Counselling Case Study: Working with Grief
Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of each stage will be different for each individual.
It is therefore understandable that an eclectic counselling approach to grief can be beneficial in allowing for the flexibility needed to work with individuals through various stages of the grief process. The following case study is a practical application of a variety of counselling approaches to one client and her experience of grief.
The client’s name is Joan. Joan sought counselling to deal with the unexpected loss of her daughter in a car accident. She received counselling about 2 weeks after her daughter’s death and continued with the counselling process over a period of 8 months.
The key features of Joan’s grief were her feelings of guilt and despair. In these areas, the counsellor worked mainly from a Person-Centered approach (PCT). The counsellor also utilised some techniques from Solution-Focussed Therapy (SFT) and Cognitive-Behaviour Therapy (CBT). A brief analysis of the case study and application of the various techniques are provided below.
Joan is a semi-retired accountant, maintaining contract work with a few long-term clients to support herself in retirement. Joan is a divorcee, who lives on her own, in her family home. She is a mother of 2 children, Kirsten and Mathew, aged in their mid 20s. Joan has a supportive network of family and friends, including her sister, father, children, and friends from her gardening club.
Joan’s relatively steady life was overturned with the sudden death of her daughter, Kirsten. Kirsten was 24 when she died from head injuries caused during a car accident. She was admitted to hospital in a coma. Joan spent several anxious days with Kirsten, before she passed away.
In the days that followed, Joan arranged her daughter’s funeral and affairs and deferred her work commitments. Joan described this as a whirlwind period, where she operated in a mechanical way. She was completely absorbed in the organisation of Kirsten’s funeral and pushed aside her feelings of grief. Joan said that she found some security in the numbness that filled her during that time.
After a couple of weeks, however, Joan became concerned that she was not coping as she couldn’t move on from these feelings. People had commented that she should try to carry on as usual, however her numbness persisted and she couldn’t motivate herself to “carry on” as if nothing had happened.
Joan thought that there must have been something wrong with her and it was this fear that led her to counselling some weeks after her daughter’s funeral.
For ease of writing, the professional counsellor in this case will be referred to as “C”.
The Initial Stages
(Numbness) In the first session, Joan appeared somewhat vague and tired. She seemed focussed on describing the details of the funeral, the family members who attended and her concern about her daughter not having a will. “C” observed that Joan’s behaviour reflected a need to be in control of the situation and was a useful coping strategy for Joan at this time. “C” used PCT to build an empathetic understanding of Joan’s experience. She did not attempt to move Joan towards experiencing her grief, but trusted that Joan would reach this stage in her own time.
Joan began discussing the rapid way in which the whole event had occurred and the numbness that she was feeling. “C” used paraphrases and encouragers to assist Joan to express herself. “Everything has happened so quickly that you haven’t had time to absorb it all, is that right Joan?” “Yes”, Joan replied, “I’ve hardly had time to miss my little girl.” “You miss her,” responded “C”.
With this encourager, Joan began to cry and express her grief. Joan cried for some time whilst “C” sat with her in silence. At one point Joan apologised for her crying. “C” responded “It seems that you have a lot to cry about Joan. It shows me how much you loved your daughter.”
In the first session, Person-Centered therapy and Active Listening techniques enabled “C” to be guided by Joan’s readiness to express her feelings. The encouragers and reflection of feeling used, demonstrated to Joan that “C” understood her and allowed Joan to experience her feelings of grief, rather than to keep them at arms length.
Whilst “C” could have indicated to Joan that she was avoiding her grief, “C” instead trusted in Joan’s ability to express her grief in her own time. If Joan had not expressed her grief in this session, “C” would not have pressed the issue, although she may have encouraged Joan to have a further session within a few days.
(Grief and Despair) The following sessions were characterised by further experiences of grief and despair. Joan had found that her grief was no longer avoidable and her days were mostly filled with mourning. Joan abandoned her daily routines such as grooming, making meals and other basic self-care practices.
Joan’s disheveled appearance at the counselling sessions were concerning. At this point, “C” became more directive and suggested that Joan might have someone live-in with her for a while. Whilst “C” was encouraged by Joan’s regular adherence to the counselling sessions, she felt that Joan may need some extra support at home.
Joan contacted her sister Kerrie, who was available to stay with her for a month. Kerrie proved to be good support for Joan and provided her with gentle, yet insistent encouragement to face the everyday challenges.
Over several weeks of counselling, Joan had moved further into stages of despair and guilt. She described her life as being swallowed by a black hole and felt that she would never get over her daughter’s death. She felt that every day dragged by with no release from the pain. She had difficulty getting out of her bed in the morning and was constantly tired from lack of solid sleep.
“C” continued to employ PCT to allow Joan to explore and express her feelings and thoughts about her daughter’s death. Joan focussed heavily on her pain and seemed to stay with these feelings for a long time. “C” observed that Joan’s thoughts did not seem to be focused; she quickly moved from one topic to the next. “C” used summarising skills to help Joan highlight the key recurring issues from her thoughts.
“C” continued to trust that Joan would move through her feelings of grief in her own time. “C” did however experience some frustration with Joan’s continual despair. “C” sought the counsel of a colleague, who advised her to maintain her faith in Joan’s ability to grow and heal and reminded “C” of how the resolution of grief can often be a long-term process. The colleague also suggested some role-play techniques that “C” could use to work on Joan’s experience of her feelings.
(Guilt) Guilty feelings about her inability to prevent her daughter’s death were also of concern for Joan. “C” avoided telling Joan that she was not responsible for Kirsten’s car accident, and encouraged Joan to explore her guilt. In many instances grieving people feel guilt in relation to their loss. Often they will be told that they are not at fault, by well meaning people. The concern for counsellors is that grieving people are feeling guilty and will benefit more from expressing their guilt.
Dismissing guilty feelings won’t stop the grieving person from feeling blame and may lead to the increase of these feelings. “C” realised that Joan’s guilt was a means of expressing how fervently she wished to have her daughter with her still. “C” invited Joan to express her sorrow and guilt to Kirsten in a role play activity.
Afterwards, “C” encouraged Joan to debrief and talk about the effect of the activity. Joan was able to acknowledge the depth of her love and concern for Kirsten. “C” supported Joan by offering encouraging feedback. “C” was particularly taken with the extent of love and devotion that Joan displayed towards her daughter.
Joan left the session a little lighter for the experience. She said that she had been able to release some of her guilt and that she felt her despair ease a little. After two months of counselling, both Joan and “C” recognised this as a small breakthrough of acceptance.
Joan’s grief and despair continued into the middle phase of the counselling sessions. Her emotions came in waves, rather than the constant fog of despair that had characterised her earlier sessions. “C” was continuing to utilise PCT with Joan to explore her issues. Joan expressed a readiness to establish goals during this stage. “C” implemented some CBT techniques for this purpose.
(Feelings of Panic) Kerrie had been encouraging Joan to take on small, everyday tasks such as walking to the shops, or posting the mail, in order to get out of the house for a while. Joan said she had done these tasks reluctantly as she was concerned about trying to “put on a brave face” in public.
Joan related a particular incident where she was at the local shop. She explained that when picking items from the shelves, she had selected her daughter’s favourite brand of biscuits. Feelings of panic had come over her as she realised that she no longer needed to buy the item, but she couldn’t bring herself to return the item to the shelf. In this state, she left all her purchases in the shop and walked straight home.
This incident had increased Joan’s anxiety about her ability to cope and accept her daughter’s death. In the session, “C” validated Joan’s experiences as being normal and a legitimate part of her grieving. As a part of the CBT process, “C” clarified and identified the causes and effects of Joan’s feelings of panic. These were as follows:
A realisation that her daughter was absent in her everyday life A rejection of awareness that her daughter was absent in her everyday life Conflicting emotions about acceptance of daughter’s absence
- Causing anxiety
- Causing a belief that she will never be able to accept her daughter’s loss
- Causing a fear of losing control in public places
“C” and Joan discussed the nature of the anxious feelings, and Joan’s associated beliefs and fears. Together they devised a number of goals, including (1) the development of new beliefs, (2) relaxation and (3) taking it one step at a time – otherwise referred to as a graded-task assignment.
Joan’s new beliefs included:
- It is normal to want my daughter back
- I am normal to grieve for and miss my daughter
- It doesn’t matter if I cry in public
- Time will help me to heal
She kept notes in a personal journal about when she used these new beliefs. The journal writing was also a process that allowed her to identify other problematic beliefs and thoughts. Once identified, she developed more appropriate and accepting beliefs.
In preparation of taking it one step at a time, Joan and “C” devised some relaxation techniques for Joan to use when she felt a sudden onset of panicky or anxious emotions. Joan had used imagery before and found that an effective method of relaxation. Joan was to imagine a warm, white light surrounding her whenever she felt even slightly anxious. They also devised some imagery to help Joan continue to experience the overwhelming nature of her grief.
Joan often referred to her feelings as a fog, and so “C” encouraged her to imagine sitting in a fog, which was black, thick and impenetrable. Little by little, she suggested that Joan should try to make the fog thin out with her mind. (It is important to note that this imagery was to be used at times when Joan felt bogged down in despair, but not during her anxious moments).
Joan was to record her practice of her relaxing imagery (white light) and to note her responses to the technique. She also recorded the times she used her despairing imagery (black fog) and the extent to which she was able to thin the fog with her mind. The purpose of the exercise was to increase her relaxation and to give her an image of her despair and a means to control it as time went on.
The ‘one step at a time’ goal consisted of Joan taking small steps towards running errands and taking on more of her everyday responsibilities. Her tasks involved the following:
- Plan meals for week
- Write a grocery list
- Go shopping with Kerrie.
Using her relaxation imagery, Joan completed the following graded tasks:
- Imagine walking around the shops
- Drive with Kerrie to the shop and stay in the car
- Walk with Kerrie to the shop door
- Walk with Kerrie around the shop for 10 minutes approximately
- Start to purchase a small number of items
- Complete an entire grocery shopping task
Each week, Joan completed a harder task. It took her only 4 weeks to complete a full shopping trip, although she experienced several occasions of feeling overwhelmed. Each time this occurred she gripped the shopping trolley and imagined the white light. Kerrie encouraged her to breathe deeply and relax. A couple of times, they left the shop (abandoned the trolley) when Joan felt she could not cope. They came back the following day to complete the shopping.
The important thing for Joan was to accept the times when she could not cope. Kerrie proved to be a supportive role model for Joan, helping her to accept her reduced ability to cope by offering encouraging comments and faith that Joan would heal.
Joan applied the graded-task technique to other areas of her life. “C” observed Joan’s increasing attention to self-care and other routines of everyday living.
(Acceptance) Joan’s increasing acceptance of the loss of Kirsten became more obvious with the passing of time. By dealing thoroughly with her despair and grief, she naturally moved on with her life and mourned less and less. After six months, the rewards for both “C” and Joan were evident in her long term improvement and growth.
Joan’s ability to develop goals for herself was greatly improved, as was her motivation. Joan was living independently again and without Kerrie around, she took on more responsibility and began to make plans for her life without Kirsten. Joan’s plans included a number of support mechanisms, as well as long-term goals for herself.
Joan had taken to visiting her daughter’s grave on a monthly basis. During her intense despair, she had been unwilling to venture to the cemetary. Due to her increasing acceptance, she was more inclined to visit and found the visits to be a sad, yet calming experience. The visits allowed her the opportunity to tell Kirsten the things she had left unsaid, and to update her daughter about her life, as she would have when Kirsten was alive. Joan found the visits kept Kirsten’s spirit and memory alive within her.
In these stages, “C” continued using PCT, and incorporated SFT to assist Joan to define her goals. “C” complemented Joan on her inventive ways of honoring her daughter’s memory. “C” was encouraged to see that Joan was actively seeking personal ways to express her grief.
Together, they worked to build Joan’s miracle picture. Joan expressed an interest to honor Kirsten’s life, by writing a book. Joan wanted to combine her own and Kirsten’s journals to recount the significance of her life and death. The process would also be a means to resolve her grief and offer a parting gift to her daughter.
Joan’s miracle picture included redefining her life goals to determine what was important for her. Kirsten’s death, whilst painful, had also brought growth and changes with it, and Joan was increasingly inclined to shed parts of her life that no longer held meaning for her. She threw out material things such as old furniture, files and boxes of junk and mentally discarded the maintenance of acquaintances that she no longer felt obliged to remain in contact with.
She renewed her bonds with close friends and family. Kirsten’s death allowed her family to grow closer to one another. Joan was buoyed by the love and support of these few, special people during her long months of despair.
Joan accepted that she would never completely ‘get over’ Kirsten’s death and that that was okay. Counselling assisted her to realise that her daughter would remain a part of her forever. She made a pledge to herself that she would continue to learn ways to live with Kirsten’s absence. Her journal writings and the possibility of publishing a book for Kirsten, would provide her with some therapeutic means of coping and expressing her grief. Joan would also draw from the support of her family and friends in times of need, particularly around the times of Kirsten’s birthday and the anniversary of her death.
End of Session
The case study has illustrated some of the stages that clients may experience due to the loss of a loved one. It has also attempted to demonstrate the way in which PCT lent itself to the complex and individual experience of Joan. The key issue from the PCT perspective was “C’s” respect for Joan to grieve and grow to acceptance in her own way and time.
CBT was applied to changing Joan’s negative thoughts about her ability to cope with her daughter’s loss and the fear of losing control of her emotions in public places. The imagery was a technique that Joan had prior experience with and was therefore ideal for her. Another client, may prefer other relaxation methods. It is important to identify strategies that the client is comfortable with.
Graded task assignments, journal writing, role plays, homework and other practical strategies such as developing support networks are also invaluable CBT techniques. Timing is important when introducing strategies, and the client should not be pushed into solutions before they are ready to accept them. Wherever possible, the counsellor should consult with the client about their ideas for, and their suitability to, particular techniques.
Once the client is ready to focus on solutions to their problems, SFT can be an invaluable tool for identifying the client’s goals through development of the miracle picture. The use of SFT has been briefly presented in the case of Joan, to illustrate its effectiveness in drawing out the plans and goals that Joan aspired to.
Author: Jane Barry