefs and values at times of great loss and redefine who they are andwhat 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 tochoose how to express grief. We can choose to think about loss in a positive way and hopeto have adequate support and self-care through the process. As counsellors we need to lookfor 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 wellbeingafter a lossThere is an elevated risk to health and wellbeing after a loss. Without expression andresolution and without support for a loss the individual may be traumatised, may not adjustto the loss and/or may have negative thinking leading to poor mental health. They may alsoadopt 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 mentalillness. Grief is not recognised as a mental illness although depression is very much part of anormal grief experience and depression is identified as a mental illness. Sometimes it is afine line. We have to consider that people need time to recover from loss and that feelingdown is part of that. The fact is that if someone stays depressed for too long, six months ormore, 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 aMajor Depressive Episode. The shock of severe losses as well can impact the nervoussystem resulting in panic attacks and nervousness. The diagnosis of this may be GeneralisedAnxiety Disorder or Panic Disorder if it is persistent. Too much stress for too long canmean that someone can develop Post Traumatic Stress Disorder.1.5 Recognise and understand disenfranchised griefWe have looked at the concept of disenfranchised grief above. This is when a loss cannot beshared publically and the grief is unexpressed because of stigma or shame. It is importantthat we recognise how disenfranchised grief works in our counselling practice. To do this weneed to understand typical situations where our society may attribute blame in experiencinga loss.For example if someone chooses a path but then grieves as a result of the change that hasoccurred the person may feel inclined to hide their pain, believing they may be judged orjudge themselves for the action. To show the grief is to make themselves vulnerable toothers. Examples include abortion, breaking up with a husband or wife, adopting out a child,quitting a job, moving away from family voluntarily etc.
  30. 30. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 0We need to comfort individuals about the fact that the grief is real despite our sense of adecision being right or wrong. This is because change requires adjustment and longing forthe familiar, or for something that has worth even symbolically, and it can be a bitter pill toswallow. Whether the outcome of the change is seen as ‘good’ or ‘bad’ doesn’t negate thegrief experience.1.6 Identify and demonstrate understanding and respect for specific approaches andresponses of individuals, families and communities to griefThe ways in which people negotiate their losses and go through their grieving will beextremely different. Our job as counsellors is to show respect and to grow in ourunderstanding through observation, gentle questioning and testing strategies that bringrelief to individuals, families and communities.1.7 Demonstrate understanding of integration of lossLoss is a normal part of life and needs to be integrated into our thinking and our lives. Weneed to understand that losses are normal (as is failure) and that none of us, no matter howclever or avoidant, will be able to live without experiencing a loss. We need to normalise lossfor our clients.Self-blame for loss is quite common. It is always important to explain to clients that blameand refusal to forgive yourself or others will not help. Typically the thinking behind this isthat people ‘should be good, and if possible perfect’. We need to observe individuals andfamilies and support them in positive ways of managing the grief experience and encouragehelpful thought processes.Dealing with a loss caused by another person can be incredibly hurtful. We can explain toclients confronting this scenario that the people responsible have had experiences whichhave caused them to act in the way they have. To understand this is better than holdingonto a grudge. To forgive themselves as an imperfect human being who is on a learningcurve is also better than to sit in guilt.2. Engage empathically with people who are living with loss2.1 Interact with individuals with empathy, sensitivity, professionalism and courtesyThis may include: Empathic listening Identifying and affirming the grieving persons strengths and opportunities Helping manage overwhelming feelings to facilitate coping Using questions and concreteness to focus on identifying immediate needs andconcerns Facilitating informed choices by the grieving person Unconditional positive regard for the grieving person Non-judgemental approach
  31. 31. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 1 Genuineness of response2.2 Identify and respect social, cultural, ethnic and spiritual differences which may affectgrief and bereavement responsesAgain, while we may recognise the different ways that people grieve and their variousbereavement responses, to respect these can be incredibly difficult. It is all too easy tojudge, especially around emotionally charged issues and situations. We need to practisewhat 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 nothelping her. It may be that you believe that it is better to speak about the deceased but theperson won’t. You may worry that someone may be repressing their feelings and will sufferlater because their faith expects them to be cheery about the death of their loved one whois now ‘in heaven’. Respecting other people’s beliefs will assist us to help other people. Thetools to help can be found through understanding the individual’s own culture.2.3 Apply, within culturally appropriate boundaries, verbal and non-verbal approaches todealing with and responding to grieving individualsAppropriate 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 courtesy2.4 Apply, within culturally appropriate boundaries, empathic listening skillsEmpathic listening skills may include: Appropriate brief encouragers which help the grieving person relate their story andconcerns 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 persons 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 boundaries3. Provide support for individuals who are grieving and identifypotential for healing and growth3.1 Recognise common reactions to loss and the range of grief responses
  32. 32. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 2As mentioned above our capacity to recognise common reactions to loss and the wholerange of grief responses will be the first step in assisting people. Dealing with young peoplefacing grief poses additional problems however.In teenagers grief responses may be more difficult to detect. Even under normalcircumstances adults have difficulty interpreting teenage behaviour. Young people who aregrieving may become involved in drug taking and other risky behaviour. They may oscillatebetween withdrawal and excessive socialisation and in extreme situations contemplatesuicide. Being aware of teenagers’ verbal and written expression, their music choices andunusual behaviours is important, especially after experiencing a loss. It is useful to enlist thesupport of peers after a significant loss for a young person to watch them and report anydisturbing behaviours.Grieving children may oscillate between normal play and distraction behaviours andfeelings of helplessness and sadness. Like adults this movement between grieving andavoidance of grieving is important for the adjustment process. Assisting younger children toexpress their feelings can bring security and relief to the child. This can be done throughdrawing and play (for instance with sand tray therapy) and helping them to normalise whatis happening through bibliotherapy (the reading of books for therapeutic purpose). Ensuringthat children do not take on blame for a loss event is also critical. Children are ego-centricand tend to believe that bad things that happen around them must be linked to their ownbehaviour.3.2 Recognise common reactions to trauma and the range of responsesTrauma 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 isimportant to refer to an experienced psychologist.The reactions to a traumatic loss can be substantially different to a loss which is anticipatedor expected, for example the sudden loss of a child in a car accident compared to the deathof an elderly parent who has been ill for some time. This does not mean that an anticipatedloss is not traumatic however. Loss experiences are individual and trauma may beexperienced in some seemingly innocuous situations.3.3 Identify individuals experiencing difficulty in coping with grief and trauma and linkthem with options for further help as neededDifficulty in coping with grief and trauma may include: Symptoms of separation distress Symptoms of traumatic distress/stress Complex grieving Suicidal ideation
  33. 33. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 3In dealing with all of these situations the counsellor will need to assess whether thesedifficulties mean that the client needs referral to other specialist services for additionalsupport or treatment.3.4 Demonstrate understanding of the role of complex grief reactionsWe have looked at the features of complex grief in previous sections. When grief doesn’tend 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 fromwhat it fears is ‘worse’ emotional pain. It is important to refer clients experiencing complexgrief for specialist treatment.3.5 Identify and assess an individual’s suicide risk and where necessary refer toappropriate servicesSuicide risk can be assessed by observation of body language and by listening to the client’sexpression (either in writing or verbally) for signs which indicate loss of connection ormeaning or overwhelming emotional pain. When the client has the means of harm at theirdisposal and no one to watch them the potential risk is magnified. If a client has hadthoughts of overdosing, for example, and they have access to tablets and live alone, asuicide attempt is a very real possibility if they have been thinking about themeaninglessness 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 respondto each individual’s needs in relation to their grief and bereavementAs 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 providesome useful guidance.The need to tailor communication techniques to suit the client applies as in any counsellingscenario. The skill of the counsellor is in being able to assess what techniques will beappropriate for each individual.3.7 Identify, suggest or use strategies for formal and informal grief and bereavementsupportGrief and bereavement support strategies and grief and bereavement care services mayinclude: Aboriginal health services Coronial services Emergency services Empathic listening General practitioners Group grief counselling
  34. 34. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 4 Health services Individual grief counselling Palliative care services and teams Practical support Psychological services Spiritual and faith care services Support group Telephone counselling services3.8 Maintain confidentiality in line with organisation practicesConfidentiality 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 hurtother people you may need to call the police if you are not able to satisfy yourself that theyare completely safe.4. Identify, inform and refer to appropriate grief and bereavementcare services and resources4.1 Identify grief and bereavement care services available in the communitySome general support services were listed above. The type of specific support servicesavailable will depend on the community. In larger cities specialists of all descriptions areavailable, including for grief support. Sometimes there can be problems in accessing theseservices as they may be at a great distance from the client. Finding these services can alsobe a challenge with a number of organisations vying for attention through advertising.Internet searching can refine this task considerably. We typically think that a smallercommunity has limited services for grief support, however on the other hand it may beeasier to review each of the possibilities more quickly.Lifeline telephone counselling is a nationwide service which is particularly useful for grievingpeople as they can access it at all times of the night or day and talk to someoneconfidentially who is trained to identify suicidal ideation and can also provide ideas onfurther bereavement support within the client’s area.4.2 Identify referral procedures in accordance with organisation policies and proceduresReferral procedures may include: Referral information Referral databases Referral protocols4.3 Identify and make accessible general grief and bereavement care informationresourcesGrief and bereavement care information resources may include: Internet resources
  35. 35. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 5 Fact sheets Information packs Books4.4 Fully inform individual about grief and bereavement care service optionsIn 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 homesmore than necessary. Other people are more inclined to connect with an ‘expert’ to assistthem. Still others may appreciate a help group like ‘Seasons for Growth’ where they canmeet with others who have experienced a loss and form a support network. Find out fromyour client what they would prefer.4.5 Obtain feedback from individual to determine whether options are clearly understoodDon’t forget that a grieving person may have a limited capacity to remember informationand digest it. Ensure you find out that they clearly understand their options by asking forfeedback. You might also provide information on a hand out.5. Identify and recognise risks associated with grief andbereavement supportRisks associated with grief and bereavement support may include: Compassion fatigue Vicarious traumatisation Burnout Lack of adequate supervision Lack of access to external expertiseGrief is a very sad area to work in for the counsellor. Stories of loss can easily trigger ourown fear of losing a loved one or a valued situation. As counsellors we focus on our capacityto be empathetic but this can also be our own undoing. It is extremely important to havegood supervision and have a place to ‘empty’ our own sadness in hearing a great number ofloss stories. We may be especially vulnerable if the story has some connections to our ownlife experience. For example we may have a sick mother and a client’s mother has just diedof cancer. Their painful story may make it difficult for us to adequately support them as ourmind is focused on our own situation. In these cases it may be important to refer the clientto someone else. The way you do this must be gentle and caring and should provide theclient with ‘reasons’ so that they do not feel abandoned.5.1 Identify and recognise a range of risks associated with grief and bereavementsupportAs a mental health professional it will be important that you don’t take this role inbereavement support lightly. Keep regular supervision in place and reflect regularly on yourown wellbeing and capacity rather than continuing regardless and ignoring your own self-care.
  36. 36. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 65.2 Develop and implement appropriate strategies to minimise risks associated with griefand bereavement supportStrategies to minimise risks associated with grief and bereavement support may include: Self-care Supervision Debriefing Back-up support External networks and expertise6. Access appropriate supervision and debriefing6.1, 6.2 Identify the need to access appropriate supervision and debriefingThis may include: Duty of care to clients Self-careAs 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 anddebriefing, as discussed below.6.3 Develop and implement appropriate strategies to access supervision and debriefingVarious agencies have different rulings around supervision and debriefing and some do nothave 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 mayfeel awkward about initiating supervision and debriefing outside of ‘regular’ times, howeverit is very important that this occurs on a needs basis.7. Review and evaluate grief and bereavement support provided7.1 Reflect on outcomes during and after support is providedIt is important to consider how effective your support has been to the client. Ways to do thisinclude 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 responsescan be hard to evaluate objectively. You might ask the client whether they could rate howhelpful 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 isnot 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 themto do more of that. We always hope that our help is incredibly useful. However somegrieving 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 theywill need continued support.
  37. 37. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 77.2 Identify where further support is requiredYou may encourage other supports concurrently with your counselling sessions or refer to aspecialist psychologist or grief counsellor or other service provider afterwards if the need stillexists.7.3 Review practices for continuous improvementAs with any therapeutic intervention it is important to constantly review counselling practicesto see where there is room for improvement. None of us can hope to be immediatelyeffective in all counselling sessions with clients but we can grow in our capacity. It is usuallyour own clients that teach us the most.
  38. 38. © Copyright CTA CHC51712 MODULE 6 Grief and Loss Version Date: 30.04.13 P a g e | 3 8READINGS & RESEARCHReview 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 ChecklistREFERENCESKubler-Ross, E. 1969, On Death and Dying, Simon & Schuster/TouchstoneMarriage and Family Encyclopedia, available at <family.jrank.org>, accessed April 2013Stroebe M. and Schut H. 1999, ‘The Dual Process Model of Coping with Bereavement:Rationale and Description’) in Death Studies, Vol 23(3), April-MayWorden, JW. 1982, Grief Counselling and Grief Therapy, Springer Publishing Co., New YorkZubin and Spring. 1977, The Stress Vulnerability Model,http://www.hearingvoices.org.uk/info_professionals_stress.htm, accessed April 2013WEBSITESThe following websites provide support material for grief and loss.National Association for Loss and Grief (NSW)  www.nalag.org.auAustralian Centre for Grief and Bereavement  www.grief.org.auAustralian Child and Adolescent Trauma, Lossand Grief Network www.earlytraumagrief.anu.edu.auNational Association of Loss and Grief(Victoria) www.nalagvic.org.auCompassionate Friends  www.compassionatefriendsvictoria.org.auSIDS and KIDS  www.sidsandkids.orgLifeline  www.lifeline.org.auEmail to heaven  emailtoheaven.org/

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