How grief works
Healthcare Counselling and Psychotherapy Journal, October 2022

I have worked with bereaved people for 22 years, but it was a counselling specialism I got into quite by chance – and certainly with no intention of it becoming a career. Before I trained as a therapeutic counsellor, I had been a science teacher, a background that has been instrumental in my current work. 

A couple of years after I qualified, I was working part time in student counselling, when I successfully applied for a second part-time job in the Bereavement Support Service at Saint Catherine’s Hospice in Scarborough. I didn’t expect to be there long; it was intended to be a stepping-stone to gain experience for private practice. I even toyed with the idea of downsizing and early retirement. I am glad that never happened, as over several years I became immersed in my hospice role. 

Saint Catherine’s had been something of a pioneer in bereavement support services, because, for historical reasons, it was community based, accepting clients bereaved from any cause, as well as supporting those who had lost loved ones in the hospice. I found the work rewarding and I was part of a supportive team, but my deep fascination with loss and grief slowly crept up on me.

Towards the end of the 20th century, grief theory and practice went through a period of change, and it was at this time that I was trained for this wing of the profession. Stage models of grief were popular. Clients were often led prescriptively through the stages by well-meaning bereavement counsellors, although this was never the intention of John Bowlby and Colin Murray Parkes.¹

Grief was seen as work, a task to be completed, giving rise to John William Worden’s tasks of mourning.² Even if it was never actually said, it was implied that the final stage of grief involved letting go of the deceased and moving on with life. We have Sigmund Freud to thank for the concept of ‘letting go’. Freud³ viewed the lost love object as an introject, from which those of a melancholic disposition needed to separate. The psychoanalysts who carried Freud’s banner through the first half of the 20th century believed that grief needed to be worked through, and that those who did not do so were in a state of pathological denial. It is arguable that modern, evidence-based research did not really begin until the second half of the 20th century, with Bowlby’s and Parkes’ stages of grief.¹ Parkes used interviews and observational studies of the grief of widows in the US, where he met the young Elisabeth Kübler-Ross. Meanwhile, Camille Wortman and Roxane Silver were challenging the concept of grief work,^4,5 which had taken centre stage for so long. Dennis Klass and colleagues were questioning the notion of ‘letting go’⁶ and Margaret Stroebe and Henk Schut were perfecting the dual process model,⁷ based in part on the realisation that grief work has a cultural aspect and is not a universal need.

At the time, most of these late 20th century developments passed me by. I was reliant on the books in the hospice library and knowledge of new developments gleaned from courses and workshops at other hospices. However, one piece of worrying information did filter through the hospice bereavement support community by word of mouth. There was credible evidence out there that some bereavement counselling was ineffective – and might even be harmful.

As a result of my teaching background, it was not long into my time at Saint Catherine’s Hospice before I began to deliver workshops to colleagues, which gave me an opportunity to read more around the developing theories. Eventually, I was invited to develop external training in partnership with York St John University. Now I could use the university library and gain access to peer-reviewed research, including the accumulating evidence on the limitations of bereavement counselling, which was persuasive.

With my co-trainer, Kath Atherton, we delivered the university module to several cohorts of students. Each time, we updated and refined the teaching materials to reflect developments in the research field. By 2010, I felt I had enough knowledge and original material to write a book.⁸ In recognition of the part played by the hospice in my professional development, the first four years of royalties went towards patient care.

In the workshops I provided for my colleagues, I had begun to address the evidence for the limited efficacy of bereavement counselling. As you can imagine, this was not well received. Everyone working in our service believed they were making a difference, and our outcome measures and levels of client satisfaction did appear to indicate that this was the case. However, our evidence was anecdotal.

So, I made the decision to self-fund a PhD. On a snowy January day in 2011, my proposal for a six-year, part-time PhD was formally accepted. Through recording and transcribing my clients who had given informed consent, I wanted to know exactly what takes place in the counselling session during those moments of therapeutic change. My hope was that I could explain the limitations of bereavement counselling from the evidence I was able to collect.

With my doctoral supervisors’ support, I designed an observational methodology, predicated on a theoretical proposition that although each person’s grief is a unique personal and cultural construct, it follows a generalised pattern of evolved grief behaviour that can be observed and recorded.⁹

Central to this doctoral research was a desire to explain the apparent limitations of grief counselling. Robert Neimeyer¹⁰ presented evidence that bereavement counselling is not always effective and might also do harm. John Jordan and Neimeyer¹¹ reiterated these findings and offered a possible explanation. They noted that research projects tend to recruit participants, whereas best results come from clients making their own decision and being ready for counselling. The timing of the intervention appeared to be an important factor. They also hypothesised that emotionally focused interventions might not be right for everybody and that some clients might need a more cognitive approach.

A meta-analysis, published by Schut and colleagues, presented similar evidence.¹² They concluded that to offer counselling simply on the basis that somebody was bereaved was likely to be ineffective. For people with moderate to intense grief, there were some positive effects, although these were not long-lasting. Only the people with intense grief achieved positive and enduring outcomes, and it helped if they self-referred for support. Another clear result was that early counselling interventions appeared to be ineffective, suggesting that it is unhelpful to offer bereavement counselling for the first six months following the loss.

My research explained many of these apparent limitations to bereavement counselling. An audit of hospice clients revealed that around half of the people assessed by our service did not need counselling, although many appeared to benefit from the reassurance of a single session to normalise and explain their grief reaction.¹³ The group is characterised as resilient and will not benefit from counselling. They have a grief trajectory in which grief behaviour rapidly diminishes.¹⁴ Moreover, a therapeutic intervention for a resilient person who is grieving normally might disrupt their unique process of finding their way through grief.

For people grieving intensely, I would concur that it is natural and helpful to have a period of denial and dissociation from the reality before embarking on counselling.¹⁵ Readiness for therapeutic change is a well-known factor in successful outcomes.¹⁶ An inappropriate and poorly timed intervention could partly explain Neimeyer’s¹⁰ claim that grief counselling can be harmful.

What of my theory that grief follows a generalised pattern of biologically driven grief behaviour? Using the 10 case studies in my dissertation, I was able to demonstrate that there is, as I proposed, an observable sequence of changing behaviour that describes a person’s typical journey through grief. It relies on the person’s ability, through a process of assimilation and accommodation, to find meaning in their thoughts and feelings towards the deceased, alongside making sense of the death and accepting the reality of what has happened. 

Meaning making theory has a strong pedigree in the field of grief research.¹⁷ In order to demonstrate the process as a sequence, I drew on William Stiles’ assimilation model, the assimilation of problematic experiences sequence (APES), adapted as the assimilation of grief experiences sequence (AGES).¹⁸ AGES is a useful tool for tracking changes in a bereaved client’s therapy, both as an outcomes measure and as a way of planning focus and direction with the client on their unique grief journey.

What I suspected anecdotally was confirmed: that person-centred counselling, in its pure Rogerian form, is inadequate for most clients. The work invariably needs a structure, based on the current models and theories of grief, matched to the individual needs of the client.

Psychoeducation is in the bereavement counsellor’s toolkit. Most clients can also be helped with reassurance and explanations. I like to think of the sessions as a shared journey of mutual curiosity, where the client and I discover together what is needed, what helps and where the focus should be at the present time. It’s about trusting myself to let the work go where the client takes it, and believing that they will engage in a process of active self-healing,¹⁹ working at their own speed.

But that’s not to say I am never a guide on the journey. Having the dual process model in mind is always a helpful point of reference. Each client spends some time on loss orientation and some time on restoration through distracting activities. So long as they can oscillate between the two, they find their own, unique balance.

Some clients spend most of the time between sessions on restorative distractions and grieve tearfully through their counselling sessions. It works for them. Others grieve without respite throughout their week, and there is a danger that directionless counselling prolongs and perpetuates the client’s distress, an example of counselling doing harm. Clients who ruminate in a fruitless attempt to find meaning might need to be steered towards distraction. The counselling sessions can be a time to discuss ways of doing this. I have even suspended a client’s counselling for a few weeks, encouraging them to join a support group that included social activities. Events proved that this had been the right decision.

During the first session, I can usually get a sense of which model or theory in the bereavement counsellor’s toolkit will be helpful. Some clients struggle with how different the world feels now. ‘For so long, the house has been busy, like Piccadilly Circus sometimes, with the doctor coming, Macmillan nurses calling and Marie Curie nurses at night. The friendly guys who delivered her oxygen cylinders. Now it’s all quiet. The hospital bed, commode, walking frame, wheelchair, all gone. The house is so quiet.’ It isn’t a real quote, but it is typical of what many clients express.

When I hear a story like this, I introduce assumptive world theory.²⁰ Parkes theorised this explanation for grief, which is not related to a broken attachment. It is the grief experienced after a traumatic event, or a life that is changed beyond recognition, through illness, disability, divorce, separation, retirement, redundancy and so on. Often, the negotiated focus of the work is helping the client to relearn their world.²¹ Many clients find it helpful to read Thomas Attig’s book, How We Grieve: relearning the world.²²

Some clients are hampered in their grieving process by fear they will forget aspects of their loved one if they move on with their life. They interpret ‘moving on’ as an abandonment, even a betrayal. It’s perhaps not surprising, as so many 20th century theorists either hinted at ‘letting go’, or actually said it. Klass and his colleagues⁶ put into an excellent book what many bereavement counsellors discovered independently – that their clients did not let go and move on, nor did they need to. What helps most is to develop a continuing bond with the deceased. It’s not ‘freeze framing’, a beautifully descriptive phrase used by Neimeyer,²³ but a different, symbolic bond that is carried into the future.

I use the phrase ‘moving forward’ rather than ‘moving on’. I also invite clients to bring photographs or artifacts into sessions and talk about the deceased. Dodie Graves’ book, Talking with Bereaved People, ²⁴ is helpful to both clients and counsellors.

It introduces the idea of ‘legacy’; the beliefs and values passed on from those we have lost, the valuable life lessons they taught us. I never fail to be touched by the unique way in which each client develops their continuing bond, once the reassuring possibilities have been explained.

To adapt to a post-loss world and develop a new relationship to the lost loved one requires the making of new meaning. Neimeyer²⁵ describes the process of assimilation and accommodation in the construction of new personal schemas. These schemas, or mental constructs, are how we make sense both of the loss and of the grief that follows.

It was as a teacher that I became familiar with the work of Jean Piaget²⁶ in the young child’s process of assimilation and accommodation, as they seek to make sense of their world. Early in my counselling career, I noticed that my enabling language, summarising, paraphrasing and open-ended questions to bereaved people had a puzzling similarity to my previous work with young children. It is this way of working with bereaved people that formed the basis of my doctoral thesis and is central to what I teach now.

Doctoral theses are rarely read by more than a handful of people. There seemed little point in six years of hard work unless it benefitted the bereaved. So, my second book, The Plain Guide to Grief,²⁷ presents the typical grieving sequence, evidenced by my research, while recognising and validating each reader’s uniqueness. 

What of future developments in bereavement counselling practice, research and theory? I have already said that I find pure, person-centred counselling inadequate for grieving clients. It seems to me that the best work is done when both client and counsellor actively determine the client’s needs. It requires the client’s readiness to collaborate in the process. It also requires the counsellor to recognise the client’s role in active self-healing and a willingness to forego grandiose feelings of being the expert, valuing instead that the client is expert in their own, unique grief.

Research into the effects of COVID-19 bereavement is a current priority. Important work in the UK is being carried out by Emily Harrop and colleagues;²⁸ in the US, Sherman Lee and Neimeyer devised the Pandemic Grief Scale.²⁹ My second book²⁷ contains COVID-19 case studies; colleagues and I have also been investigating the effectiveness of online support groups and the role of social media.

Advances in neuroscience have the potential to further our understanding of grief processes, in particular the possibilities afforded by functional MRI scans.³⁰ Our understanding of resilience in grief has moved forward with George Bonanno’s work on grief trajectories,^14,31 but there is still far more to be done there. Likewise, Stroebe and Schut’s work on the concept of grief overload³² is something to be taken into account and explored in the therapeutic space.

Last, but by no means least, the time has come to decolonise our understanding of grief,³³ as we cannot assume that all ethnicities and cultures grieve in the same way. Indeed, it is long overdue. It should underpin all that we do as practitioners, teachers and researchers.

Seeking solace in togetherness, Therapy Today, February 2021

Making meaning out of loss, Therapy Today, September 2019