GRIEF COUNSELLING-

- Modern use of the term bereavement is associated with the loss of a loved one, usually of
a person or animal, normally through death. The response to this loss is typically grief,
which can include a sense of sorrow, burden and heaviness, and mourning the loss is
associated with feelings of longing for the person.
- Often our immediate reaction to a loss is panic; perhaps even thinking that it cannot be
true, that there must be some mistake. This is sometimes followed by searching for the
lost object, eventually realizing that the object may never be found, perhaps feeling angry
or sad about the loss and, in time, accepting that the object is gone. Depending on what
the object was, we might replace it with something else, but of course, if it had sentimental
value, that emotional aspect of the item can never be replaced.

MODELS OF GRIEF-

- until recently, grief often was treated as if it was an illness, with models drawing on
Freud’s4 writing on mourning and melancholia, which conceptualized loss as a state that
required a path to ‘recovery’, often identifying various stages of grief (for example,
Worden’s5 four tasks of mourning or Kübler Ross’s6 five stages of grief), before a resolution
culminating in the redirection of emotional ‘energy’ elsewhere.
- More recent bereavement theorists, particularly Klass et al., have challenged this
approach, instead considering that bereaved people have a continuing bond with the
deceased. Independently, some social constructionst, narrative therapists, notably White
and Hedtke and Winslade, have also questioned traditional approaches to working with
death and bereavement, instead exploring ways for the bereaved individual to maintain a
relationship of grief with the dead person. They keep open possibilities of staying in love
with a dead partner and the possibility of being able to continue to maintain and shape
the identity of that person. This is in stark contrast with help that is directed towards
enabling the bereaved person to recognize their feelings of loss and sadness, to accept the
reality of the death and emotionally to move on to a life without the deceased person.

- SIGMUND FREUD- identified two forms of grief: Trauer (mourning) and Melancholie
(melancholy). According to Freud, mourning is a normal reaction to the loss of a loved
person, or to the loss of some abstraction (for example, ‘home’ or ‘liberty’). He identified
that this is normal response to loss and should not considered to be an illness, and,
following a period of grieving, a person will overcome their sorrow and become free and
unburdened. In contrast to mourning, Freud suggested that, although melancholy derives
from the same circumstances, it can present in more extreme and damaging ways, where
the individual experiences profoundly painful dejection, loss of self-esteem, and loss of
interest in the outside world.

- BOLWBY- Bowlby’s attachment theory was heavily influenced by Freud’s writing about the
relationship people have to idealized objects and real figures. Bowlby identified three
stages of grief – shock and numbness, yearning and searching, despair and disorganization.
Later, Parkes added a fourth: reorganization.
- These stages don’t necessarily follow sequentially, but might be experienced at different
times. These stages are:

- • Shock and numbness. In this phase, there is a sense that the loss is not real and is not
easy to accept. There can be physical distress during this phase, which can result in physical
symptoms.

- • Yearning and searching. Here, the person is aware of the gap in their life left by the loss,
with a loss of the imagined future that included the person. At this time, attempts to fill this
void are made and the person may appear preoccupied with the deceased.

- • Despair and disorganization. Here, the bereaved person is able to accept that life has
changed and cannot go back to how it was or how the person hoped. Some of the
emotions associated with this phase are hopelessness, despair and anger and questioning.
• Re-organization and recovery. In this phase the person begins to rebuild their life
without their loved one and move on.

ELIZABETH ROSS-

- Elizabeth Kübler-Ross was strongly influenced by Bowlby and Parkes and her well-known
model of grief appeared in her book On death and dying, 6 which outlines five stages of
grief: denial, anger, bargaining, depression and acceptance. these stages are not
necessarily experienced in sequential order.
- During the stage of denial, grieving people are unable or unwilling to accept the reality of
the loss. Might feel as though they are experiencing a bad dream, that the loss is unreal,
and they are waiting to ‘wake up’ as though from a dream, expecting that things will be
normal.
- Once accepting the reality of the loss, the person may begin to feel anger at the loss and
the unfairness of it. They may become angry at the person who has been lost or towards
other people – for example, friends, relatives or caregivers.
- The next phase, bargaining, is characterized by the person begging a higher power to undo
the loss, perhaps saying that if the person is returned to them, they will change.
- The next stage is one of depression, where the person confronts the reality of the loss and
their own helplessness to change it.
- Ultimately, the person will enter a stage of acceptance when they will have processed their
initial grief reactions, accept the loss and begin to move on and plan for a future without
the loved one.

WORDEN- similar approach, emphasis upon maintaining connection with the lost one.

- Task I: To accept the reality of the loss. When someone dies, there is often a sense of
unbelief; that it cannot really have happened. This is sometimes referred to as denial, and
part of this first task is to arrive at the realization, both intellectually and emotionally, that
the person is dead and will not return. Rituals, such as funerals, are helpful to clients as
they signify the reality of the death.
- • Task II: To process the pain of grief. Sometimes clients will try to avoid the intense pain
of losing a loved one. Society offers us lots of opportunities to distract ourselves, and it
encourages this due to subtle messages about not showing distress and a general discomfort
with grieving. However, processing the pain of loss and grief is necessary, and can help
stop individuals carrying the pain into their future where it may be more difficult to work
through.
- • Task III: To adjust to a world without the deceased. - Losing a loved one requires the
bereaved to make external, internal and spiritual adjustments. External adjustments might
include having to take on roles previously undertaken by the dead person and having to
undertake the normal tasks and activities of living in their absence. Internal adjustments
are those changes that are required to create a new sense of identity without the person;
‘Who am I now?’ Spiritual adjustments are about the wider meaning of being bereaved and
a changed relationship with the world, perhaps with a revision of spiritual beliefs.
- • Task IV: To find an enduring connection with the deceased in the midst of embarking on
a new life. In this task the clients may find themselves considering how to stay emotionally
connected with the deceased without it preventing them moving on in their own life. It is
not a forgetting of the deceased, but rather the client finding themselves reconnecting and
enjoying their life while remembering the memories and thoughts of and feelings about
the loved one.

STOREBE & SCHRUT DUAL PROCESSING MODEL-

- Stroebe and Schrut’s model proposes that the bereaved tend to cope with stressors by
oscillating between two types of coping processes that they describe as ‘loss-orientation’
and ‘restoration-orientation’. Loss-orientation refers to how the bereaved cope with
issues that are directly related to the loss (for example, feeling lonely or sad), and
restoration-orientation refers to coping with issues related to the secondary changes
brought about by the loss (for example, dealing with financial matters), and adapting to
them.
- Stroebe and Schrut consider that loss-oriented coping behaviours, such as crying and
talking about feelings, can help people to process their emotions. On the other hand,
restoration-oriented coping behaviours, which might include developing new skills, such
as managing finances, can help the bereaved person by distracting them, to an extent,
from the focus on ‘loss’ as well as helping them to adapt to a different life. This dual
process model proposes that the bereaved oscillate between confronting their stressors
and taking breaks from their stressors. Stroebe and Schrut recognize that the focus will
shift between these dual processes, and that there will be times when individuals may be
more focused on coping with the loss itself, while at other times they may be more
focused on adapting to an altered life.

NARRATIVE THERAPISTS

- recent move towards thinking about ‘continuing bonds’ with the deceased person rather
than ‘letting go’, and some social constructionist, narrative therapists (for example,
Michael White and Hedtke and Winslade ) offer therapeutic approaches intended to enable
the bereaved individual to maintain a relationship with the dead person.
- Klass et al. used the expression ‘continuing bonds’ as an alternative to the familiar model
of grief that requires the bereaved to ‘let go’ from the deceased. They argued that the
 bereaved maintain a link with the deceased, which leads to the construction of a new
relationship. This relationship continues and changes over time, typically providing the
bereaved with comfort and solace.
- White, in a brief article entitled ‘Saying hullo again’, offered an alternative to traditional
approaches to bereavement. – Re-membering.
- Describe a focus of ‘re-membering’: a process that redirects the focus of grieving toward
maintaining an ongoing relationship with the dead person. Here the bereaved can seek
comfort in keeping the deceased person’s membership current in their own ‘membership
club’ of life. They utilize the subjunctive as a means to open up new possibilities and new
ways of understanding situations; in terms of bereavement, moving away from talking
about the dead person in the past to ways of including the dead person in the present.
- Identified several strategies for saying hullo again, including writing letters to the
deceased, visiting the grave and remembering them with others, but importantly also
recognized the importance of using dreams as a means to say hullo again.

MENTAL HEALTH ISSUES DUE TO BEREAVEMENT-

- Complicated grief refers to a description of the normal mourning process that leads to
chronic or ongoing mourning. Individuals experiencing complicated grief generally are
those who have difficulty accepting the death, and the intense separation and traumatic
distress may last well beyond six months. Bereaved individuals with complicated grief find
themselves in a repetitive loop of intense yearning and longing that becomes the major
focus of their lives, along with sadness, frustration and anxiety. The person experiencing
complicated grief may perceive their grief as frightening, shameful and strange, and might
believe that their life is over and that the intense pain they constantly endure will never
cease.
- Bereavement in mental health - A bereaved individual with a pre-existing psychiatric
disorder is especially vulnerable to depression and depression-related physical illnesses.
- person’s pre-existing mental health problems may overshadow a grief reaction, and
consequently practitioners may be tempted to explain a change in symptoms as a change
in the underlying mental health problem rather than considering that the person may
actually be grieving. For this reason, it is important to be aware of baseline behaviour that
would normally be expected for the person, and be alert for exacerbation of pre-existing
mental illness.

Sense of presence of deceased-

- One particular aspect of grief that many bereaved people report is that of sensing the
presence of a deceased person in some way.
- Traditional grief literature typically describes these types of experience as ‘wishful
thinking’ symptoms of grief or even ‘hallucinations’, while popular literature attributes
these experiences to ‘afterlife communication’, ‘afterlife encounters’ or sometimes ‘after
death communication’.
 INTERVENTIONS AND COUNSELLING
- It is important to remember that most people who are bereaved do not necessarily need
or benefit from counselling, and in fact, interventions for some people experiencing
normal grief may even be harmful. Intervening too early can impair the experiencing of
emotional pain that is a normal, healthy response to loss, and is a necessary experience
for the bereaved. To provide appropriate support to those who are bereaved requires
basic counselling skills along with an appreciation of the process of grief.
- any intervention with a bereaved person should be undertaken with the core conditions of
warmth, empathy and genuineness outlined by Rogers. According to Worden, the overall
goal of grief counselling is to ‘help the survivor adapt to the loss of a loved one and be able
to adjust to a new reality without him or her’. He goes on to link the process of counselling
with the four tasks of mourning.
- Careful and attentive listening can enable the bereaved person to talk and process the
reality of the loss, especially as in most social and family situations the person may feel
actively discouraged from being able to talk about their feelings. One important tip is to
avoid using euphemisms such as ‘passed away’ or ‘resting in peace’ when counselling a
person who is bereaved. When talking to a bereaved person, using the terms ‘dead’ or
‘died’ are unambiguous and reinforce the reality of the loss.
- it is really important to help the person accept and work through their pain, which may
also include feelings of anger, guilt, anxiety, helplessness and loneliness. Sometimes a
bereaved person will be angry – at the person who died, with themselves or towards other
people, perhaps family members or professionals who cared for the person who died.
Sometimes this anger will be directed at the professional. Letting the person know that
these feelings are normal and providing a safe space for the person to ventilate them can
be very healing. Gently encouraging the person to find counter examples to the anger,
perhaps feelings of forgiveness and acceptance, can be helpful.

Helping the client overcome various impediments to readjustment after the loss

- The focus of interventions here is on supporting the bereaved person to adapt to a loss by
facilitating their ability to live without the deceased and to make decisions independently.
Worden recommends that the counsellor uses a problem-solving approach that explores
the specific problems the survivor faces, and the means by which they can be resolved.
- the person who died may have fulfilled several roles in the life of the bereaved person –
for example, friend, companion. Depending on these roles, the bereaved partner might
feel quite lost, and sometimes help in developing practical, financial or decision-making
skills can be valuable. Sometimes advice regarding social activities will encourage the
bereaved person to create networks that provide company and companionship. Issues
regarding the loss of a sexual partner will need handling with sensitivity.
- Utilizing the narrative therapy concept of ‘re-membering’, described previously, can be
tremendously helpful in helping the bereaved person maintain a bond with the deceased
person, with the aim of keeping the voice of the dead person as a resource. Being able to
talk freely about the dead person can bring renewed strength into a person’s life.
 SYSTEMIC APPROACHES TO COUNSELLING
- From a more systemic, constructionist perspective, Gunzburg offers a helpful process of
affirmation, deconstruction and reconstruction during therapy or counselling for people who
are grieving. This process includes defining the problem, exploring the context and exploring
options for the future.
- • Defining the problem- Here, the role of the therapist is to encourage clients to describe
their emotions related to unresolved grief; therapists gain an understanding as to how
clients construct their views of the context within which those emotions arose.
- • Exploring the context. When clients relate their problem to loss, the role of the therapist is
to affirm the client’s view, highlight their strengths, and utilize creative resources to express
unresolved grief. Alternately, some clients may relate their problem to a cause other than
loss, often involving blaming and linear thinking. The role of the therapist is to deconstruct
the client’s view, offering another context in which to view the problem. Therapists the n
can affirm the client’s changes and utilize creative resources to express unresolved grief.
- • Options for the future. Therapists and clients mutually reconstruct a context which offers
autonomy, increased options, freer emotional expression, creative and holistic thinking, and
new direction towards a more rewarding life and agreeable relationship.

TRAUAMA AND CRISIS INTERVENTION-

- crisis is defined as “a perception or experiencing of an event or situation as an intolerable

difficulty that exceeds the person’s current resources and coping mechanisms.” A crisis can
be described as a state of disequilibrium which occurs when a person has reached a state
where their resources and coping mechanisms are stretched too far. Individuals who
experienced the crisis might have irrational beliefs toward self, others, and the world.
- A disaster can be natural, such as a hurricane, tsunami, or tornado, or can be man-made,
such as a mass shooting or terrorist attack. It is a sudden event that disrupts the
functioning of a community or society and often results in human, material, or economic
losses.
- At the most basic level, trauma refers to the emotional response an individual has to an
event that was perceived to be physically or emotionally harmful.
- DSM lists a traumatic stressor as: exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) of the following ways: directly experiencing the traumatic
event, witnessing, in person, the event(s) as it occurred others, learning that the traumatic
event(s) occurred to a close family member or close friend..., experiencing repeated or
extreme exposure to aversive details of the traumatic events(s). The traumatic event has
“lasting adverse effects on an individual’s mental, physical, social, and spiritual wellbeing”.
While crises are relatively brief events, a trauma response is more extreme, enduring and
involves specific psychological and physiological responses reported that trauma exposure
is correlated with increased risks of medical and mental health problems, such as PTSD,
depression, anxiety, substance abuse, attempted suicide, and so forth. The effects of
trauma are prolonged, as individuals may have recurrent experiences of the event,
amplified arousal, negative thoughts, moods or feelings and avoid thoughts, places, and
memories related to the event. While all traumas are caused by a crisis, not all crises result
in trauma. Crises and traumatic events are highly subjective experiences from which people
construct their own meaning. A person’s response to a crisis or traumatic event is often
 determined by factors such as time, cultural beliefs, availability of social supports, and
developmental stages. For example, in some cultures, the subjugation of women is a
common practice, and the experience of domestic violence is not necessarily considered to
be a traumatic event.

HISTORY OF TRAUMA, DISASTER, AND CRISIS COUNSELING

- A modern understanding of trauma began to develop in the mid 1800s when Jean-Martin
Charcot, a French neurologist, studied symptoms of hysteria in women. Charcot
recognized that many of his patients experienced sexual assault, violence, and poverty. He
determined that the symptoms observed were psychological in nature and occurred as a
result of an unbearable experience. Charcot named this phenomenon “nervous shock.”
- In the late 1800s, Freud conducted a study on hysteria, in which he determined that hysteria
resulted from trauma and that the symptoms could be alleviated through talking about the
experience. In 1896, Freud published The Aetiology of Histeria, a collection of 18 case
studies on women. Freud resumed his work on trauma following World War I. In 1917, he
published Introductory Letters on Psychoanalysis, in which he outlined symptoms of trauma
that would later serve as the core of the classification of post-traumatic stress disorder
(PTSD) in the DSM-III (1980). Freud also expanded his concept of events that caused trauma
to include war, accidents, and any event that could result in fatality.
- The major catalyst for the beginning of crisis intervention occurred in 1942 with the
Cocoanut Grove Nightclub fire, where almost 500 people died. Eric Lindemann worked
with many of the survivors and noted similar emotional responses that required
psychological support. Lindemann’s work was one of the first to conceptualize what
thoughts, feelings, and behaviors may be “normal” following a crisis or disaster.
- Grassroots movements in the 1970s and 1980s led to the further development of crisis
theory and trauma. Veterans returning from the Vietnam War were exhibiting high levels of
distress related to combat exposure. The women’s movement was also gaining momentum
and women were drawing more attention to the negative consequences of rape, incest, and
sexual assault. Psychiatrists began to notice similar symptoms in combat veterans and
women who experienced sexual assault, including patterns of numbing, dissociative
symptoms, and increased arousal. This realization encouraged professionals in the field to
broaden their concept of traumatic experiences. The increased attention to crisis, traumatic
experiences, and traumatic symptoms led to the incorporation of PTSD in the 1980
revision of the DSM-III (1980). Prior to the 1980 revision, stress-related conditions were
defined narrowly and were said to be caused by combat or civilian catastrophes. The 1980
revision of the DSM removed lists of qualifying traumatic events and instead listed a
“recognizable stressor” as the cause of stress. Since then, substantial revisions have been
made to trauma and PTSD in the DSM.

DIFFERENCES BETWEEN CRISIS INTERVENTION AND THERAPY

- Working with clients in crisis may differ significantly from a traditional therapeutic
relationship. Crisis work is much more time-limited than long-term therapeutic work. The
counselor typically has to build rapport quickly and may work with more resistant or
overwhelmed clients. What may occur over the course of a few weeks in long-term therapy
may need to occur in a matter of hours in crisis intervention. Additionally, crisis work does
 not involve an in-depth exploration of the client’s issues. The counselor works to understand
the presenting problem, but does not explore further. Lastly, the therapist does not aim for
long-term change in crisis counseling. The overarching goal is to move the client from a state
of immobility to mobility and to return to his or her pre-crisis state.

Characteristics of an Effective Crisis Helper

- When working with a client in crisis, counselors do not always have the time to reflect on
which techniques and theories would be the most beneficial for the client. For this reason,
counselors should be introduced to and have a basic understanding of crisis theory and
intervention techniques. Additionally, it is helpful if the counselor possesses some of the
following characteristics: life experience, poise, creativity and flexibility, energy and
resiliency, and quick mental reflexes. Experiencing a situation similar to the client’s can help
counselors gain emotional maturity and enhance the depth and sensitivity of their
interactions with clients. While personal experience can be beneficial, it is also important for
the counselor to be aware of and manage counter transference as it arises.
- Poise refers to the counselor maintaining internal and emotional responses and appearing
stable and in control for the client. A calming presence may help bring the client’s
emotional level down and can serve as a model for highly reactive clients.
- Creativity and flexibility refers to the counselor’s ability to adapt to the crisis situation.
There is no “right” way to approach a crisis situation, and counselors must be willing and
able to draft a tentative course of treatment and then get rid of it if it is not working.
- Energy and resiliency refers to the counselor’s personal wellness. Crisis work can be
exhausting and can have many downs. It is important that counselors practice wellness to
promote resiliency.
- Lastly, crisis counselors must possess quick mental reflexes. Crisis work requires more
activity and directiveness. Counselors need to be comfortable and assured in making quick
decisions, especially in the assessment and action phases.

ASSESSMENT IN CRISIS COUNSELING

- Assessment in crisis counseling is done rather quickly and with limited information. For
this reason, the counselor must be able to ascertain the difference between a client who is
emotionally upset and a client who is in a state of crisis. Importance is placed on an accurate
assessment because it is the baseline for the interventions and treatment planning.
- An assessment tool, such as the Triage Assessment Form (TAF) is helpful in assisting
counselors in providing quick, effective, and accurate assessments. The TAF was developed
to serve as a reliable and easy to use tool so counselors with limited assessment skills could
use the form without difficulty.
- counselor can utilize informal measures to assess the client’s affective, behavioral, and
cognitive states. The goal of these types of assessments is to gauge the severity of the crisis,
the client’s level of mobility, assess for suicidality or lethality and to assess the client’s ability
to think about the situation in a logical manner.
- Recognizing Symptoms of Trauma and PTSD Recognizing possible indicators of PTSD is an
integral part of crisis counseling because it may be a precursor to some crisis situations such
 as substance abuse, or an after effect of others such as sexual assault. PTSD frequently
presents with a comorbid diagnosis, such as depression or substance use, and symptoms
often get overlooked when the focus is placed on the personal or interpersonal distress that
occurs as a result of the PTSD.
- Trauma assessment is most commonly done through a structured clinical interview;
however, counselors may find it useful to use additional assessment tools to increase
understanding and treatment of a multitude of potential trauma responses [4]. It is also
important for counselors to recognize symptoms of trauma so they can make accurate
referrals in the action phase; when necessary. Counselors should be able to recognize when
they are working outside of their competence and may risk doing more harm because of an
ill-informed approach.

PSYCHOLOGICAL FIRST AID

- Psychological first aid (PFA) has become the basic approach clinicians use when responding
to crises. This approach attends to Maslow’s hierarchy of needs, in which physical needs and
safety are addressed before moving to emotional stabilization. Given the time-sensitive
nature of crisis work, this approach is not meant to be curative. Rather, it is meant to
alleviate the problem until further action can be taken. PFA is a non-intrusive method that
offers practical assistance and stabilization. PFA is not meant to serve as a full-blown theory
or intervention model. It is the basics of crisis intervention. Although PFA is presented in a
step-by-step manner, crises are chaotic and often do not occur in a linear format [1]. For this
reason, assessment is a continuous and ongoing process when working with a client in crisis.
The first three steps of PFA are focused on attending, observing, and understanding the
client’s problem (James, 2008). In the first step, counselors use their core listening skills to
define and understand the problem from the client’s perspective. In the next step,
counselors assess the client’s safety and work to minimize physical and psychological
dangers. The third step involves providing emotional, instrumental, or informational
support. The type of support is dependent upon the needs of the client.
- In the fourth step, the counselor and client examine appropriate choices that are available to
the client. The amount of input from the client is dependent upon his or her level of distress.
The counselor and client should examine social supports, coping mechanisms, or behaviors
the client can engage in to get through the crisis, and positive and constructive thinking
patterns to help reduce stress and anxiety. The fifth step in PFA involves making plans. The
counselor and client identify additional people and referral sources that can be contacted
for immediate support and develop concrete actions the client can do in the moment. This
step is central in the client regaining control and autonomy. The final step involves obtaining
a commitment from the client. This step is often very brief, and the goal is to have the client
commit to one or more behaviors that will assist in restoring them to their pre-crisis state.

COUNSELOR SELF-CARE
- Crisis, disaster, and trauma counseling is challenging work, and counselor self-care is an
important and essential aspect. When working with clients in crisis or with people who have
experienced intense psychic trauma, counselors are also at risk for experiencing vicarious
traumatization (VT), or stress resulting from working with clients who have been
traumatized or are suffering (Levers, 2012). Counselors may be at risk of experiencing
symptoms similar to their clients. One way to mitigate the chances of experiencing VT is to
seek out supportive and regular supervision. Experiences in supervision often reflect
experiences in the counseling relationship, and ongoing supervision may assist practitioners
in recognizing when they may be experiencing symptoms of VT. Counselors must take the
time to promote their emotional, physical, mental, and spiritual wellbeing. Self-care is a time
for reflection, healing and growth. Without it, the effectiveness of the crisis and trauma
work may be diminished. Counselors cannot effectively assist clients without attending to
their own emotional needs. When they engage in self-care, they are able to remain present
and fully attend to the needs of the client. Counselor self-care can also assist clients in
developing resiliency. While crises and trauma can be painful experiences for both the
counselor and the client, working through them provides an opportunity for the client to
recognize their strength and ability for growth.