How to Work with Grief in Therapy: Beyond Bereavement

Grief is a natural response to loss, and working with grief in therapy is something most practitioners will do sooner or later. Although grief is most commonly associated with bereavement, clients can experience grief following many different types of loss. These can include changes in relationships, lifestyle, identity, health, beliefs, or environment. Understanding the different forms grief can take helps therapists recognise and support clients. Even those whose difficulties may not initially appear to be grief-related.

Losses That Create Grief

Relationship losses are those following a miscarriage or termination, the ending of a marriage or other relationship, and the loss of friendships or social support following lifestyle changes. Bereavement would also be a relationship loss, whether the death has already occurred or is something the client is anticipating.
Life Cycle or Personal Identity losses happen around changes such as ageing, health issues such as severe or long-term illness, or an inability to conceive, ’empty-nest syndrome’, job loss, career change or retirement, the realisation that a cherished dream will never come true, family changes.
Environmental losses occur when geographically relocating, after experiencing natural or man-made disasters, or even losing a treasured object, belonging or opportunity.

Despite this, most of the better-known studies on loss do seem to focus on how we deal with death.

The Grief Curve

Psychiatrist Elisabeth Kübler-Ross was interested in the ways that hospitals dealt with terminally ill patients. She published a book in 1969 (On Death and Dying), which suggested that there were five stages of grief. These are:

denial – a refusal to accept the truth, used as a defence mechanism,
anger – which comes along with the realisation that denial isn’t realistic. Anger can be directed at themselves or others, or at the general ‘unfairness’ of the situation,
bargaining – an attempt to reshape the situation to postpone or mitigate the grief. For example, at the end of a relationship, someone might say, ‘Can we still be friends?’. Or, if faced with a terminal illness, they might offer reformed behaviour to their deity in return for more time,
depression – a period of sadness, regret, fear, and uncertainty as the person accepts the reality of the situation. And perhaps begins to disconnect emotionally from it,
acceptance – a final coming to terms with the situation.

As we mentioned, Kübler-Ross was talking about individuals who are terminally ill, and how they came to terms with it. However, her model has been generalised and used in all kinds of situations, including business change analysis and staff management. Used in this way, it’s generally represented as a graph, and called the ‘Grief Cycle’ or ‘Grief Curve’.

The Kübler-Ross Grief Curve

Kübler-Ross suggests that most people experience most of these stages. But she also said they did not necessarily occur in a defined sequence. People can jump forward or return to an earlier stage. So, this might be a more useful representation.

Therapists using the Kübler-Ross Model of grief suggest that problems arise when people become ‘stuck’ in one stage. This has been called complicated grief. Unfortunately, each person works through their issues differently and needs different lengths of time in order to do so. So it can sometimes be hard to define when this has happened.

The Kübler-Ross model is still widely used today. However, not everyone accepts the basic concept of progressing through ‘stages’ of grief. A study at Yale University (2000-3), for example, found that while some people seem to follow through the stages, others do not.

Alternatives to the Grief Curve:

Bonanno and Natural Resilience

George Bonanno of Columbia University (2004 and others) studied people grieving in a variety of extreme stress situations. This included war, terrorism, terminal illness, death and abuse. He concluded that most have a natural resilience which helps them cope. Not everyone who goes through one of these experiences develops long-term problems. He identified 4 main responses to this kind of trauma.

Resilience: The most common response, where individuals experience interruptions to their daily routines but maintain healthy functioning.
Recovery: This is a longer time of distress or depression that gradually fades. It may take a year or longer to pass.
Chronic Grief: When severe, debilitating symptoms of grief and distress persist for years without relief.
Delayed Grief: Where the griever appears to cope well, but goes on to experience symptoms and emotional difficulty after an interval. This is often triggered by later events.

Bonanno (ibid.) also said that our ability to grieve successfully depended on many factors. These include the cultural and environmental context of the loss, the griever’s individual ability to regulate their emotions, the availability of social support, and how people change the ways they think about the loss over time.

For example, many pet owners find it difficult to mourn properly over the loss of a pet. Their feelings are often not taken seriously by others. If you have a client with this specific grief, try referring them to the Rainbow Bridge website. There are plenty of resources, support and helpful ideas, including a worldwide pet-loss candle ceremony.

Bonanno’s Flexibility Sequence

His ideas about supporting clients experiencing grief relied on encouraging what he called the “Flexibility Sequence”. This involves:

Flexibility Mindset – trusting that things will improve, trusting your own ability to handle your emotions, and reframing grief as a temporary challenge rather than a permanent state.
Flexibility Sequence – focusing on what’s needed in the moment, having a variety of tools to apply, and evaluating their effectiveness so you can switch from a technique that isn’t working to one that will.
Core Coping Repertoire – allowing yourself to feel your emotions when that’s safe to do, using distraction and compartmentalisation when you need to, grounding yourself in the present and future, and actively seeking out positive emotions and connection with others to act as a buffer.

Sign up for YHT's Newsletter: tips, research, articles and training discounts

Berger and the Five Identities Model

Susan Berger (2009) looked at how people came to terms with loss, and she identified five main coping strategies. These are:

Nomads, who have not yet resolved their grief and don’t often understand how their loss has affected their lives.
Memorialists, who commit to preserving the memory of their loved ones by creating concrete memorials and rituals to honour them.
Normalisers, who commit to re-creating a sense of family and community.
Activists, who focus on helping other people who are dealing with the same disease or issues that caused their loved one’s death.
Seekers, who adopt religious, philosophical, or spiritual beliefs to create meaning in their lives.

Like Kübler-Ross’s model, Berger’s work began with a specific group, the recently bereaved. But her ideas have also been used with other forms of grief, mourning, and loss. The two approaches are not mutually exclusive. One could suggest that Berger’s strategies outline the ways in which people reach acceptance within the Kübler-Ross model, for example.

Berger’s model is less about working through stages of grief and more about building a new identity that includes the loss, a “new normal”, if you like. This involves normalising the client’s response and reassuring them that their response is healthy. You can also consider responses based on their coping type.

The Berger model in therapy

Nomads may need help finding their feet again. Grounding exercises, new routines and gentle exploration of their feelings can all be useful.
Memorialists often take comfort from keeping the memory alive, whether through rituals, keepsakes, anniversaries or other meaningful reminders.
Normalisers tend to cope best by getting on with life, solving practical problems and establishing a new routine after the loss.
Activists may throw themselves into helping others or raising awareness. This can be incredibly valuable, but it’s worth checking that they’re not neglecting their own emotional needs in the process.
Seekers are often looking for meaning. They may want to explore spiritual ideas, philosophy, creativity or personal growth as they try to understand what has happened and how it fits into their life story.

Working with Grieving Clients

Remember that grief may not be your client’s presenting issue. For example, someone grieving following a relationship break-up may use words like ‘obsessed’, ‘unable to let go’ or ‘loss of confidence’. I had a client whose public speaking phobia was a result of losing her Dad in traumatic circumstances many years before. She had simply not connected the two things in her conscious mind. You have to listen to what is being said, and left unsaid. As always, work with what the client gives you.

Clients may ask you to ‘make them forget’ which, even if possible or ethical, would not be a healthy resolution. (Have a look at my blog on the topic.)

You don’t need to stick to one theory of grief or another, either. You can take elements from each or just listen to what your client is telling you they need. These notes will give you some other ideas.

How hypnotherapists can help grieving clients

Initially, offer relaxation and an uncritical forum in which to express any emotions that the person does not feel are safe or appropriate to express elsewhere. Then help them to:

Face their actual emotions, rather than trying to experience what they (or others) think they should be feeling.
Express their feelings tangibly or creatively (e.g. keeping a journal, using the empty chair or inner advisor technique for unresolved issues).
Work with parts, to explore if the grief is serving a positive purpose, and whether the client is ready to release all or some of it.
Consider Berger’s coping strategies outlined above to see if switching strategies might help.
Have realistic expectations of themselves.
Look after their physical health, especially including elements of stress management. Remain aware of increased dependency on tobacco or alcohol.
Plan ahead to cope with grief ‘triggers’ like anniversaries, holidays, and milestones.
If there has been trauma with the loss (e.g. death in an accident, an emotional or public break-up scene) consider using the rewind, swish or other desensitising techniques on the bad times, whilst reconnecting the client to the good times.
Reframing may be appropriate in some circumstances e.g. at the end of a relationship helping the client to see that they are mourning what they hoped the relationship was going to be rather than what it actually was.
Some clients may also need help with getting in touch with positive feelings like self-esteem or confidence. You should never ‘jolly’ them through the grief process, which can feel insensitive or dismissive of their feelings.
You can encourage the client to find support (family and friends, support group). And at every stage, consider whether it’s necessary to refer them on to a specialist grief/relationship counsellor or GP.

And, as in all areas, how the client wants to feel and what their solutions are should come primarily from them and not you.