Course:SOWK551/2021/Counselling Clients after the Death of a Loved One
Short Summary
Literature review informing healthcare social workers about grief conceptualization and counselling interventions to support clients after the death of a loved one.
Author: Anonymous
Date: April 6, 2023
Introduction
Although loss is a universal human experience, and death and dying are natural to the life cycle, the process of grieving can feel far from natural to a bereaved individual (Stroebe & Schut, 1999). Healthcare social workers are often tasked with supporting individuals when grieving, and literature shows that due to the complex, overwhelming, and long-lasting symptoms of grief reactions, mental health professionals can feel a sense of helplessness when counselling individuals through grief and loss after the death of a loved one (Duffy, 2015; Yousuf-Abramson, 2021). It is imperative for social workers involved in grief counselling to be knowledgeable of the broad range of behaviours that fall under the description of grief and to have up-to-date information on effective ways of framing assessments and interventions to support their clients (Mason et al., 2022). This literature review will explore historical and current conceptualizations of grief, review literature regarding evidenced-based interventions to support grief processes and will discuss application to social work in health care.
Keywords: grief, culture, intervention, conceptualization, social work, healthcare.
A Brief History of the Conceptualization of Grief
Grief rituals and bereavement support have existed since time immemorial in culturally and spiritually specific ways for individuals hoping to honour, process, and adjust to the death of a loved one (Martin, 2022). The way that grief and bereavement are framed is socially contextual, influenced by historical and cultural understandings of death and dying, as well as emotional well-being (Neimeyer, 1999).
Early Western grief theory pathologized the bereaved and forced them to conform to rigid societal norms around grieving (Yousuf-Abramson, 2021). Freud’s studies of ‘Trauerarbeit’ (grief work) concluded that one must confront the experience of bereavement to come to terms with loss to avoid detrimental health consequences (Stroebe & Schut, 1999). This aligned with modernist beliefs that grief support should focus on guiding individuals to regain a sense of independence by detaching from the loss (Yousuf-Abramson, 2021).
In 1969, Kubler-Ross developed the linear five-stage model of grief, including stages of denial, bargaining, anger, despair, and acceptance (Yousuf-Abramson, 2021). This model was widely accepted and used in grief therapy. Bowlby and Parkes also developed an influential phase model based on attachment theory with an acknowledgement of the biological functions of grief (Worden, 2018). This model is grounded in supporting individuals to reorganize their representations of the loss and their own identity to achieve adjustment to life without their loved one's physical presence. The phases include numbness, yearning, disorganization, despair, and reorganization (Worden, 2018).
While Modernist grief work and the phases and stages models offered individuals the acknowledgement of the pain and transition that occurs during grieving, they have been critiqued by post-modernist understandings of grief for being linear when individuals often experience feelings, thoughts, and physical sensations of grief in non-linear ways. These theories lack application across cultures and are highly individualized, not accounting for the relational contexts grief often occurs within (Stroebe & Schut, 1999). Furthermore, interventions within modernist grief work can be a passive process of waiting for individuals to move through stages or phases (Hashempour & Anand, 2023). Grief is now understood to be a unique and complicated process impacted by culture and context, and tailored interventions that validate a client's reality without pathologizing their response are accepted to be the most effective (de Mönnink, 2017).
The Task Model of Grief
Informed by post-modern grief theories, Worden’s Task Model of Grief has been used by social workers and counsellors when supporting individuals experiencing grief (Yousuf-Abramson, 2021). Worden defines bereavement as the process in which a person comes to terms with a loss. Grief is defined in this model as a person’s reaction to bereavement comprised of thoughts, feelings, and behaviours experienced after the loss that changes over time (Worden, 2018). Worden proposes that grief experiences are comprised of tasks for the individual including accepting the reality of the loss, processing the pain of the grief, adjusting to the world without the deceased, and remembering the deceased while incorporating their memory in their life moving forward (Worden, 2018).
Interventions exploring meaningful grief rituals for the bereaved individual have been developed to support individuals in moving through the tasks. A ritual is defined as “a specific behaviour or activity which gives symbolic expression to certain feelings and thoughts of the actor” (Martin, 2022). Rituals that are helpful in supporting individuals through the first task of acceptance include saying goodbye to their loved one, funerals, and visiting the cemetery or ceremony around the deceased’s ashes (Martin, 2022). For the second task, processing the pain of the loss, interventions that support individuals in expressing their emotions related to the loss are helpful, these include acknowledging feelings, somatic experiencing of emotions, communal grieving, and talk therapy among others (Martin, 2022; Worden, 2018). The third task, adjusting to the world without the deceased, can be supported by rituals that “mark a transition” and demarcate a moment in time to signal change and transition (Martin, 2022). For the last tasks, grief rituals that “establish ongoing connections” to the dead and “validate their legacy” such as memorials, keeping precious objects or pictures in memory, speaking or writing to the deceased, and including their memory during life milestones and celebrations are common ways of actively moving through this task (Martin, 2022; Worden, 2018).
Like the previously proposed stages and phases models, Worden’s tasks model has been critiqued for defining grief as a linear process, and social workers have modified this model to acknowledge that an individual may experience tasks in a different order, or simultaneously, and by considering that grief is often a lifelong experience with potentially no end (Yousuf-Abramson, 2021).
The Dual Process Model of Coping with Bereavement
The Dual Process Model, developed by Stroebe & Schutz (1999), expanded modernist grief theories and Worden’s task model to provide a model for understanding how individuals cope after a significant loss. This model describes two coping processes individuals experience during grief (Stroebe & Schutz, 1999). One coping process is loss orientation, which refers to the bereaved person’s processing of the loss experience, including the painful dwelling on the lost person. Restoration orientation, the other process, refers to the struggle to reorient oneself in a changed world without the deceased person (Stroebe & Schutz, 2010). This model acknowledges the oscillation between the experiences rather than experiencing them linearly, and the oscillation between the positive and negative emotions of each process (Stroebe & Schutz, 1999). The dual process model also describes the importance of taking breaks from grieving, where the individual distract themselves to support managing their emotions (Stroebe & Schutz, 2010). This model, although it attempts to account for gender, cultural, and intrapersonal differences, has been less used in social work theory and practice for building grief interventions than Bowlby’s Phases Model and Worden’s Task Model (Simpson, 2013; Yousuf-Abramson, 2021).
Cognitive Behavioural Therapy & The Principles of Loss Model
Cognitive behavioural therapists have developed comprehensive intervention models to address clients’ grief and loss in an active therapeutic approach (Hashempour & Anand, 2023, Weinsten, 2008). The Five Phase Principles of Loss Model encompass traditional meta-cognition approaches from CBT, as well as compassion-focused and acceptance and commitment approaches to support individuals in grief processing. The development of cognitive behavioural therapy to integrate cultural practices, mindfulness, self-compassion, and acceptance approaches allows the model to be more flexible for an individual’s needs and limits the impact of pathologizing the individual’s emotional responses (Hashempour & Anand, 2023).
This intervention is comprised of five phases. The first phase acknowledges and provides psychoeducation to clients about stress and the threat system that is activated during grief, the brain and body connection, as well as the evolutionary functions of emotions and cognitions. The counsellor and individual build awareness of the present emotions, by noticing, and naming feelings using daily feelings log (Hashempour & Anand, 2023). The counsellor and client can begin to develop distress tolerance, mindfulness, and emotional regulation strategies that support the client when they are experiencing distress with the introduction of the cognitive triangle to explore behavioural interventions (Hashempour & Anand, 2023).
The second phase of treatment involves further exploration of cognitions, and the idea of past, present, and future challenges that impact the client’s current well-being. Clinicians can employ a daily rumination log to support clients in tracking their thought content, and the emotional impact of these cognitions (Hashempour & Anand, 2023). The third phase reviews the knowledge and skills the client has developed thus far, and introduces principles of self-compassion, including examining how grief has impacted client’s perceptions of self and how their relationships, society and culture have influenced their perceptions on how grief ‘should’ look in comparison to how they experience it (Hashempour & Anand, 2023).
The fourth stage uses acceptance commitment therapy to collaborate with clients to consider their values and what they wish to embody in their present and future life. This is an opportunity to address the loss of identities that occurred through their bereavement and build hope for a fulfilling future (Hashempour & Anand, 2023). The fifth phase is building acceptance of the loss, grief, and looking towards the future to transition into a life led by values (Hashempour & Anand, 2023).
The five-phase principles of loss model is an active form of addressing grief and loss, which can be time-consuming and tiring for clients with busy lives or living in crisis (Weinsten, 2008). The biomedical understanding of emotions can be useful for some clients to understand their psychology and physiology but could be perceived by others as pathologizing their response (Weinsten, 2008, Simpson, 2013). This model has been shown to support individuals with complex grief and post-traumatic stress disorder (Hashempour & Anand, 2023).
Social Constructionism Theory, Grief & Narrative Therapy
One of the key deficiencies identified by critics of traditional grief conceptualization is the presumption of universality in experience. A social constructionist perspective, developed by Robert Neimeyer (1999) defines grief and loss as a meaning reconstruction process in which the bereaved integrates their loss into their story of themselves, the world, and themselves in the world. (Neimeyer, 1999). This approach empowers clients in an active process of decision-making in a circumstance where power and control have been taken from them through the loss, to negotiate whether their needs are to process the turbulent emotions the loss has confronted them with or to explore the restoration of their lives without the deceased (McTinghe, 2018). By acknowledging that grief is not a universal experience, the counsellor does not take the ‘expert’ position of the client's emotional world and can normalize the individual’s unique experiences and perspectives (McTinghe, 2018).
There have been many adaptations of narrative therapy to support individuals with grief meaning-making processes (Rafaely & Goldberg, 2020). Narrative therapy assumes that individuals use narration and storytelling naturally as a way of understanding their lives and the world, in both micro-stories to understand the day-to-day, and macro-stories to understand their identity and life story (Neimeyer, 1999). Narrative counsellors can work with individuals to explore their present narratives and re-write their life stories to support the individual in healing. Counsellors are encouraged to elicit a collaborative approach with clients and to emphasize the value of being as well as doing (McTinghe, 2018). Narrative therapy acknowledges that grieving takes time and is often a lifelong process, and that there are many points where no assignments or actions are needed beyond attending to what is taking place in one’s life (McTinghe, 2018).
Journaling about one’s feelings during grief, completing ‘life imprinting’ exercises where the client describes how the deceased has changed their personality, values, experiences, and life, and completing metaphorical activities to visualize grief are interventions social workers can use when employing a narrative therapeutic approach (Neimeyer, 1999). The Grief Snow Globe activity consists of the client and counsellor discussing grief emotions and assigning coloured ribbons to the feelings, as well as adding buttons or other small items to symbolize experiences they had with the deceased, or characteristics about them that they would like to remember (Rafaely & Goldberg, 2020). These items are placed in a jar to contain the emotions, to provide an external representation of their grief, and the paradoxes that exist within their stories (Rafaely & Goldberg, 2020). This approach has been shown to validate the uniqueness of the individual’s grief experience, assist in re-authoring narratives, and promotes understanding and new perspective taking on their loss (Rafaely & Goldberg, 2020).
Implications for Social Work Practice
Social workers regularly encounter individuals processing the grief and loss of a loved one and are uniquely positioned to provide consultation, collaboration, and guidance while walking alongside those facing newly distressing uncertainties following a significant loss (Johns et al., 2020). Social workers’ role in supporting individuals through grief and loss was further emphasized during the Covid 19 pandemic when the health crisis caused many sudden deaths, and those who were survived had higher rates of complicated grief or prolonged grief disorder (Aaslund, 2021). Social work theories such as a strengths-based approach, anti-oppressive practice, person-in-environment, and bio-psycho-social frameworks are essential in applying grief theory in work with clients according to social work ethics and values (Weinsten, 2008). The grief and loss theories and interventions outlined in this literature review should be used in tandem with social work interventions to support practitioners to build their knowledge base and guide their practice. Finally, access to grief counselling is a barrier for individuals who require support in processing their grief, as it is often privatized and costly, or free services have long waitlists and eligibility criteria that may exclude folks that need it (Weinsten, 2008). Social workers play an important role in connecting clients with supportive services and advocating for an increase in grief support (Simpson, 2013, Weinsten, 2008).
Conclusion
Grief support after the death of a loved one has been researched for over 100 years and the evidence basis for how to best support individuals is continuously growing (Neimeyer, 1999; Stroebe & Schut, 1999). This literature review explored historical and current conceptualizations of grief and identified several evidence-based models and interventions for social workers to employ to support clients in processing grief, such as the Task Model of Grief, the Dual Process Model of Coping with Bereavement, CBT & Principles of Loss Model, and Social Constructionism Theory. The literature identifies that although grief support has been researched extensively, social work theories have not been incorporated thoroughly into grief theory, and practitioners are recommended to utilize social work theories such as meeting clients where they are at, validating their coping strategies, providing culturally affirming care, and developing client-centred interventions in tandem with the other models (de Mönnink, 2017). Further literature to review to help social workers build a comprehensive knowledge base to support clients through grief is the physical, emotional, cognitive, spiritual, and social implications of grief, and the assessment of normal grief, complicated grief, grief versus depression, and post-traumatic stress disorder, which could not be covered in this literature review. Lastly, the implications of the lack of accessibility of grief services, and the way that intersectionality of race, class, gender, and ability impacts grief processing outcomes are salient gaps in the research and would be helpful avenues of research for social workers hoping to help clients navigate the difficult terrain of grief and bereavement and find a path towards healing and recovery.
References
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de Mönnink, H. (2017). Social work and grief support: The social workers’ toolbox (1st ed., pp. 454-488). Routledge. https://doi.org/10.4324/9781315678078-26
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Yousuf-Abramson, S. (2021). Worden’s tasks of mourning through a social work lens. Journal of Social Work Practice, 35:4, 367-379, DOI: 10.1080/02650533.2020.1843146
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