Six weeks into her pregnancy with triplets last spring, Kristin Douglas, a licensed professional counselor at Laramie County Community College Counseling Center, had a miscarriage.

Douglas, who’s earning her doctorate in counselor education at the University of Wyoming, was no stranger to the grief caused by miscarriage. At the time of her own miscarriage, she was counseling multiple clients who were going through the same thing.

With her counseling background, Douglas had a larger selection of tools for dealing with grief than most people, but her experience drove home the point of the truly individualized nature of loss and grief. “It taught me that it’s a really sacred and individual experience,” says Douglas, a member of the American Counseling Association. “No two grief experiences are alike.”

Because she was working with clients who were also dealing with the aftermath of a miscarriage, Douglas made a personal decision to share her experience with them. “That was part of my own ethics,” she says, adding that she told her clients, “I want to be fully present for your experience, and I recognize that your experience is very different.”

Grief over a miscarriage sometimes falls under the category of “disenfranchised grief,” counselors say, because it often goes unacknowledged. If a woman has yet to share the news of her pregnancy or wasn’t showing before her miscarriage, those around her are less likely to notice her loss or grasp the depth of the loss, leaving her feeling less legitimized in her sense of grief.

Talking to others about her miscarriage was helpful to Douglas in her grieving process. Also beneficial was art journaling, a combination of drawing with pastel chalk and writing that allowed her to think through her grief logically while expressing herself creatively and emotionally. As many counselors are already aware and Douglas discovered firsthand, the grief didn’t disappear – it only changed with time. At the beginning, her sense of grief was physically, emotionally and spiritually intense, Douglas says. And although she says she doesn’t “fixate” on the miscarriage now, there are times when she still feels greater pangs of grief, including milestones such as first birthdays or first Christmases that never materialized.

Beyond death

While the death of a family member or friend is commonly recognized as a substantial loss, counselors agree it’s far from the only event that produces feelings of grief. “When we think about grief, generally speaking, we think about death,” says Howard Winokuer, president of the Association for Death Education and Counseling and founder of the Winokuer Center for Counseling and Healing in Charlotte, N.C. “But I think that’s a very limited and tunnel vision view of grief. Grief is the end result of any loss, and loss is so broad.”

Keren Humphrey, a retired counseling professor and author of the book Counseling Strategies for Loss and Grief, published by ACA, agrees that losses can be wide and varied. And she says counselors need to recognize all losses as legitimate. She gives the example of a woman who has always dreamed of having children finding out that she is infertile. That discovery could bring shattered expectations, a lost sense of the future and a lost sense of self as a parent. “That could actually be more challenging and more disruptive than dealing with the death of someone,” says Humphrey, who is CEO of 4 Directions Consulting in Rockwall, Texas, and holds a doctorate in counseling. Losses can include a wide range of life events, from job loss and homelessness to acquired disability and incarceration, Humphrey points out.

Russell Friedman, executive director of the Grief Recovery Institute, defines grief as the “conflicting feeling caused by a change or an end in a familiar pattern or behavior.” He adds that grief isn’t limited to the death of a loved one or even traditionally recognized losses such as divorce. One of the most profound changes that can potentially lead to grief, he says, is moving. “Our lives are lived in our houses. Therefore, our emotions are connected to the house,” says Friedman, a member of ACA. “The human condition doesn’t like change; it rejects change. It wants stasis so it can go back to what it knows.”

Although non-death losses might not be equal to death, they can’t be compared, Friedman says. “All loss is experienced at 100 percent. There are no exceptions.” What changes from loss to loss is the strength of the feeling, he says, which can depend on the time and intensity of the relationship.

Counselors say it is completely appropriate to place non-death losses under the umbrella of grief. In fact, it’s important to recognize them. “We’re talking about loss as the real or perceived deprivation of something one considers meaningful,” Humphrey says. “If it’s meaningful for me and I lose it, then it’s loss, whether you think it is or not.” Kenneth J. Doka, a professor of counseling at the graduate school of the College of New Rochelle, has written two books on disenfranchised grief. “The concept of disenfranchised grief emphasizes that every society has ’grieving rules’ that determine a socially conferred ’right to grieve,’” Doka says. “Generally, for example, these rules give family members the right to grieve the deaths of other family members. But in many situations – including non-death-related losses – a person might experience a significant loss but be deprived of the opportunity to publicly acknowledge the loss, openly mourn and receive social support.”

Rules can’t dictate how a person feels, says Doka, a member of ACA. “Whenever somebody has a meaningful attachment and they lose their attachment, at least one of their reactions is going to be a reaction of grief. We need to be sensitive to how an individual defines attachment. We need to understand the meaning that people give to the loss and not compare losses.”

Doka traveled to North Dakota after the Red River flooded in 1997. He remembers speaking with a woman who had emigrated from Germany, bringing with her Christmas ornaments that had been in her family for hundreds of years. The ornaments had been washed away in the flood, and she was devastated. Although the loss of Christmas ornaments might not have been significant to others, Doka says the event led to a profound sense of loss for the woman.

Doka adds that grief can accompany even happy occasions. For example, when a student graduates from college, he might be excited for the next chapter of life even as he grieves what he’s leaving behind. The birth of a child can be a joyous occasion, but it can also bring a loss of independence and freedom. “It doesn’t make you a bad mom if every once in awhile you grieve the loss of independence you had before,” Doka says.

Times of change

The field of grief counseling has changed during the past 15 to 20 years, Humphrey says, and one thing that’s fallen by the wayside is Elisabeth Kübler-Ross’ five stages of grief model. “We know better than that now,” says Humphrey, who is a member of ACA. “Everybody experiences loss and grief differently and uniquely. We need to start from people’s unique experience of loss and grief rather than applying universal templates.”

One of the major problems with the stages model is its adherence to a timeline, Winokuer says. The main factor in progressing from stage to stage is time – meaning if enough time passes, the wounds will heal. But it doesn’t work that way, says Winokuer, an ACA member who has worked in grief counseling for 30 years. “Time does not heal wounds. In time, wounds can heal. But in order for wounds to heal, a person needs to do their grief work,” he says.

As counseling has moved away from the stages model, Doka says, it’s moved toward one of individual pathways. “To think that we’re going to respond to a major crisis in our life in exactly the same way is, at best, naïve,” he says. An individualized model also opens the door to better counseling of multicultural clients, says Doka, who is a senior consultant to the Hospice Foundation of America and runs a small private practice in Poughkeepsie, N.Y. Counselors should try to interpret clients’ behavior through the lens of their culture, he says. In some cultures, visible emotion might be expected at a funeral, whereas in others, the atmosphere might be more restrained.

Viewing attachment through a cultural lens is also important, Doka says. In Hispanic culture, the Spanish expression for godparents translates to “coparents,” and the relationship is an important one. While the death of a godparent might not be viewed as particularly significant in some cultures, in the Hispanic culture, it is regarded as a very serious loss. “On a very basic level, we have to understand that each culture has its own levels of attachment,” Doka says. “Each culture experiences, expresses and adapts to grief in its own way.”

Another change Humphrey has witnessed in the field of grief counseling is greater understanding of the role that meaning reconstruction plays in loss and grief. “What a particular loss means is different for everybody,” she says. She gives the example of a person who is a busy, hard worker developing a chronic illness. That person may be unable to retain the same job or maintain the same level of performance. “Their assumptions about who they are have been shattered,” Humphrey says. She adds that grieving is the process of reconstructing the meaning that was disrupted and making new meaning. Counselors can help clients with that process by encouraging them to understand the assumptions they once held, reviewing which assumptions have changed and which have remained the same and then supporting them as they discover new meanings, Humphrey says.

Individualized treatment

When seeing clients who are dealing with grief, Doka says the most important thing for counselors is to understand that everyone grieves in a different way. “The first thing we need to do is very carefully assess what their reactions are and how our clients are responding and, again, not to assume they should respond in any particular way.” Doka helped develop the theory of a continuum of grieving styles, wherein some clients fall toward the intuitive or emotional end and others fall toward the instrumental or emotionally muted end. The job of the counselor, Doka says, is to help clients identify and use their traditional strengths. “What kind of losses have you experienced before, what’s helped you through them and what has not been so helpful?” Doka asks his clients. “It’s helping people become aware of their own style.”

One of Doka’s clients came for counseling after his brother died, leaving behind a pregnant wife and an unfinished house. The client spent almost every weekend working on his brother’s house and, through that process, dialogued with his brother. “It was very effective grief work for him,” Doka says. Counselors also say the days of telling clients to move on and forget about the loss are over. In Western psychiatry, emphasis used to be placed on the need for the bereaved to cut themselves off from memories of the person to get over their loss, Humphrey says. “That really was quite an error. Now the emphasis is on helping people establish a continuing bond.” That bond, she says, is a connection with the deceased – a way to honor the relationship while still moving forward with life.

One way of maintaining a continuing bond is through linking objects, Winokuer says. Although maintaining a person’s room or closet exactly the same way years after the person dies isn’t healthy, keeping a few items to remember the person by can be very helpful, he says.

One of Winokuer’s clients was a widow in her 70s. Before her husband died, the two of them took walks together regularly. As a linking object to her late husband, the woman kept the jacket he had worn during their walks and wore it herself to feel close to him. A linking object is not only a constant acknowledgment of the new reality, Winokuer says, but a catalyst to feel.

In keeping a continuing bond and not “letting go” of the loss, there will be times when grief resurfaces, Doka says. “We realize we maintain a continuing bond to our loss and that there are times in our life when it’s quite normal to expect that we may have, even years later, surges of grief,” he says. Doka experienced his own surge of grief when his first grandchild was born. While it was a very happy occasion, Doka regretted not being able to share the experience with his own father, who had already died. “At that point in time, I profoundly missed the opportunity to talk to my dad,” Doka says. “We live with the loss and we understand it and reinterpret it at different times.”

As Doka’s clients approach the end of their counseling work with him, he asks them what times in their lives they think the loss might become significant again, whether it’s a wedding, the birth of a child or any other milestone. By examining this question ahead of time, Doka says his clients aren’t caught by surprise when a resurgence of grief happens somewhere down the line.

Help in healing

Since the stages of grief model first appeared, many new treatments have surfaced. Here are some methods counselors recommend to help clients who are dealing with grief.

• William Worden’s task-centered approach. Winokuer says Worden’s tasks imply that healing isn’t simply a matter of time passing; rather, there is work to be done. The first task is accepting the reality of the loss. With a death, that might mean making calls to family members or planning the funeral. In a divorce, that might mean someone moving out, taking off the ring and telling friends.
• Worden’s second task is feeling and working through the pain of grief, third is adjusting to the new environment and fourth is “reinvesting yourself and learning to live again,” Winokuer says. The process isn’t linear, Winokuer stresses, so a client might be reinvesting herself and then feel the pain again.
• Thematic genograms. Humphrey recommends asking clients to create a three-generation genogram and then trace the loss and grief experience of various family members through the generations. She says the process opens up opportunities to discuss how loss affected the family through the years and how family members dealt with it.
• Written dialogue. One of Winokuer’s clients, a 70-something physician, suffered a loss when his wife died of breast cancer. The man wasn’t very emotive, but he was a very good writer, so Winokuer asked the man to write a letter to his wife about what had happened since she had died. After the client read it to Winokuer, Winokuer then asked him to write a return letter as though his late wife were responding to what he had written.
• Objects of connection. Like Winokuer’s linking objects, Humphrey says people often have a keepsake they hold onto that reminds them of and connects them to their loss. Bringing that object into a counseling session can be a springboard for people to begin talking about the item and the meaning of the loss. The objects of connection give counselors a chance to validate the loss and to ensure that the person is healing in a healthy way. If either not having the object or not being able to check on the object is troublesome and impairs the person, it alerts the counselor that there might be a problem, Humphrey says.
• Making a booklet. Douglas creates little booklets for her clients that help them detail their grief journeys. She encourages clients who have lost someone to write down information about the person, what their relationship was to the person, what their reaction was to the news of the death, details of the funeral, how they are coping with the loss, things they wish they had told the person, things they’ll miss about the person and so on. This provides clients with a chance to tell their grief story while working at their own pace, Douglas says.
• Creating a resilient image. To withstand feelings of grief, Humphrey assists clients in developing an image of themselves as resilient people. She gives the example of a man struggling to stay focused at work because he’s troubled with thoughts of his mother’s death. Humphrey might help the client create an image of himself floating in water, not having to push or swim or make any effort. The client could then use the image to cope in the moment, she says.
• Journaling. Winokuer recommends journaling to his clients because writing helps to organize and give structure to thoughts. “It makes it more concrete, more real,” he says, adding that writing also helps clients acknowledge the reality of the loss.
• Empty chair. Counselors recommend the Gestalt empty chair technique with clients who are dealing with the loss of a person through death or other events such as divorce. The client can talk to the person as if he or she is there, sharing feelings, saying goodbye or working out an unresolved issue. Much like journaling, Winokuer says, this method helps make a person’s thoughts more concrete. (For more, read “Empty chair offers closure to grieving clients” on page 34.)
• Art. Douglas recommends using art as a powerful tool for working through grief and the many painful feelings that accompany it. One of Douglas’ clients was an art student who lost a loved one to suicide. Over the course of several weeks, her client drew multiple images representing each of the feelings she had experienced at the time of the suicide and throughout her grief journey. Douglas and the client discussed the images during session, and over time, the artwork turned from bleak, dark, charcoal black-and-white drawings to bright, colorful images of peace and hope. “The drawings were a way to help her make sense of her feelings, express herself in a language she was very familiar with and visually see patterns and progress to her healing journey.”
• Rituals. Doka is a believer in the healing power of rituals after people experience a loss. The ritual of continuity emphasizes the continuing bond with the deceased, Doka says. He and his family put up memorial ornaments on the Christmas tree every year for loved ones who have died. “It’s a way of saying this person’s still part of our holiday,” he says.
• Doka says one of the most powerful rituals is a ritual of transition, which marks some movement or change in the grieving process. One of his clients, Marion, was a middle-aged woman whose husband had died seven years prior after having been ill for many years with Lou Gehrig’s disease. Every night before going to sleep, they had touched their rings together and recited their wedding vows, “in sickness and in health.” Years after her husband’s death, Marion was ready to begin dating again but felt unable to take off her wedding ring. Doka helped Marion, a committed Catholic who took her wedding vows very seriously, plan a ritual of transition at her church. After celebrating Mass, the priest called Marion to the altar. In front of her family and friends, the priest repeated the wedding vows in the past tense – “Were you faithful in good times and in bad, in sickness and in health?” Marion affirmed she had been, and the priest asked for the ring back. Marion’s ring was later linked with her husband’s ring and welded to the frame of their wedding photograph, “symbolizing that her vow was now fulfilled,” Doka says.

Becoming an expert

All these counselors agree that to be an effective grief counselor, professionals must be properly educated. Winokuer says the Association for Death Education and Counseling offers certifications in thanatology, or the study of death. Although earning a grief counseling certification might be helpful for some professionals, Humphrey doesn’t believe it’s the only way to become educated on the topic. “The most important thing is to be intentional about expanding knowledge and remaining current with the research,” she says. Doka also emphasizes the importance of staying up to date in the field by paying attention to grief counseling research and literature and attending conferences. “Get current, keep current,” says Doka, who edits Omega: The Journal of Death and Dying.

Validating a person’s loss is another important component of grief counseling, Doka says. Douglas agrees, adding that for many disenfranchised losses, such as miscarriage, clients need counselors to acknowledge the loss and be nonjudgmental. Clients will be uncomfortable talking about their grief if they think someone is going to judge them, Douglas says, so counselors must honor and validate their experiences.

Before counselors take on the job of helping clients deal with loss and grief, Humphrey says, they need to look in the mirror. “Get your own house in order,” she says. “If you’re going to help people with grief and loss, you need to have examined your own loss and grief issues.”

Based on her experience helping grieving clients, as well as grieving her own losses, Douglas offers a reminder to her fellow counselors. “Educate yourself on the grief process and ways to work well with those who are grieving, but also remember that you are your best instrument. Your compassion, warmth, presence, attention to detail and intuitiveness will be your most powerful healing tools.”

ACA offers a Grief and Bereavement Interest Network for counselors looking to network with colleagues. For more information, contact Bernadette Joy Graham at bernadette_joy@yahoo.com.

Grief in the workplace

Dealing with a loss is hard enough, but when those who are grieving are expected to get on with life and go back to work, the challenge to heal looms even larger. Joanna Parker, coordinator of bereavement services at Duke University Hospital, developed a workshop for managers and supervisors at Duke on helping employees cope with loss and grief in the workplace. She’s adapted the workshop for other audiences, so Counseling Today asked her what counselors should know about grief in the workplace.

“The topics of death and grief are not very comfortable topics for people to engage in,” says Parker, a member of the American Counseling Association. “Especially with workplace norms, this might be where you put on your professional demeanor and you leave all your personal stuff at home.” But the challenge of leaving the grief at home, Parker says, is that people spend so much of their lives in work settings, and for many individuals, work serves as their de facto social network as well.

A traditional three-day leave of absence for bereavement often means people return to work in the thick of grief. “For a significant loss – loss of a spouse, loss of a child – that’s so insignificant as far as what somebody is going to need, as far as not just dealing with logistics, but just being able to come through that acute grief,” Parker says. “I think there’s a lot of pressure on employees – What’s the expectation? How am I going to be viewed? – to buck up and get back to work.”

Even if clients have to resume their jobs while still dealing with intense grief, there are a few ways counselors can help them make a smoother return, Parker says. First, help normalize the experience for clients and help them see that a wide variety of reactions to grief can be very normal. Then brainstorm with the client about what might be helpful to them when they go back to work. Help them determine their limits and learn to speak up if they need to be taken off a project or work from home. Finally, encourage clients to open an avenue of communication with their supervisors. Parker says it’s often helpful for employees to request setting up a regular check-in time with a supervisor. The supervisor can see on a regular basis how the employee is coping, while the employee is given a low-stress opportunity to express concerns or problems.

– Lynne Shallcross

Lynne Shallcross is a staff writer for Counseling Today. Contact her at lshallcross@counseling.org. Letters to the editor: ct@counseling.org.