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TopGrief: A Clinical Model for Healers
I. Definition: Grief is a process of facing a significant loss and of adjusting to it, resulting in a resolution of the loss and a choice to live life again.
It is absolutely important to belief that grief is a healing process. There is nothing wrong with grieving—it is not a sickness calling for us to help the person find a cure. If it were not for the process of grief the person would be faced with two options. The person can pretend that what was lost really wasn’t important, or he could defend against the pain of loss by refusing to allow anything or anyone to become so central in his life again. The first option is a lie. The second option is to live in a Hell of isolation. The process of grieving is the healing that allows us to reinvest ourselves in life after a loss. You must believe this, not just with your head, but also with your heart. Our general attitude toward the grief process will be communicated to the person grieving, whether we wish it to be or not.
B: Significant Loss: The full grief process can be triggered by any significant loss. We do not determine what is significant for any other person, he either experiences a grief process or he doesn't. If he has organized his life, his love, or his identity around a particular person or thing, and that is lost, a grief reaction will be triggered.
It is not just the death of a loved person that can cause a grief reaction, but literally any loss. The death of a pet, divorce, loss of a job or house, amputation of a limb, or a change in body image are common triggers. Even a positive, joyous, voluntary change can lead to grief because of a loss associated with it. For example, marriage, a promotion, graduation, or the birth of a child can also be times of losing a friend, personal freedom, or security.
At times, one loss that is objectively minor may be a symbol for a much more important loss, leading to an intense grief process. Again, no one can judge what is or should be significant for someone else. For the purposes of clarity in this presentation I will be speaking as if the only loss is the death of a family member.
C: Resolution: This refers to the point in the grief process when the person comes to be able to "say good-bye" without pretending that the loss didn't matter. It does not mean that you ever forget the person who was lost, but it does mean that not only with the head but also with the heart a person is able to release what had been a central part of his life.
D: Choice to Live Life Again: True resolution results in a real choice to live life again. When you face loss and resolve it, I believe that you attain a greater depth of maturity as a person—there's a greater ability to hope and to love. There is a courage in opening your heart to another person even in the midst of knowing how vulnerable we are when we love. This is the end result of the grief process.
II. Types of Grief:
B: Actual: Grief triggered by a loss that has actually happened—an accomplished, completed event. Following awareness that the event has taken place, we grieve.
C: Hybrid: Grieving when there can be no immediate, objective certainty that the event has indeed taken place. There is a strong internal drive to be certain and yet, at least for a time, there can be no certainty. Good examples would be a situation of someone Missing In Action, a teen-aged runaway, or a drowning where the body is not recovered.
Each of these forms of grief will follow the same general pattern and involve the same dynamics with one exception. I do not believe that the hybrid type can be resolved until the person begins to identify the loss as having really taken place and switches to an "actual grief."
Preparatory grief, while being a full grief process, does not take the place of actual grief. When the loss does occur, the person begins a new grief process, but depending on the extent to which the person has already been grieving, the new actual grief reaction can be expected to move more rapidly.
III. A Short Model
A: Shock/Denial: The realization of loss (impending or actual) triggers the process. There are close parallels to the physical shock syndrome and this emotional shock reaction serves as a buffer shielding from being overwhelmed by the event. Nausea, a sense of unreality, weakness, and dizziness are common. Shock allows time to cope with the reality of the loss.
B: Catharsis: There is then an intense expression of emotion, usually involving tears, anger, guilt, or profound sadness. The reality of the loss is experienced, and emotions directly connected with are experienced.
C: Mourning: This is a process of reviewing and reflecting on the relationship and its meaning. Usually early in the grief process there is an idealization of the person or object that's been lost, followed later by a more realistic assessment. Usually there is a going over of "treasured moments" one by one as part of the process of letting go a little at a time.
D: Resolution: There is a recognition of the loss, a saying good-bye, followed by a choice to continue with life. There can then be development of new activities and new interests, not as a form of escape, but as a function of reinvestment in the process of life. If the grief is anticipatory (preparatory) grief over your own death, this stage is usually termed "acceptance" and is characterized by a sense that life and relationships have been completed. There is a tying up of "loose ends" followed by a sense of peace.
In looking at this short model of the dynamics of the grief process, it's important to recognize that the person doesn't go through each part of it one time. In the same conversation with a person, you frequently see evidence of all four phases simultaneously. Over the course of time, however, the periods of shock become less, then the periods of intense emotion become less, etc. The person gradually comes to release the lost object over time.
IV. To Be of Help: A Clinical Model
Each of us, depending upon training, experience, and opportunity, will differ in the degree to which we become involved with those going through one of the processes of grief. All of us can be involved helpfully with a person grieving by assisting the person through the process of ventilation described below, if we also carefully adhere to the cautions listed. We may choose to intervene in the grief process after becoming aware of a "block" by using the appropriate intervention. Finally, we may choose to attempt to have an impact upon the intensity of the grief process for a particular person by influencing one of the six "intensity factors" listed below. The most important consideration in all of this is to avoid is "trying too hard."
While much of what will be described and suggested may seem self-evident, as we go through this model increasing levels of skill and experience are necessary to appropriately be of assistance in the grief process. What may seem relatively simple in theory can become much more complicated in an actual clinical setting. Unless you are sure that you are assisting the power to heal of the grief process and giving a full measure of respect for the uniqueness of each person as he grieves, it is essential to remain on the level of "ventilation." The rule to follow is the ancient directive of medicine, "First do no harm."
It helps to be aware that difficulties are compounded when you are in contact with more than one person at a time in a grief situation, when someone is asking advice about another person who is grieving, or when you do not have access to some significant information.
Frequently the person you are working with will use these types of statements themselves. While not directly confronting the usage, it is very helpful to avoid them yourself. By using open, direct language, you are tacitly conveying your stance of openness. You are modeling an attitude of facing the grief directly.
3. Don't try to "solve" the grief. It is a healing process, not a sickness calling for a magic cure. All of us like to succeed. Success in a contact with someone in grief is not measured by whether we have somehow "damped down" or ended the grief process, but in much simpler ways. If the person was very anxious at the beginning of the contact, is he less anxious now that he has had a chance to talk about it? If the person felt "bottled up" at the beginning of the contact does he now feel more free for having expressed a particular emotion? "Success" is measured by whether a process of healing is taking place more smoothly for a person, not in a "solution." The person goes through the grief on his own. You are there to support him, to walk with him part of the way if he would like you to.
4. Avoid using the term "depressed." The term can be a way of stereotyping a person who is grieving and emotionally stepping back to a more comfortable distance.
A frequent, recurring, intense part of the grief process is a profound, heavy sadness, a preoccupation with the person or thing that has been lost; and a difficulty in developing an interest and involvement in the ordinary details of everyday life. A certain amount of this is normal and natural. This sense of sadness can be characterized as: self-limiting in intensity; of relatively short duration (no more than a few days at a time); and roughly proportionate to the significance of the loss. It is best simply talked about as "sadness" or "mourning" and spoken of in a way that identifies it as a common human experience. There is nothing wrong with it, although it is uncomfortable for both the person and those around him.
"Depression" is a symptom of an emotional problem calling for treatment, and is also the name for a specific psychiatric diagnosis. This type of problem may not be self-limiting. The person's mood drops down, and he may have a very difficult time returning to a normal range of mood. He may need medical treatment to be able to do it at all. It is of long duration, and is frequently out of proportion in terms of intensity to whatever served as the trigger. A person who is chronically depressed may have an acute episode, or a person with no history of depressive disorder may have a one-time clinical depressive reaction. Sadness and depression. though, are two distinct realities.
B: Working with "Blocks" in the Process of Grief: For a variety of different reasons a person may become "stuck" at a particular point in the grief process. For example, a person may feel anger toward the person who has died, but be unable to express the feeling that the person has "abandoned" him. Ordinarily, the person will still find his own way through or around the block with time, as part of the move toward health. However, by being available to the person, and by your sensitive, careful involvement, you can choose to help the person to find his way through. You can help avoid unnecessary pain and shorten the time of grieving. The following interventions, in the absence of a history of serious psychiatric illness, can be chosen in working with someone. However, be as sure as possible that your intervention will actually end up being helpful. If you are not sure with a particular person, stick to the process of ventilation.
Intervention: Carefully, gently "defend" the person's right to grieve. You are acting as a counterbalance to the contamination coming from outside the person. The strength of the defense is proportionate to the strength of the contamination. Without damaging the person's relationship with the "advisor" you are giving the person "permission" to reject the faulty information.
2. Suppression of Emotion: Usually the emotions being held back are those of sadness (crying), anger, guilt, or a sense of ambivalence toward the person himself. The person may feel that if the emotion is acknowledged or expressed that it will never end. He may feel or have been told that a particular emotion is "wrong," that he shouldn't be feeling what he is. For some reason, though, the person tries to "bury" the emotion within himself or to "swallow" it. If there is suppression the drive to resolve the emotion is strong enough that if it is not expressed directly, it will often be expressed in some symbolic form. The end result of the struggle may be physical sickness.
Intervention: Simply give explicit "permission" to express that emotion in appropriate ways, i.e., "It's OK to cry." If necessary, help the person find ways to express the emotion in small doses or symbolic ways. Don’t be afraid to question inappropriate or destructive expressions. It’s OK to be angry, but it's not OK to blow down the front door with a shotgun. Always accept the reality of an emotion that is actually present.
3. Fear of the Grief Process Itself: The power and intensity of the process may cause the person to fear that he is "going crazy," that the present intensity of pain will never end, or that he cannot cope with the barrage of different emotions being experienced. Particularly if the person's support system is somewhat weak, there can be fear of facing the process alone.
Intervention: When this block becomes evident, there is also usually an implied or direct request for information about the grief process. The appropriate intervention is simply to explain it as a process of healing. The open discussion should lessen the power of the fear to the point that the person can move on from there. Never promise help that you may not be able to deliver.
4. Delusional Guilt: The person often may need to "feel guilty" for a time, and this feeling may have nothing to do with objective reality. The person is unable, for a time, of making an objective assessment of guilt that he can accept in his heart.
Intervention: Accept "feeling guilty" as an emotion. Avoid "cheap absolution." If you attempt to diminish the sense of guilt or assess it, what the person will hear is that it is not acceptable to "feel guilty" or that he is foolish. Never go along with a request to in some way "punish" the person, even symbolically. Avoid confirming or denying the person's assessment, but accept the feeling (very difficult in practice).
C: Modifying Intensity Factors: It is often possible to identify one or more factors that are contributing to a high intensity, or by planning ahead to avoid them. The factors listed below are, I believe, the most important in determining the power of the emotions in the grief process, its duration, and its impact upon other parts of the person's life. These factors will act jointly to either increase or decrease this intensity. The insight and creativity of the helping person can be brought to bear on a factor increasing intensity, whether it is already apparent or you can foresee that factors will conspire together later to make the grief more difficult. There is such wide variation in grief from person to person that interventions may range from formal therapy sessions with a clinical psychologist to work through an early unresolved grief to increasing the level of the person's support system by recommending an appropriate bereavement group. Creativity comes in recognizing what is an important factor in a particular grief process and then choosing an appropriate means of influencing it. Wisdom in developing a sense of how to influence what can only come from practical experience, and even when complete respect is given to the uniqueness of each person's grief, working with any one of these intensity factors can easily backfire. HANDLE WITH CARE.
2. Past Unresolved Grief: Each grief reaction in the person's past life that has not been fully resolved has left as a residue unresolved strong emotions. The person himself may have forgotten the cause of the grief, but the emotions surrounding the grief are eternal. Ordinarily, unresolved past grief will be triggered by a similar present loss, and will be experienced at the same time. Even to the person himself, the power of a grief where a past loss is acting as a "multiplier" can be surprising to the point of being shocking or even lead the person to fear that he may be going insane.
For example, if a person's wife died ten years ago, but for some reason the grief was never resolved, and his pet canary dies, a grief reaction of great intensity may begin. As the person grieves for his canary, his wife is also being mourned.
3. Circumstances of the Loss: During anticipatory grief, and during the very early stages of actual grief, the details of the experience of the loss are frequently subject to improvement.
4. Personal Grief Pattern: Each of us has a unique style of grieving that ideally fits our own personality. We will usually follow the same general pattern for all of our times of grief unless there is a choice to change it at some point. At times, my grief pattern (or the one I have learned) may not be very helpful to me or have been "contaminated" to a degree beyond that mentioned as a block.
5. Quality of the Support System: Involves anyone who takes on a role of support, or to whom the person looks for support. Both quantity and quality are important.
6. Belief/Value/Culture System: Especially important in terms of the person's relationship with God. Not always a support, can encourage a complete denial of the reality of the loss (I must believe in the Resurrection), increase the sense of loss (Not only did my baby die, but now he's in Limbo), or cut off important support (If I admit I'm angry at God, my church will cut me off). Obviously, can also be a strong help, provide patterns for expressing grief, and proclaim hope.
V. Referrals: Tailored to the individual person, the following are some general options:
B: If the grief appears unusually intense, overwhelming, or long-lasting, and is beyond your ability to assess, refer the person for assessment and/or counseling. Among the resources to consider for either general support or assessment would be the following:
D: If there is a history of serious emotional problems in the past, encourage contact with whatever professional was being seen at that time. Reopening lines of communication can be powerful "preventive medicine" and help the professional to act quickly and appropriately if problems do arise.
E: In rare circumstances, there may be symptoms of emotional disorder severe enough to warrant referral to a crisis center for immediate assessment.
WANTED:
Strong, deep
person,
- wise enough to allow me to grieve in the depth of who I am,
- strong enough to hear my pain without turning away.
I need someone
- not too close, because then you couldn't help me to see,
- not too objective, because then you might not care,
- not too aloof, because then you couldn't hug me,
- not too caring, because then I'd be tempted to let you live my
life for me.
I need someone who believes that the sun will rise again, but who does not fear my darkness or my walk through the night.
Someone who can point out the rocks in my way without making me a child by carrying me.
Someone who can stand in thunder, and watch the lightening, and believe in a rainbow.
© Fr J Mahoney