Common Client Issues in Counselling An Australian Perspective Grief and Loss

GRIEF AND LOSS 135 Grief and Loss JUDITH MURRAY ABSTRACT The experience of loss and its consequent integral and unavoidable aspects of life . Loss is also implicit in nearly all adverse life experiences however , it is not often specifically recognised within psychological formulations except in situations of bereavement . This universal nature of the suffering of grief means that loss can provide a key integrating concept of care for adverse life events . As such , an understanding of loss and grief is essential knowledge for every counsellor . This chapter is an overview of loss and grief theory and research and discusses the process of grieving and when grieving becomes problematic . It will show how this knowledge can guide an integrative approach to care . Learning objectives To define loss and other associated concepts to gain an understanding of the different theories that have been used to describe the process to consider how grieving becomes problematic and the assessment of such difficulties to use loss and grief theory and research to support an integrative approach to intervening with people experiencing loss . INTRODUCTION In counselling and other mental health disciplines , loss and grief have often failed to be a focus of care compared to the search for empirically supported interventions for more serious diagnosed disorders . Loss has largely only been considered when dealing with death and bereavement . As with many other conditions we have sought the most appropriate means of fixing grief . But grief has not been a condition that fitted the mould of clear definable symptoms , single definitive theories and targeted session specific interventions . So why would we argue that grief and loss is fundamental to our work in counselling ?

There are many reasons why knowledge of loss and grief is vital for counsellors . Grief is universal and inevitable irrespective of age , culture , status ( SES ) gender , or context independent of all ways of people . As such loss and grief offer a shared language and a shared experience among us all , including counsellor and client . Loss and grief are not confined to situations of death and includes whenever someone is separated from something of importance to him or her . Grief is commonly with , or integral to understanding other disorders . 135

136 loss as a universal experience offers a key integrating concept that can underpin prevention and early intervention when dealing with adverse life events . Besides these above reasons for knowing about loss and grief , there is ample evidence that failure to deal with issues of loss and grief can lead to long term problems disorders . These include Prolonged Grief Disorder as defined in the ( WHO , 2019 , 2018 ) This diagnosis is also proposed for the version ( et , 2021 ) but is currently termed Persistent Complex Disorder within the current section on Conditions for Further Study ( APA , 2013 ) Other disorders such as mood disorders ( 2006 ) and Post Traumatic Stress Disorder ( 2011 ) have been associated with grieving . In particular there has existed a blurring between the symptoms of depression and the sadness leading to misdiagnosis as a disorder or confusion as to a differentiation ofthe conditions ( 2007 ) Case Study The Story is a 45 year old man who owns his own small but successful plumbing business . He is the father of two adolescents , He presented to counselling on the demands of his wife due to a serious risk of relationship breakdown . Fifteen months previous and his family had experienced the death of his 17 year old son to suicide by a drug overdose . had found his son body and suicide note . Initially was seen as a great support to his wife and remaining 15 year old daughter . Over time he has found himself very angry and pulling away from his wife and daughter , Three of his staff have left following disputes with and his business is suffering from not being able to replace these workers . He is thinking of simply selling the business and just checking out . In discussing background it was noted that he was brought up in an environment in which his father , while not abusive , was lacking in affection and was highly critical of both his children and mother . left home as soon as he could at age 16 and took up an apprenticeship in a nearby town . He met his wife at age 20 and they married young . He had found in being a family man . While he admitted to being a tough Dad , he believed his children knew they were loved , something he had not felt growing up . TOPIC DESCRIPTION Before we go any further , let us gain some consensus around some ofthe concepts we will use in this chapter . Change Besides death and taxes , change is about the only other thing that can be guaranteed in this life . Sometimes change alters our world in ways that we do not wish to occur . We ache to return to the world as it used to be . Such a change involves loss . Loss Loss is not a particular event but a lived experience , a sense of being kicked in the guts , a desire to want the hands of time to turn back to a time where our world had come crashing down around us . Miller and ( 1998 ) offer a useful definition of this experience as Loss is produced by an event which is perceived to be negative by the individuals involved and results in long term changes to one social situations , relationships or ( 12 ) This definition recognises that loss is a ) experienced , perceived and defined by the person experiencing it , involves many adverse life events and ) has far reaching effects . Grief Put most simply , grief is the reaction to loss whatever that reaction happens to be . The reported symptoms of grief can be manifest across all domains of the model ( 1977 , 2002 ) Biological effects may include crying , headaches , tremors , appetite changes , sexual problems and a compromised immune system . Psychologically , people may report anxiety , sadness , anger , confusion , concentration difficulties , suicide ideation , among other symptoms , while socially , those in grief can report loneliness , estrangement from others , role confusion , and social network changes . When we speak of spiritual and existential effects , these often move beyond religious crises of faith to more general effects such as loss of purpose and meaning , and questions about life and death . The symptoms across all the domains also interact

GRIEF AND LOSS 137 leading to an even greater sense of confusion and feeling overwhelmed . Grief affects the whole person and may manifest itself very differently in people even if they are facing the same type of loss or situation of loss . Grief is the manifestation of an internal process as people try to deal with varying levels of disarray and struggle to find some stability in this altered world . This internal process is what we call grieving . Mourning then is this process in situations of bereavement . Consistent with the theorists such as Raphael ( 1984 ) and Rando ( 1993 ) I prefer to use the terms grieving and mourning to reflect this internal process of adjusting to loss . Some prefer to define mourning in terms of the public expressions of grief , including culturally relevant rituals ( et , 2001 ) Grieving is a natural healing process experienced in all cultures and societal groups . It is a process that has been part of the human experience ever since people became attached to things or people of importance in their lives and lost those things . It is reflected in the art , music , stories and rituals of all peoples around the world . In considering grieving from a medical model viewpoint that sees grief as a condition to be treated , it may be more useful to see grieving as being a natural healing process rather than a disease in need of treatment . COMPLICATED ( For most people , the process of grieving proceeds to the point where people are able to themselves in their lives although in many ways , changed . For a significant minority of grieving people , this natural process of healing does not proceed toward restoration but rather leads to some form of perceived deterioration . Common patterns of symptoms are associated with problems in grieving a death . Few areas of adversity besides death have been defined in terms of grieving a loss and hence attempts to categorise problematic patterns in adjustment have been confined to the area of bereavement . In the area of bereavement , these patterns of symptoms have been defined by terms such as Complicated Grief , Prolonged Grief Disorder or Persistent Complex Disorder . While intense distress after a death is normal and anticipated , symptoms that persist at least six months after the death become concerning . The patterns of symptoms indicating problems in grieving a bereavement include a searching or yearning for the deceased that preoccupies the person to a disabling degree severe distress when reminded of the deceased or circumstances of the death avoidance of reminders a loss of the sense of role in life ongoing impaired functioning in life domains patterns of distress that are outside what is expected from usual cultural , social or religious norms . 2018 Shear , 2015 ) The prevalence of such problems in grieving following a death is difficult to determine . Unlike other mental disorders where only those diagnosed with the condition meet the full diagnostic criteria for the range of symptoms , all those grieving a death display intense symptoms in the early days following the bereavement . Hence determining when normal grieving becomes problem grieving can be difficult to ascertain clearly . Shear ( 2015 ) and et al . 2015 ) estimate between and display these patterns of symptoms , and this appears consistent across a number of different national studies ( et , 2010 et al . 2011 Williams et , 2017 ) Problems associated with losses have been less likely studied in terms of grief responses . In such cases grieving people may be diagnosed with other disorders such as depression , anxiety , adjustment disorder , or substance use disorder ( et , 2008 ) Problems associated with grieving losses may be underestimated , with their impact spread across many disorders .

138 RISKS FOR PROBLEMS IN GRIEVING If we accept that some people will struggle to heal through grieving , being able to ascertain who may be at risk for problems in grieving is valuable to counsellors . Many explanations for problems in grieving will be offered through the theories of grieving that we shall discuss later in this chapter . Some studies though have determined various risk factors through statistical means in exploring outcomes among grieving people . Many studies have considered risks associated with problem grieving . We see risk associated with three broad categories the person of the griever him or herself , circumstances surrounding the loss and the context of the loss . In reviewing empirical studies of complicated grief , et al . 2010 ) found risks within the person included previous loss , previous mental health , attachment style as well as cognitive appraisals and high distress at the time of the death . Factors associated with the loss itself included death involving violence and other trauma , the quality of the or dying experience , close kinship relationship to the deceased , marital closeness and dependency , and lack of preparation for the death . In terms of the context of the loss , perceived social support played a key role . It is difficult to easily separate these risk factors as their interactions may be more important than their singular effects . The risk factors may also influence grieving in discrepant ways in different populations . For example , there is risk of being a young widow yet there is also noted risk in losing a lifelong partner in older people . Hence rather than simply assuming risk based on noted characteristics , we need to hear the story of the client in depth for possible risks , and the priority of those risks or their interaction in terms of disruption to the normal process of healing through grieving . Understanding how risks work against healing occurring through grieving is through recognition of the loss and grief theories that suggest how the grieving process progresses and how it may be compromised for some people . So let us consider very briefly the major theories concerning this process of grieving . MAJOR THEORIES Counsellors have often become wedded to a single theory or school of thought and view all people experiencing a condition only through the lens of this favoured theory . With such a limited view , we risk missing the true story a person tells in all its complexity . We hear only the part of the story that fits our theoretical view of the world . Loss and grief is one of the best examples of a concept or condition that refuses to be boxed into a single theory . There is no one size fits all definitive theory of grief . Rather what we have is an amazing picture ofa deeply complex human experience for which each theory offers us part of the picture . just like the story of a person grief , the story of the theories of grief is complex and much more interesting than a singular view of grief offered by only one theory . Theories around grief and loss are largely considered WHY models ( why grief occurs ) HOW models ( how the process of grieving proceeds ) To suggest that theories of grieving began in the century is naive . Philosophy , religions and stories from every culture have sought to understand grief , loss and suffering and comfort it . We should never discount the innate and cultural understandings of grief that a person brings . They form an integral part of the story they will tell and so form the basis of understanding how we best care for grief . From a more formal psychological perspective , we can follow a story of the theories of grief and loss . However , we need to recognise that the theories mainly discuss loss through death . Moving to losses will require us to go even beyond this theoretical story . Early theories came from the psychodynamic work of Sigmund Freud in Mourning and Melancholia ( 1917 ) He largely argued that as people became attached to love objects , they attached psychic energy ( libidinal bonds ) to these things , a process known as cathexis . While these love objects remained , the internal energy remained in equilibrium and the mind remained stable . Any disequilibrium , and hence mental instability caused by loss of these love objects was seen in the intense grief reactions . The key to successful grieving was the removal of this psychic energy from the lost love object , a process of , and its placement in new available objects . This required an exchange process whereby the griever undertook grief work . By repeatedly

GRIEF AND LOSS 139 aspects ofthe relationship with the lost object , the griever can relinquish the libidinal bonds that bound him or her to the lost object . in this exchange process through unresolved ambivalence would then result in problems in grieving . While also a , john ( 1970 , 1973 ) in his attachment theory , enhanced the understandings of grieving . argued the need to consider the interpersonal perspective of grief with emphasis on the early experiences and attachment patterns developed between the griever and the deceased . He argued that yearning and searching for the lost loved one was normal . Therefore , the intense feelings and behaviours of grief were not indicative of pathology but were aimed to try to restore the lost love object to the griever . It was who suggested that problematic attachment patterns may lead to problems in grieving . These theories were later expanded ( and Shaver , 1999 , 2002 ) This idea ofan ongoing relationship with the deceased was expanded to the concept of continuing bonds by , and ( 1996 ) 1980 ) was also the first to suggest that the process of grieving seemed to follow a pattern of stages phases Shock and numbness , Searching and yearning , Reorganisation . These theories were also advocated by others ( 1972 Raphael , 1984 , The most stages model was offered by Ross in her book On death and dying ( 1969 ) However , her stages were concerned with the process of dying and not on the situation of bereavement itself . Stages theories often spoke of the symptoms most noted in each stage rather than the part of the grieving process that was occurring that underpinned these symptoms . A number of theorists ( 1991 , 2009 Rando , 1993 ) tried to bring together the idea of grief work and stages in the Task Based models , which described the work the griever may be doing in each stage . spoke of four tasks , being to accept the reality of the loss processing the pain of grief to adjust to a world ( both external and internal ) where the deceased is no longer and finding an enduring connection with the deceased within a new life . Anything that prevents a person moving through the stages of healing by successfully undertaking the tasks required of that stage can lead to problems in grieving . As social beings our grief is more socially than individually constructed . The Social Constructionist theories increase our understanding of grief by helping us understand a ) what our social context considers a loss , and so determines the right to be grieved or not , the rituals around the grief , the adjustments that will be needed to deal with the loss , and ) the language and attitudes around grief itself ( et , 1974 ) At times the loss is not given legitimacy by the surrounding social environment and the grief is disenfranchised by others leading to its lack of recognition by others and a loneliness for the griever ( 1989 ) The school of thought argues that rather than grieving being a process over which a person had little control , and behaviours could alter the experience . The that people hold concerning the lost object , the process of grieving itself , as well as understanding the use of solving and planning to rebuild the world are all important aspects of grieving . Irrational thought patterns , problematic core beliefs and coping patterns are often viewed as at the root of problems in grieving ( et , 2006 ) Personal Construct Theory ( Kelly , 1955 ) is a humanistic theoretical approach that argued that each of us constructs our individual reality based on patterns or templates that we create . The theory recognises that an important question we then need to consider in loss is What is the meaning ofthe loss to the person ?

From a constructivist perspective , problems in grieving occur when the person is unable to construct or a meaningful personal reality following the loss ( et , 2002 ) These theories noted above are the main schools of thought that guide our thinking about loss and grief , and collectively offer a much better representation of the lived experience of grieving . A number of theoretical models have been developed that bring together aspects from several theories of grief . and ( 1999 ) offered a Four Component model , while Rubin ( 1999 ) offered a Two Track model of bereavement . Bryant ( 2013 ) offered a cognitive attachment model that distinguishes both adaptive and prolonged grief by integrating aspects of attachment , memory , and identity . The most influential integrative model is the Dual Process model ( and , 1999 ) It argues there are two forms of stressors related to grieving loss oriented stressors and restoration oriented stressors . Throughout grieving

140 people oscillate between reacting to these two stressors . Initially people spend more time with loss oriented stressors and as healing occurs , move to spend more time working with restoration oriented stressors . However , it is the oscillation between the two forms of stressors that assists with grieving . Neurobiology offers us new insights . However , rather than a new theory , neurobiology offers us a greater understanding of the mechanisms of grieving and explanations as to why good theory has persisted and been validated within people experiences of grief . When we look at the grieving brain we see areas in the brain that are associated with processing of emotions , understanding the mental states of others , retrieval of laden episodic memories , processing faces , visual images , unconscious automatic motor responses , autonomic regulation and modulation , and coordination of a combination of functions ( Freed et , 2009 , 2005 ) Neurobiology shows us how important it is for a grieving person to deal with the oscillation between approaching and avoiding the memories and finding a sense of accommodation of both ( Freed Mann , 2007 ) Hence a counsellor needs to have comfort in sitting with the person often changing state of moving toward and running confusion and pain by in the people . Neurobiology also points to potential mechanisms of problem grieving finding the nucleus , the centre of the brain that determines if something is worth doing over and over again , working hard in those reporting complicated grief ( et ) LOSS These many theories offer us a fuller understanding of grieving associated with death rather than any other loss . If we look at the definition of loss more broadly , we see that loss and resultant grief occurs following many situations . Grief symptoms have been found among people experiencing situations as diverse as brain injury ( Carroll , 2015 ) parenting children with mental disorders ( et al . 2010 ) migration ( Knight , 2019 ) unemployment ( Archer Rhodes , 1987 ) foster care ( Mitchell , 2018 ) and nursing home placement ( Van et , 2016 ) However , often these symptoms of distress have not been interpreted as grief reactions but designated as adjustment disorders or their sadness interpreted as depression or anxiety . In trying to categorise the many losses , 1999 ) suggests a ) obvious losses such as relationship breakdown , not so obvious losses such as loss of a dream , developmental losses across the life span , temporary losses and such as small changes in life and ) limbo losses associated with an uncertainty or a tenuous situation . Boss ( 1999 ) offered the term ambiguous loss to describe a situation of loss in which a person is unsure if a loss really has occurred or not . For example , the loss surrounding the situation of a missing person or a threatened miscarriage or the diagnosis of a but potentially curable condition may all involve ambiguous loss . This contrasts with what are termed losses that occur over a long period of time where an may not be clear ( Bruce Schultz , 2001 ) These losses are associated with a different grieving to that of the grieving of a death . This grieving is often termed chronic sorrow ( Teel , 1991 ) Chronic sorrow is sadness that accompanies ongoing loss and that sometimes comes to the fore , and sometimes sits uncomfortably on the periphery of the consciousness ( 1962 ) The grief associated with death tends to display an intensity of distress that , while it may fluctuate to some extent short term , generally lessens over time . Chronic sorrow may be episodic in nature , but the intensity of distress in difficult times remains consistent over the . Counsellor Reflections In working in grief and loss there is one word that always remains foremost for me respect . Deep and genuine respect is the absolute key to this work respect for the lived experience of those who grieve , respect for those around them , respect for what was lost , respect for what people can and can not tell you , respect for the natural process of healing and respect for the challenge of hearing their story as it is meant to be heard . More than any other area , loss and grief brings us to the core of who we all are as human beings . We can never truly understand the loss experience of another but knowing how

GRIEF AND LOSS 141 lonely loss can be often makes us as counsellors deeply committed to to know their story as they live it and helping them to tell it . There is no for me as a counsellor than to hear a person say that they have finally found a place for their loss . COUNSELLING WITH GRIEF AND LOSS ASSESSMENT Rather than conjuring a picture of the expert counsellor deciding what part of a person grief will be heard and explained and evaluated , I prefer to consider assessment as hearing the most complete story that may help the counsellor to generate in collaboration with the grieving person some hypotheses as to what may be causing their pain . A vitally important aspect of counselling with grief is the undertaking of a holistic assessment of the person experience . The primary aim in caring for the grieving person and being able to gain a useful and focussed assessment is ensuring the person feels safe within the therapeutic relationship . It is important to hear about the circumstances of the loss and its repercussions in the life ofthe person and also to understand the world that was , the one lost to the person . We need to understand how the world they now inhabit ( the world that is ) most differs from the one they knew before the loss and in which they felt some sense of safety . In understanding the often complex story of grief there are key questions we can consider . These questions should not simply be asked as in a structured clinical interview . Rather the questions allow us to sort the story we are able to bring out using our interpersonal skills according to what we know about grief and loss . Murray ( 2016 ) offers ten questions of loss based on the various theories and studies of grief . These offer a means of ensuring a fuller assessment ofa person grief . What has been lost ?

Identify the many death and losses that can be involved in a loss experience as well as seek those causing the most distress , the primary losses . What was the importance ofthat loss in the life ofthe person ?

Consider the centrality and the meaning of the loss to the person and hence the likely disruption to other areas ofthe life . What are the major symptoms of grief that this person is experiencing ?

Are there any causing particular distress ?

Consider the physical , emotional and social manifestations of grief and potentially problematic symptoms such as suicide ideation or trauma responses . Howfar along thejourney has the person progressed ?

Consistent with phasic and task models , this allows us to consider the progress of grieving . What is the world ofthe person like ?

Consider how different is the world of the person now ( the world that is ) and hence what makes their current situation feel safe or unsafe . How is the person trying to deal with the transition from the world that was to the world that is ?

Consider the current coping mechanisms being used and so recognise both adaptive and forms of coping . What strengths does the person bring to his or her loss ?

This forms the basis of a approach encouraging us to identify the resources both within and around people to stabilise their world . What are there to the progress ?

Consider the risk factors present that may compromise the healing process . Is there any indication that mourning has become complicated ?

Signs of problems in grieving suggest a need for more targeted interventions to occur that can unblock the normal healing process of 142 grieving . 10 . Are there particular characteristics of the person that are going to challenge my care of him or her ?

Consider issues that may challenge care , such as culture , sensory or cognitive impairment or existing disorders . GRIEF COUNSELLING AND GRIEF THERAPY Grief following a loss is normal . Distress in itself is not indicative of pathology and hence does not necessarily require therapy . What is required is support for the healing process of grieving . Basic supportive counselling is a vital area of prevention and early intervention . Loss threatens a person sense of safety , mastery and control . The basic aim ofall grief counselling for normal grief is the stabilisation of the griever and the returning of some sense of safety . It will be the grieving person who determines how best to return to a sense of safety as they will tell you what aspects of the loss are making them feel most unsafe . They will also tell you what makes them feel safe as paradoxically loss can increase safety in some areas . For example , a relationship breakdown may cause grief , but if that relationship was emotionally taxing or harmful to the person , there may be a sense of increased safety in some aspects of this loss . Safety will always be defined by the griever and needs to be respected and understood by the counsellor . Safety can be felt internally , or . Internal safety comprises the thoughts , memories , feelings or sensations , making the person feel most safe or unsafe . safety may be enhanced through helping the person to improve communication with health professionals , or partners or family and friends . It may also be enhanced through community education to reduce stigma or ignorance about grief . Supporting organisational safety requires interaction with systems that may cause concern , such as hospitals or coroners or mental health services . GENERAL PRINCIPLES OF GRIEF COUNSELLING Several writers ( Humphrey , 1996 , 1991 ) have offered general principles of care . In situations of loss , basic processes of support and symptom modulation will be needed initially to build trust , stabilize the person and allow the experience to be put into words . Once this personal sense of greater equilibrium has been supported in the griever , other important issues can be dealt with utilising the most appropriate therapeutic approaches . Currier , Holland ( 2008 ) surveyed 119 practitioners concerning their approaches to grief counselling and found three overarching categories . The first category is the importance of the presence of the helping professional . The study found the need for cultivating a safe and supportive environment , providing deep and empathic listening , and assuming a respectful and stance . The second category concerned the elements of the process of therapy and included storytelling facilitating integration or finding meaning expressing and processing emotions facilitation of continuing bonds focussing on the good , and exploring of spirituality and existential concerns drawing and expanding upon existing resources and toward future and hope . In terms of facilitating these processes , all psychological techniques may be potentially valuable for caring for someone affected by the loss . More than one approach is required over time to assist a person in grief . A continual process of assessment and intervention and reassessment is needed . COUNSELLING TO THERAPY As we discussed , it is often difficult to determine when normal grief that simply requires support for the natural healing process becomes problematic and in need support or therapy . 2004 ) found that resilience , characterised as a pattern of high initial distress for a few weeks , followed by quite low levels

GRIEF AND LOSS 143 of distress , is common among between 30 of grieving people . Resilience is different from recovery , and chronic or delayed grief and can still be exhibited in traumatic losses and alongside . Even for those who display symptoms of problematic grieving that fits a diagnosable category , there is no one definitive method of intervention that fits all grieving people . As much as we would like to have an easy definitive treatment for problem grieving , this is not the reality . Rather , a holistic thorough assessment for what may be causing problems in healing for one griever may not be applicable for another . For example , for one person , the problem may be due to an inability to process grief because of the avoidance of the memories due to trauma while for another , the grieving difficulties occur due to a problematic attachment pattern that existed between the griever and the deceased . Different theories and the techniques of care associated with such theories may then be required to assist the grieving person . For the first person , trauma techniques such as prolonged exposure or may be a first step necessary , while for the second person , attachment or psychodynamic work or Interpersonal Therapy ( may be the most valuable approach . As such , an integrative , approach is vital in caring for problems in grieving . A COUNSELLING MODEL EXAMPLE BUILT FROM THEORY According to the Dual Process Model ( of grief , problem grieving occurs when a person becomes stuck ' in dealing with one category of stressors , most commonly the loss oriented stressors . According to the , the healing of grieving requires an ability to accommodate the oscillations between and oriented stressors . As they are restored , grieving people find the ability to live with their experiences of the loss within their new world where the lost object is no longer present . When oscillation is reduced , and the griever remains stuck in one group of stressors , healing does not occur . Such problems may be manifested in the symptoms of Prolonged Grief Disorder . According to the model then , intervention needs to restore this oscillation between the stressors , so the normal process of grieving is then restored . Complicated Grief Treatment ( is a individual therapy . It is grounded in the , Attachment Theory and with techniques modelled from both Interpersonal Therapy and Cognitive Behavioral Therapy . It also includes elements of Therapy ( and theory ( Ryan , 2000 ) Case Study Assessment and If we return to the case of whose son suicided we can see how a holistic assessment of the whole story helps top guide effective care Assessment of From a perspective of the Ten Questions ( Murray , 2016 ) we could organise much of what reported , as well as generate and test several hypotheses as to what may be causing his difficulties . What has been lost ?

reported many losses that all required their own grieving loss of his son as a person , loss of his sense of being a good father or boss , loss of trust in his son and their relationship , loss of meaning in his work , loss of his sense of self , loss of closeness to his wife and daughter , loss of financial security etc . The primary loss was the loss of his sense of being a good father and husband . What was the role and the importance of the loss in his life ?

family has been the prime motivating force in his adult life and the reason he worked so hard . He believed he had shown he could be a better father than his own father , and the suicide had destroyed this belief . What were the main symptoms he was experiencing ?

reported great distress in his of finding the body . He also reported waves of uncontrollable anger mixed with an intense desire to be alone . He reported that he was using alcohol and doing inane risky things with his mates to help him forget . How far along the journey of healing had he progressed ?

While it had been 15 months since the death , reported little healing with vivid grief symptoms that preoccupied him .

144 What is the world of the person like now ?

described his whole world as being destroyed . He no longer trusted himself or others . He expected his family would leave him , a belief that was in part becoming a reality in his marriage . His work no longer mattered to him . How was he dealing with the transition from the world that was to the world that is ?

He reported not coping . He slept only erratically , drank more than he should , was angry and controlling . He refused to talk about his son as it was too painful and what was the use anyway ?

What strengths did he have ?

obviously still loved his wife and daughter . He was able to be honest and open . Most importantly , he wanted to get better and would do anything to fix things , What were there to his mourning ?

For of memories made it difficult to discuss his son . He also has no role model for being a good father and had some very high expectations of what that should be . Was there any indication the grief has become complicated ?

reporting suggested problems in his grieving . He agreed to the administration of the Inventory of Complicated Grief ( et , 1995 ) was found to be experiencing complicated grief . Besides a score , in discussing the items of the measure , was able talk about the sensations he was experiencing and offered some useful symptoms specific to his experience that we could use to monitor his progress over time . Were there characteristics that were going to make it difficult to care for him ?

There were no issues of concern here , Intervention with The most important aspect of caring for was the building of a safe and trusting therapeutic relationship . He found it difficult to use emotional language especially when memories of his son arose . Besides talking we used ( the projective use of picture and metaphor to expand the story ) to give him another way to put words on his experience . about grief was used to enhance the ongoing process as required . Being able to remember his son was important to , but was avoided due to the distressing memories . He wanted very much to remember his son without the distress , We began slowly to achieve this for him by encouraging him to help me to get to know his son . Slowly we were able to bring him toward the difficult memories of his son death , and using techniques , he was able to the last moments in a manner that moved from a distress to a heavy but close sadness as described it . We also looked at how he felt he had failed as a father and , in so doing , explored his own childhood , His strong desire to be a good deserving father was explored and meaning found for him in the father he had been and wanted to be . was able to speak about the loneliness of his childhood and the great fear that his son may have been lonely and suicided because of it . was committed to his daughter but feared that as he was not good enough as a father , she too may suicide . Even though he was able to acknowledge that this was not a rational thought , this was the thought that was at the basis of disconnecting from his daughter . His fear of abandonment was also on the basis of his reactions to his wife . We worked with these fears as the biggest problems to his his life in the present . The outcome Like all problematic grieving , healing for did not come easily or quickly , Over time was able to hold his good memories of his son and felt more in control of his distressing memories . His relationship with his wife and daughter improved , and he reported much less anger . About a year later , became involved with a group working with adolescent boys who were considered as at risk of entering the juvenile justice system . This became his positive way of honouring his son . CONCLUSION Loss , and grief that may result from it , is universal to us all and so integral to the work of counsellors . This chapter has considered the many theories that , when taken together , offer us a clearer picture ofthis complex human experience . It has also highlighted that loss and grief may be implicit in many of the presenting

GRIEF AND LOSS 145 problems we see with clients that are not specifically labelled as grief . We have seen how theory can also guide our assessment and care of people who are grieving in such a way that we can offer respectful care across the many diverse loss experiences we may encounter among clients . RECOMMENDED RESOURCES Books Harris , 2011 ) Counting our losses Reflecting on change , loss and transition in everyday life . Murray , A . 2016 ) Understanding loss a guide for caring for those facing adversity . Ed . 2012 ) Techniques of grief therapy creative practices for counseling the bereaved . 2001 ) Handbook of bereavement research Consequences , coping and care . American Psychological Association . websites Australian Centre for Grief and Bereavement Australian Child and Adolescent Trauma Loss and Grief Network Good Grief ( Includes Seasons for Growth Program ) Learning activities . Define loss , grief and grieving . What are the main theories that help us understand grieving ?

is telling her counsellor about her grief after the death of her mother . In listening to her counsellor becomes concerned about her healing . What types of information may have led to such concerns for the counsellor ?

GLOSSARY OF TERMS Ambiguous loss Loss associated with a situation of loss in which a person is unsure if a loss really has occurred or not . Chronic sorrow sadness that accompanies ongoing loss and that sometimes comes to the fore , and sometimes sits uncomfortably on the periphery of the consciousness ( 1962 ) Complicated grief A pattern of symptoms associated with problems in adjustment to the loss and so is noted in grief that does not heal or is delayed in healing . Has been termed Prolonged Grief Disorder and Persistent Complex Disorder in classificatory systems . Grief The reaction to loss , whatever that reaction may be . Loss Loss is produced by an event which is perceived to be negative by the individuals involved and results in long term changes to one social situations , relationships or ( Miller and , 1998 , 12 ) The process that occurs internally as people try to deal with loss . loss Loss that occur over a long period of time where an may not be clear and chronic sorrow occurs . REFERENCE LIST American Psychiatric Association . 2013 ) Diagnostic and statistical manual of mental disorders ( et al . 2015 ) Who needs bereavement support ?

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Psychological Medicine , 37 , AUTHOR INFORMATION Judith Murray is a qualified counselling psychologist , registered nurse and secondary school teacher and has worked in all these areas . Most recently , to July 2021 , Judith worked as an Associate Professor in Counselling and Counselling Psychology at The University of ( Australia , She was the director of both the Master of Counselling Program and the Master of Psychology Program at . She has also worked time in and Oncology nursing at The Princess Alexandra Hospital , Previously she was responsible for the establishment of a Loss and Grief Unit in the Centre for Primary Health Care in the School of Population Health at . She is currently working in private practice in the area of loss and grief . Please reference this chapter as Murray , 2023 ) Grief and Loss . In , Machin du ( Common Client Issues in Counselling An Australian Perspective . University of Southern .