Best Practices in Counseling Grief and Loss:

Finding Benefit from Trauma

Elizabeth M. Altmaier
Grief may be a primary presenting concern of clients or may form a background to another presenting
concern. In either case, use of best practices in assessing and treating grief is essential. In this article I
review what best practices are in general and in assessment and treatment. I also evaluate ways to
measure grief and describe domains of the grief experience. The article also discusses controversies
within the literature on grief counseling, including the potential for deterioration after treatment. It
concludes with a view of counseling grief that promotes finding benefit ß-om trauma.

This special section describes the devastating impact of loss on the life of a person. However common it
may be, loss causes significant individual grieving, which in turn can impair emotional, cognitive, and
behavioral fiinctioning. Throughout this special section we have emphasized the difficulties caused by
the crisis of loss and the experience of bereavement, such as the potential of complicated grief and the
special case of parentally bereaved children. We have also noted the importance of culture-based
counseling issues related to grief. More important, however, is a larger perspective introduced by
Harvey, who deñned toss as a "fundamental human experience" (Harvey, 2002, p. 2) from which we can
grow and learn to understand others, help others, and develop our own courage to live with pain. It is
critical to keep this positive view of grief in mind when considering best practices in counseling those
who are grieving because it treats counseling as facilitating growth rather than simply mending loss. In
this article I focus on the evidence that underlies assessment and treatment, and on practices that
should be considered in counseling the grieving client. Thinking of grieving within the context of
posttraumatic growth will deflne alternative counseling approaches.

IMPLEMENTING BEST PRACTICES: FROM RESEARCH EVIDENCE TO COUNSELING

EACH CLIENT

What are best practices'? Though the term has been adopted widely, its usage is not agreed upon
—much like terminology related to grief. Concisely, best practices, a term borrowed fi-om the
business world, suggests that there is a particular technique, approach, or method that when used
with a particular target is more effective (reaches its goals) and efficient (uses fewer resources)
than other techniques, approaches, or methods. It also suggests that there are data available to
influence the decision to use this particular technique. Within the mental health field, other terms
that denote a similar emphasis on using data to make decisions on assessment and treatment are
evidence-based practice and empirically supported treatment. One approach to understanding
best practices is to focus on outcome data gathered in clinical trials of a particular treatment
(empirically supported treatments). Many consider these studies to be the best basis upon which
to select a treatment. Advocates of empirically supported treatment argue that although a
treatment is only one of several influences on client outcome, it is the influence that a counselor
in training can most readily learn and the influence that can be most easily studied scientifically
(Norcross, Beutler, & Levant, 2005). There are two other sources of data to inform treatment
choice. One is clinical lore—the accumulated experience of many practitioners transmitted
through personal testimony, continuing education, client reports, news coverage, and so on.
Unfortunately, clinical lore has the drawback of promoting treatments later shown to be
ineffective or less effective than alternatives. Fad diets might be the health counterpart to
selection of counseling approaches predicated on clinical lore. Another data source is the
counselor's own personal clinical experience. A seasoned counselor can recall similar clients,
similar desired outcomes, similar contexts, and so on—memories that can inform a present
treatment decision.
Unfortunately, clinical experience can fall prey to the biases that influence human memory, such
as confirmation bias, which emphasizes previous successes and overlooks previous failures.
Another bias is the availability heuristic, where clients who are memorable for any reason are
prominent images in the counselor's memory, while less memorable clients fade. An alternate
view of counseling effectiveness is the primacy of the counselor within the interpersonal
relationship. In this view, treatments are essentially equal in their effectiveness, but it is whether
the counselor is, for example, warm or rejecting, sensitive or insensitive, astute or ignorant that
most influences outcomes. When data are sought to support treatment decisions, the personhood
of the counselor is typically overlooked although it accounts for as much of the outcome as
treatment. Wampold (Norcross et al., 2005), for example, argues that overlooking the
personhood of counselors in research on best practices, particularly research that focuses on the
treatment as the sole or primary influence on outcome, causes two types of misattribution: First,
it inflates the effects attributed to treatment and thereby creates a false sense of confidence in a
treatment when the counselor may be the agent for change. Second, a focus on treatment alone
creates an impression that counseling is a package of techniques that can be delivered
impersonally—a gross misunderstanding of the deeply human enterprise of counseling.
Alternatively, the counselor-client relationship may be the primary source of influence. Lambert
(Norcross et al., 2005) notes that when clients are asked about their counseling experience in
qualitative and retrospective studies, the relationship with the counselor is typically cited as the
primary reason for change: clients feel understood, valued, appreciated, supported, and so on.
Technique and theoretically based explanations of treatment outcome (e.g., change in
dysfunctional cognitions) are almost never mentioned.
Last, the fact that clients are active agents in their own improvement and change cannot be
overlooked. Rather than being a passive recipient of a treatment, the client elaborates on the
insights of counseling outside the session, works the information and insights into her life, and
through self-healing and self-determination mechanisms creates a medium for effective outcome.
In summary, the background of best practices is important in selecting counseling approaches for
a grieving client, keeping in mind that there is controversy over whether grief counseling is
appropriate for everyone, only for persons seeking treatment, or only for persons experiencing
complicated grief. Moreover, though in general some counseling approaches may seem to be
effective, research should not imply that the personhood of the counselor, the relationship of
client and counselor, or the client's own self-healing processes are insignificant aspects of
change.

BEST PRACTICES IN GRIEF ASSESSMENT

Although grief is a universal phenomenon, it has not been adequately conceptualized. As the
accompanying articles note, the lack of consistency in defining grief has led to inconsistency in
the development of grief measures. In what follows I describe the most prominent of these
measures. They were chosen because they (a) are the most widely used; (b) focus on grief, rather
than broad psychiatric symptoms; (c) assess normal, not complicated, grief; and (d) consider
grief across all possible losses, rather than a specific loss, such as the loss of a child. (See
Stroebe, Hansson, Schut, & Stroebe, 2008, for more complete coverage of conceptual issues in
the measurement of grief).

Grief Measures
Texas Revised Inventory of Grief (TRIG; Faschingbauer, Zisook, & DeVaul, 1987). The TRIG,
probably the most widely used measure of grief, is a brief measure with two subscales: Current
Grief and Past Disruption. Items, created based on a review of the literature and the clinical
experience of the authors, contain sentences of personal description to which the participant
responds on a five-point scale (1 = completely false to 5 = completely true). Because of the
contrasting temporal nature of the two sections, the developers assert that the two scores can be
used to assess progress in grieving. Niemeyer and Hogan (2001) summarized the psychometric
qualities of the scale. Internal consistency ranged from .77 to .87 for the Current Grief subscale
and .86 to .89 for Past Disruption. For the original Texas Inventory of Grief, Faschingbauer
(1981) reported an exploratory factor analysis study in which items were retained with factor
loadings greater than .40. Though there are few data on validity, the widespread usage of the
scale provides considerable comparative data for users.
From a construct validity perspective, there are several concerns about the TRIG. The Current
Grief subscale contains three items related to crying (e.g., "I still cry when I think of the person
who died"). There is considerable overlap of this subscale with depression: items assess sadness,
loss of interest in previously pleasurable activities, irritability, and sleep problems. Finally, the
scale fails to incorporate constructs that have been both theoretically and empirically associated
with grief (e.g., guilt, hearing the dead person's voice).
Grief Experience Inventory (GEI). The GEI was designed to be sensitive to the longitudinal
process of grief (Sanders, Mauger, & Strong, 1985). Items derived from the literature are
presented as self-descriptive sentences to which the participant responds true or false. Scoring is
similar to that of the Minnesota Multiphasic Personality Inventory: there are three validity scales:
Denial, Atypical Responses, and Social Desirability; nine clinical scales: Despair, Anger-
Hostility, Guilt, Social Isolation, Loss of Control, Rumination, Depersonalization, Somatization,
and Death Anxiety; and six "research" scales: Sleep Disturbance, Appetite, Loss of Vigor,
Physical Symptoms, Optimism-Despair, and Dependency.
Niemeyer and Hogan (2001) summarized the psychometric properties of the scale. Internal
consistency is rather poor, with six of the nine clinical scales having an alpha coefficient below .
70. Sanders et al. (1985) present a factor analysis with three dominant factors that do not
correspond to the scale's structure-the largest factor seems to measure depression. Validity data
(Sanders et al., 1985) reveal that the clinical scales differentiate between bereaved and
nonbereaved persons and yield higher scores for persons who indicate they are having difficulty
accepting the loss of the loved one.
Core Bereavement Items (CBI). Burnett, Middleton, Raphael, and Martinek (1997) describe their
CBI as a "scale of core bereavement items that could be used to assess the intensities of the
bereavement reaction in different communify samples of bereaved subjects" (p. 51). Their items
were formulated from focus interviews with recently bereaved adults and a review of the
literature. After selecting 76 items, the authors used factor analysis to narrow the pool to seven
subscales. Validify studies further reduced coverage to 17 items in three subscales: Images and
Thoughts (e.g., "Do images of the lost person make you feel distressed?"); Acute Separation
(e.g., "Do you find yourself missing the lost person?"); and Grief (e.g., "Do reminders of the lost
person, such as photos, situations, music, places, etc., cause you to feel a longing for him or
her?").
Items are responded to on a four-point frequency scale with anchors indicating increasing
frequency.
Niemeyer and Hogan (2001) report reliabilify and validity data for the CBI; coefficient alpha
was estimated at .91 for the scale as a whole. Middleton et al. (1998) noted the following validity
data: bereaved parents scored higher than bereaved spouses, who in turn scored higher than
bereaved adult children.
There are no factorial validity data.
Hogan Grief Reaction Checklist (HGRC). The most recent scale (Hogan, Greenfield, & Schmidt,
2001) was explicitly intended to "delineate normal grief (p. 2) and in particular to avoid blurring
grief with symptoms like depression or anxiety. Hogan et al. also used an empirical method of
scale development, obtaining and analyzing interview data from bereaved adults, to identify six
categories: Despair, Panic Behavior, Blame/Anger, Disorganization, Detachment, and Personal
Growth. Initially focus groups analyzed items that were then given to a community sample of
adults who had experienced the death of a family member. Factor analysis revealed six factors
that corresponded to the initial categories; items with loadings of .40 or greater were retained.
Hogan et al. (2001) present alpha coefficients ranging from .79 to .90 for the subscales and .90
for the whole measure. They suggest using a total score for the 61 items. However, although this
scale is presented as useflil for general grief, the final set of instructions pertains to the death of a
child for parents rather than as a general grief measure.
In assessing grief it is important to remember that no single measure captures all its
manifestations. Counselors might well consider assessing domains of grief rather than the
general concept of grief because clients will have differing experiences and may well be
expressing their grief within different domains across time.
Schoulte and Altmaier (2008) analyzed grief measures to identify a consensus of domains that
encompass the experience of grief After a thorough review of the literature that yielded all
relevant inventories, superordinate grief domains and deflnitions were determined via qualitative
content analysis of all items on these inventories (see Table 1).
Table 1. Grief Domains and Definitions
Domain Deilnltion
Physical symptoms Somatic and physiological reactions
Cognitive difficulties Difficulties remembering, learning, or thinking
Uncertainty over future Loss of meaning of life and pessimism about the future
Denial Not accepting the loss, with responses including shock
and numbness
Interpersonal interaction Changes in interpersonal reactions, needs, and
relationships
Emotional response Range of internal feelings related to the loss
Injustice of loss Frustration over the loss, feeling as though the loss was
not deserved, shattered assumptions of a "just world"
Symbolic rituals Behaviors with symbolic meaning an individual may
engage in during the grieving process
Continuing bonds Continued emotional, cognitive, and behavioral links with
the deceased
Benefit finding Positive changes about the self as a result of the
experience of loss

One approach to grief assessment is for the coimselor to assess each domain, either through
clinical interviewing, published measures, or client self-reports. The use of diaries, journaling,
and drawing can supplement the experience of a particular domain in addition to measures or
conversation. In any assessment, client reactions should be normalized because there are socially
perceived barriers to showing grief
As Schoulte describes (above, pp. 11-20), cultural context is also necessary to assessment.
Inquiring about social and cultural expectations is a fhiitful way to transition to discussing the
influence of family and culture. Questions as simple as "What do you think your family's
expectations are of you at this time?" can help a client explore what may be hidden influences on
the grief experience.

BEST PRACTICES IN THE TREATMENT OF GRIEF

Is grief counseling effective? Although intuitively it would seem that providing a supportive
environment in which to grieve—in the presence of an empathie counselor, with gentle
encouragement to consider the role of the deceased in the client's life—would promote
adjustment, there is controversy about how effective grief counseling is. Larson and Hoyt (2007)
have summarized the empirical evidence for and against it. Two particular sotirces of concern for
them are the possibilities of a deterioration effect after treatment and of a minimal positive
outcome.
Two researchers who conducted meta-analyses have argued that clients who received grief
counseling may end up worse off than they began: Fortner (1999) cited a rate of 37% of clients
deteriorating after treatment; Niemeyer (2000) found a similar rate, 38%. Larson and Hoyt
(2007) studied the two metaanalyses in detail and concluded that the rates of deterioration found
were based on a statistic that may have been defined erroneously. Specifically, Fortner (2008)
notes that an error in his dissertation text may have led to confusion about the calculation of the
deterioration rates he cited.
A second criticism is that the outcomes of grief counseling, expressed as an effect size, are not
large enough to warrant confidence in such treatment. Reviews considered by Larson and Hoyt
(2007) established an effect size (. 11 to .43) lower than the .80 typically obtained in estimates of
counseling outcome (see Wampold, 2001, for discussion). Schut, Stroebe, Van Den Bout, and
Terheggen (2001) concluded that "based on the evidence to date, outreaching primary prevention
intervention for bereaved people cannot be regarded as being beneficial in terms of diminishing
grief-related symptoms, with a possible exception for interventions being offered to bereaved
children" (p. 731).
Taking this perspective, however, ignores the four views of the influence oncounseling
effectiveness previously discussed. The current controversy rests on the treatment technique
alone; what is not known are outcome effects attributable to the person of the counselor, the
characteristics of the client, and their relationship. The widespread acceptance and promotion of
groups such as Compassionate Friends (for suicide survivors) and online groups such as
MyGriefSpace.net suggests that at least some grieving persons find support from compassionate
others to be of help.
There is preliminary evidence that persons with complicated grief may achieve better outcomes
than clients with normal grieving responses. Shear, Frank, Houck, and Reynolds (2005)
compared two treatments for complicated grief, interpersonal therapy and a new treatment for
complicated grief. This new treatment focused on ways in which to "retell" the stories associated
with the loss so as to reduce distress and increase positive memories. Both treatments produced
improvement in the target symptoms of complicated grief (assessed by an inventory of
complicated grief), but the new treatment was found to be more effective.
Overall, the best conclusion regarding the efficacy and effectiveness research on grief counseling
is that the matter is still unresolved. Considering solely the treatment, which is the basis of
outcome research in this area, yields a conclusion that counselors should continue to strive to
provide counseling to persons in need while gathering data on effectiveness and efficacy. The
Association of Death Education and Counseling has posted a statement on research efficacy and
the findings related to deterioration that promotes this balanced approach (ADEC, 2008).

INTERVENTION STRATEGIES
One way for counselors to begin thinking of grief counseling strategies is to utilize the
perspective described above on the domains of influence on client outcome. Because of the
importance of the personhood of the counselor, in this section I consider first qualities that
ensure that a counselor will be an effective helper for grieving persons. (Here I rely heavily on
the thoughtful writings of the director of the Center for Loss and Life Transition, Alan Wolfelt
[1998].) A framework for those qualities consists of empathie presence, gentle conversation,
available space, and engaging trust. Within empathie presence are qualities of listening, silence,
and support. Many grieving persons will need to tell and retell stories associated with the loss.
Empathie listening, accepting and encouraging the expression of feelings, and allowing pain to
be expressed freely are critical.
Gentle conversation avoids clichés and easy answers. Telling grieving clients that they will "get
over it," "better days will come," or "the darkest hours are just before dawn" is demeaning. The
best response may be "I am sorry. Tell me more about it." A gentle conversation allows
opportunities for remembering. Memories can be encouraged through pictures, drawing, and
other expressive modalities.
Counselors should strive to provide available space for the client. Helping the client find support
and encouragement from other sources as well as counseling is also critical. Time itself is
important. Because grieving does not follow a predictable trajectory, counselors will need to be
patient. Last, engaging trust communicates to the client that she has the ability to recover and
grow. Grieving clients may not see a ñiture without the loved one, may not have confidence that
they will ever be free of their feelings, or may feel overwhelmed by the demands of everyday
life. Communicating a trust that continues to engage the client in the tasks of grief is essential.
Using books that allow clients to have their own journey through grief may be helpfiil; Wolfelt
(1997) is an example.
Most writers about grief counseling do not propose techniques per se. Rather, the best technique
or treatment may be a different view of the relationship between counselor and client. Wolfelt
(1998) argues that certain treatment goals are misguided, among them treating grief as a
syndrome to be eliminated, promoting the client disengaging from the deceased and terminating
the relationship, having the client finish a series of tasks, using a recovery or resolution model to
suggest a return to the pre-loss state, considering grief as a life crisis where balance can be re-
achieved, and failing to attend to the spiritual aspects of grief. Companioning for these goals
involves several tenets, Wolfelt says, including learning from the client, discovering the gift of
silence, and listening with the heart (Wolfelt, 2007).
Using this perspective focuses the counselor on facilitating client grieving needs (Wolfelt, 1997).
These needs form a structure for the relationship, but meeting them is not a linear or "led"
process. Rather, within the relationship with the counselor, maintaining a companioning model
helps the client to meet the needs of "acknowledging the reality of the death, embracing the pain
of the loss, remembering the person who died, developing a new self-identity, searching for
meaning, and receiving ongoing support from others" (p. 2). Meeting these human needs will
lead to healing and reconciliation, what Wolfelt describes as "the new reality of moving forward
in life without the physical presence of the person who died" (p. 135).

CAN GRIEF COUNSELING PROMOTE GROWTH?

In their research on trauma and growth, Tedeschi and Calhoun (1995) described characteristics
that make an event traumatic: being sudden, unexpected, and uncontrollable; and producing
continuing, sometimes lifelong, effects. A recent interest in psychology has been to examine the
positive rather than the pathological aspects of human functioning. Research suggests that
through times of hardship, stemming from stressful life events or trauma, individuals have
experienced "benefits" or have grown. Posttraumatic growth (Tedeschi & Calhoun, 1995) has
been defined as experiencing positive growth following traumatic life events.
An increasing number of studies have begun to examine positive psychological outcomes of
trauma. Linley and Joseph (2004) found that posttraumatic growth has been documented in a
wide variety of human events: cancer, the Oklahoma City bombing, sexual assault, plane crash,
and combat. Of particular interest is a study by Davis, Nolen-Hoeksema, and Larson (1998) in
which persons who lost a family member to death were interviewed before and after the loss.
The authors considered two ways participants thought about the event: making sense of the loss
(e.g., the participant accepted the death as fate or God's will) and finding something positive in
the experience (e.g., improved family relationships). Those participants who either found benefit
or made sense of the loss were less distressed six months after the death and experienced better
adjustment.
Coping strategies may infiuence which individuals adjust better during and after trauma.
Psychosocial coping resources may protect against depressive symptoms, and social support
(perceived or actual) is thought to enhance psychological well-being by fulfilling the need for a
sense of coherence and belonging, thus counteracting feelings of loneliness (Bisschop,
Kriegsman, Beedman, & Deeg 2004). Relationships between coping and postfraumatic growth
have been reported. In Tedeschi and Calhoun's posttraumatic growth model (1995, 2004), coping
plays an important role in the abilify of individuals to adjust after a traumatic event and
ultimately experience and perceive growth. In a review of coping and posttraumatic growth
among cancer patients, Stanton, Bower, and Low (2006) identified eight sttidies that used
multiple coping strategies. They found that posttraumatic growth was more commonly associated
with approach-oriented coping strategies (e.g., active acceptance) than avoidance strategies.
Spiritualify and religion also play major roles in how individuals cope with trauma and
adversify. Both have been linked to a range of positive health outcomes, including reduced
depression and lower risk of substance abuse (Larson & Larson, 2003). Pargament, Koenig, and
Perez (2000) found that individuals cope differently depending on their perception of God, other
spiritual beings, or religion. The trend toward understanding spiritualify and religiosify as a
resource in traumatic situations has prompted the need for further research on how religiosify
impacts such phenomena as coping and posttraumatic growth. The spiritualify of individuals
experiencing traumatic events has been found
to change as a resuh of the events (Tedeschi & Calhoun, 1995, 1996; Tallman, Altmaier, &
Garcia, 2007). Such spiritual or religious changes are thought to be a major component in
changes in the life perspectives/philosophies growth domain. In a study of women who survived
sexual assauh, individuals reported becoming more spiritual (Kennedy, Davis, & Taylor, 1998),
and increased spiritualify was related to increased well-being after the assault. Tedeschi and
Calhoun (1995) state that "the degree to which religious beliefs can help survivors assimilate
traumatic events and grow from their difficuhies seems a promising area for investigation" (p.
117). Finding beneflt is a signiflcant outcome for grieving clients. Whether individuals are
assisted in finding benefit through expressive approaches (King & Miner, 2000; Smyth &
Pennebaker, 2008), where participants write about their trauma or their emotions; "beneflt
reminding" approaches (Tennen & Affleck, 2002); or enhancement of active coping (Antoni et
al., 2001) may not be as important as simply having the client participate in a process where
meaning found through grieving is articulated and integrated into her overall view of the loss.

CONCLUSION
This article and others in this section have had as the overall goal the description of ways
counselors cati effectively conceptualize, empathize with, respond to, and assist a grieving client
—much-needed but very difficult work. Indeed, counselors who work regularly with grieving
clients can suffer from compassion fatigue or even secondary traumatization. However, the
promise of counseling with grieving clients is the possibility of impacting a person in both the
present ani/the future, and perhaps also improving the health and well-being of the client's
children and other family members. It is not a task to be taken lightly. In her memoir of the year
after her husband's death, Joan Didion (2006) writes of her ambivalence over her recovery from
grief: I did not want to finish the year because I know that as the days pass, as January becomes
February and February becomes summer, certain things will happen. My image of John at the
instant of his death will become less immediate, less raw. It will become something that
happened in another year.... I know why we try to keep the dead alive: we try to keep them alive
in order to keep them with us. I also know that if we are to live ourselves there comes a point at
which we must relinquish the dead, let them go, keep them dead. Let them become the
photograph on the table, (pp. 225-226)