[acb-hsp] Best Practices . . . Traumatic Grief

[J.Rayl]

Best Practices in Counseling Grief

 and Loss: Finding Benefit from Trauma.

by Elizabeth M. Altmaier

Grief

 moor be a primary presenting concern of clients or may form a background to another

presenting concern. In either case, use of best practices in assessing and treating

grief

 is essential. In this article I review what best practices are in general and in

assessment and treatment. I also evaluate ways to measure

grief and describe domains" of the grief

 experience. The article also discusses controversies within the literature on

grief

 counseling, including the potential for deterioration after treatment. It concludes

with a view of counseling

grief

 that promotes finding benefit from trauma.

This special section describes the devastating impact of loss on the life of a person.

However common it may be, loss causes significant individual grieving, which in turn

can impair emotional, cognitive, and behavioral functioning. Throughout this special

section we have emphasized the difficulties caused by the crisis of loss and the

experience of bereavement, such as the potential of complicated

grief

 and the special case of parentally bereaved children. We have also noted the importance

of culture-based counseling issues related to

grief.

More important, however, is a larger perspective introduced by Harvey, who defined

loss as a "fundamental human experience" (Harvey, 2002, p. 2) from which we can grow

and learn to understand others, help others, and develop our own courage to live

with pain. It is critical to keep this positive view of

grief

 in mind when considering best practices in counseling those who are grieving because

it treats counseling as facilitating growth rather than simply mending loss.

In this article I focus on the evidence that underlies assessment and treatment,

and on practices that should be considered in counseling the grieving client. Thinking

of grieving within the context of posttraumatic growth will define alternative counseling

approaches.

IMPLEMENTING BEST PRACTICES: FROM RESEARCH EVIDENCE TO COUNSELING EACH CLIENT

What are best practices? Though the term has been adopted widely, its usage is not

agreed upon--much like terminology related to

grief

. Concisely, best practices, a term borrowed from the business world, suggests that

there is a particular technique, approach, or method that when used with a particular

target is more effective (reaches its goals) and efficient (uses fewer resources)

than other techniques, approaches, or methods. It also suggests that there are data

available to influence the decision to use this particular technique. Within the

mental health field, other terms that denote a similar emphasis on using data to

make decisions on assessment and treatment are evidence-based practice and empirically

supported treatment.

One approach to understanding best practices is to focus on outcome data gathered

in clinical trials of a particular treatment (empirically supported treatments).

Many consider these studies to be the best basis upon which to select a treatment.

Advocates of empirically supported treatment argue that although a treatment is only

one of several influences on client outcome, it is the influence that a counselor

in training can most readily learn and the influence that can be most easily studied

scientifically (Norcross, Beutler, & Levant, 2005).

There are two other sources of data to inform treatment choice. One is clinical lore--the

accumulated experience of many practitioners transmitted through personal testimony,

continuing education, client reports, news coverage, and so on. Unfortunately, clinical

lore has the drawback of promoting treatments later shown to be ineffective or less

effective than alternatives. Fad diets might be the health counterpart to selection

of counseling approaches predicated on clinical lore.

Another data source is the counselor's own personal clinical experience. A seasoned

counselor can recall similar clients, similar desired outcomes, similar contexts,

and so on--memories that can inform a present treatment decision. Unfortunately,

clinical experience can fall prey to the biases that influence human memory, such

as confirmation bias, which emphasizes previous successes and overlooks previous

failures. Another bias is the availability heuristic, where clients who are memorable

for any reason are prominent images in the counselor's memory, while less memorable

clients fade.

An alternate view of counseling effectiveness is the primacy of the counselor within

the interpersonal relationship. In this view, treatments are essentially equal in

their effectiveness, but it is whether the counselor is, for example, warm or rejecting,

sensitive or insensitive, astute or ignorant that most influences outcomes. When

data are sought to support treatment decisions, the personhood of the counselor is

typically overlooked although it accounts for as much of the outcome as treatment.

Wampold (Norcross et al., 2005), for example, argues that overlooking the personhood

of counselors in research on best practices, particularly research that focuses on

the treatment as the sole or primary influence on outcome, causes two types of misattribution:

First, it inflates the effects attributed to treatment and thereby creates a false

sense of confidence in a treatment when the counselor may be the agent for change.

Second, a focus on treatment alone creates an impression that counseling is a package

of techniques that can be delivered impersonally--a gross misunderstanding of the

deeply human enterprise of counseling.

Alternatively, the counselor-client relationship may be the primary source of influence.

Lambert (Norcross et al., 2005) notes that when clients are asked about their counseling

experience in qualitative and retrospective studies, the relationship with the counselor

is typically cited as the primary reason for change: clients feel understood, valued,

appreciated, supported, and so on. Technique and theoretically based explanations

of treatment outcome (e.g., change in dysfunctional cognitions) are almost never

mentioned.

Last, the fact that clients are active agents in their own improvement and change

cannot be overlooked. Rather than being a passive recipient of a treatment, the client

elaborates on the insights of counseling outside the session, works the information

and insights into her life, and through self-healing and self-determination mechanisms

creates a medium for effective outcome.

In summary, the background of best practices is important in selecting counseling

approaches for a grieving client, keeping in mind that there is controversy over

whether

grief

 counseling is appropriate for everyone, only for persons seeking treatment, or only

for persons experiencing complicated

grief

. Moreover, though in general some counseling approaches may seem to be effective,

research should not imply that the personhood of the counselor, the relationship

of client and counselor, or the client's own self-healing processes are insignificant

aspects of change.

BEST PRACTICES IN GRIEF ASSESSMENT

Although grief

 is a universal phenomenon, it has not been adequately conceptualized. As the accompanying

articles note, the lack of consistency in defining

grief

 has led to inconsistency in the development of

grief

 measures. In what follows I describe the most prominent of these measures. They

were chosen because they (a) are the most widely used; (b) focus on

grief

, rather than broad psychiatric symptoms; (c) assess normal, not complicated,

grief; and (d) consider grief

 across all possible losses, rather than a specific loss, such as the loss of a child.

(See Stroebe, Hansson, Schut, & Stroebe, 2008, for more complete coverage of conceptual

issues in the measurement of

grief.)

Grief Measures

Texas Revised Inventory of Grief

 (TRIG; Faschingbauer, Zisook, & DeVaul, 1987). The TRIG, probably the most widely

used measure of

grief, is a brief measure with two subscales: Current

Grief

 and Past Disruption. Items, created based on a review of the literature and the

clinical experience of the authors, contain sentences of personal description to

which the participant responds on a five-point scale (1 = completely false to 5 =

completely true). Because of the contrasting temporal nature of the two sections,

the developers assert that the two scores can be used to assess progress in grieving.

Niemeyer and Hogan (2001) summarized the psychometric qualities of the scale. Internal

consistency ranged from .77 to .87 for the Current

Grief

 subscale and .86 to .89 for Past Disruption. For the original Texas Inventory of

Grief

, Faschingbauer (1981) reported an exploratory factor analysis study in which items

were retained with factor loadings greater than .40. Though there are few data on

validity, the widespread usage of the scale provides considerable comparative data

for users.

>From a construct validity perspective, there are several concerns about the TRIG.

The Current Grief

 subscale contains three items related to crying (e.g., "I still cry when I think

of the person who died"). There is considerable overlap of this subscale with depression:

items assess sadness, loss of interest in previously pleasurable activities, irritability,

and sleep problems. Finally, the scale fails to incorporate constructs that have

been both theoretically and empirically associated with

grief

 (e.g., guilt, hearing the dead person's voice).

Grief

 Experience Inventory (GEI). The GEI was designed to be sensitive to the longitudinal

process of

grief

 (Sanders, Mauger, & Strong, 1985). Items derived from the literature are presented

as self-descriptive sentences to which the participant responds true or false. Scoring

is similar to that of the Minnesota Multiphasic Personality Inventory: there are

three validity scales: Denial, Atypical Responses, and Social Desirability; nine

clinical scales: Despair, Anger-Hostility, Guilt, Social Isolation, Loss of Control,

Rumination, Depersonalization, Somatization, and Death Anxiety; and six "research"

scales: Sleep Disturbance, Appetite, Loss of Vigor, Physical Symptoms, Optimism-Despair,

and Dependency.

Niemeyer and Hogan (2001) summarized the psychometric properties of the scale. Internal

consistency is rather poor, with six of the nine clinical scales having an alpha

coefficient below .70. Sanders et al. (1985) present a factor analysis with three

dominant factors that do not correspond to the scale's structure--the largest factor

seems to measure depression. Validity data (Sanders et al., 1985) reveal that the

clinical scales differentiate between bereaved and non-bereaved persons and yield

higher scores for persons who indicate they are having difficulty accepting the loss

of the loved one.

Core Bereavement Items (CBI). Burnett, Middleton, Raphael, and Martinek (1997) describe

their CBI as a "scale of core bereavement items that could be used to assess the

intensities of the bereavement reaction in different community samples of bereaved

subjects" (p. 51). Their items were formulated from focus interviews with recently

bereaved adults and a review of the literature. After selecting 76 items, the authors

used factor analysis to narrow the pool to seven subscales. Validity studies further

reduced coverage to 17 items in three subscales: Images and Thoughts (e.g., "Do images

of the lost person make you feel distressed?"); Acute Separation (e.g., "Do you find

yourself missing the lost person?"); and

Grief

 (e.g., "Do reminders of the lost person, such as photos, situations, music, places,

etc., cause you to feel a longing for him or her?"). Items are responded to on a

four-point frequency scale with anchors indicating increasing frequency.

Niemeyer and Hogan (2001) report reliability and validity data for the CBI; coefficient

alpha was estimated at .91 for the scale as a whole. Middleton et al. (1998) noted

the following validity data: bereaved parents scored higher than bereaved spouses,

who in turn scored higher than bereaved adult children. There are no factorial validity

data.

Hogan Grief

 Reaction Checklist (HGRC). The most recent scale (Hogan, Greenfield, & Schmidt,

2001) was explicitly intended to "delineate normal

grief" (p. 2) and in particular to avoid blurring

grief

 with symptoms like depression or anxiety. Hogan et al. also used an empirical method

of scale development, obtaining and analyzing interview data from bereaved adults,

to identify six categories: Despair, Panic Behavior, Blame/Anger, Disorganization,

Detachment, and Personal Growth. Initially focus groups analyzed items that were

then given to a community sample of adults who had experienced the death of a family

member. Factor analysis revealed six factors that corresponded to the initial categories;

items with loadings of .40 or greater were retained.

Hogan et al. (2001) present alpha coefficients ranging from .79 to .90 for the subscales

and .90 for the whole measure. They suggest using a total score for the 61 items.

However, although this scale is presented as useful for general

grief

, the final set of instructions pertains to the death of a child for parents rather

than as a general

grief measure.

In assessing grief

 it is important to remember that no single measure captures all its manifestations.

Counselors might well consider assessing domains of

grief

 rather than the general concept of

grief because clients will have differing experiences and may well be expressing

their

grief within different domains across time.

Schoulte and Altmaier (2008) analyzed grief

 measures to identify a consensus of domains that encompass the experience of

grief

. After a thorough review of the literature that yielded all relevant inventories,

superordinate

grief

 domains and definitions were determined via qualitative content analysis of all

items on these inventories (see Table 1).

One approach to grief

 assessment is for the counselor to assess each domain, either through clinical interviewing,

published measures, or client self-reports. The use of diaries, journaling, and drawing

can supplement the experience of a particular domain in addition to measures or conversation.

In any assessment, client reactions should be normalized because there are socially

perceived barriers to showing

grief.

As Schoulte describes (above, pp. 11-20), cultural context is also necessary to assessment.

Inquiring about social and cultural expectations is a fruitful way to transition

to discussing the influence of family and culture. Questions as simple as "What do

you think your family's expectations are of you at this time?" can help a client

explore what may be hidden influences on the

grief experience.

BEST PRACTICES IN THE TREATMENT OF GRIEF

Is grief

 counseling effective? Although intuitively it would seem that providing a supportive

environment in which to grieve--in the presence of an empathic counselor, with gentle

encouragement to consider the role of the deceased in the client's life--would promote

adjustment, there is controversy about how effective

grief

 counseling is. Larson and Hoyt (2007) have summarized the empirical evidence for

and against it. Two particular sources of concern for them are the possibilities

of a deterioration effect after treatment and of a minimal positive outcome.

Two researchers who conducted meta-analyses have argued that clients who received

grief

 counseling may end up worse off than they began: Fortner (1999) cited a rate of

37% of clients deteriorating after treatment; Niemeyer (2000) found a similar rate,

38%. Larson and Hoyt (2007) studied the two meta-analyses in detail and concluded

that the rates of deterioration found were based on a statistic that may have been

defined erroneously. Specifically, Former (2008) notes that an error in his dissertation

text may have led to confusion about the calculation of the deterioration rates he

cited.

A second criticism is that the outcomes of grief

 counseling, expressed as an effect size, are not large enough to warrant confidence

in such treatment. Reviews considered by Larson and Hoyt (2007) established an effect

size (.11 to .43) lower than the .80 typically obtained in estimates of counseling

outcome (see Wampold, 2001, for discussion). Schut, Stroebe, Van Den Bout, and Terheggen

(2001) concluded that "based on the evidence to date, outreaching primary prevention

intervention for bereaved people cannot be regarded as being beneficial in terms

of diminishing

grief

-related symptoms, with a possible exception for interventions being offered to bereaved

children" (p. 731).

Taking this perspective, however, ignores the four views of the influence on counseling

effectiveness previously discussed. The current controversy rests on the treatment

technique alone; what is not known are outcome effects attributable to the person

of the counselor, the characteristics of the client, and their relationship. The

widespread acceptance and promotion of groups such as Compassionate Friends (for

suicide survivors) and online groups such as MyGriefSpace.net suggests that at least

some grieving persons find support from compassionate others to be of help.

There is preliminary evidence that persons with complicated grief

 may achieve better outcomes than clients with normal grieving responses. Shear,

Frank, Houck, and Reynolds (2005) compared two treatments for complicated

grief, interpersonal therapy and a new treatment for complicated

grief

. This new treatment focused on ways in which to "retell" the stories associated

with the loss so as to reduce distress and increase positive memories. Both treatments

produced improvement in the target symptoms of complicated

grief (assessed by an inventory of complicated grief

), but the new treatment was found to be more effective.

Overall, the best conclusion regarding the efficacy and effectiveness research on

grief

 counseling is that the matter is still unresolved. Considering solely the treatment,

which is the basis of outcome research in this area, yields a conclusion that counselors

should continue to strive to provide counseling to persons in need while gathering

data on effectiveness and efficacy. The Association of Death Education and Counseling

has posted a statement on research efficacy and the findings related to deterioration

that promotes this balanced approach (ADEC, 2008).

INTERVENTION STRATEGIES

One way for counselors to begin thinking of grief

 counseling strategies is to utilize the perspective described above on the domains

of influence on client outcome. Because of the importance of the personhood of the

counselor, in this section I consider first qualities that ensure that a counselor

will be an effective helper for grieving persons. (Here I rely heavily on the thoughtful

writings of the director of the Center for Loss and Life Transition, Alan Wolfelt

[1998].) A framework for those qualities consists of empathic presence, gentle conversation,

available space, and engaging trust. Within empathic presence are qualities of listening,

silence, and support. Many grieving persons will need to tell and retell stories

associated with the loss. Empathic listening, accepting and encouraging the expression

of feelings, and allowing pain to be expressed freely are critical.

Gentle conversation avoids cliches and easy answers. Telling grieving clients that

they will "get over it," "better days will come," or "the darkest hours are just

before dawn" is demeaning. The best response may be "I am sorry. Tell me more about

it." A gentle conversation allows opportunities for remembering. Memories can be

encouraged through pictures, drawing, and other expressive modalities.

Counselors should strive to provide available space for the client. Helping the client

find support and encouragement from other sources as well as counseling is also critical.

Time itself is important. Because grieving does not follow a predictable trajectory,

counselors will need to be patient.

Last, engaging trust communicates to the client that she has the ability to recover

and grow. Grieving clients may not see a future without the loved one, may not have

confidence that they will ever be free of their feelings, or may feel overwhelmed

by the demands of everyday life. Communicating a trust that continues to engage the

client in the tasks of

grief

 is essential. Using books that allow clients to have their own journey through

grief

 may be helpful; Wolfelt (1997) is an example.

Most writers about grief

 counseling do not propose techniques per se. Rather, the best technique or treatment

may be a different view of the relationship between counselor and client. Wolfelt

(1998) argues that certain treatment goals are misguided, among them treating

grief

 as a syndrome to be eliminated, promoting the client disengaging from the deceased

and terminating the relationship, having the client finish a series of tasks, using

a recovery or resolution model to suggest a return to the pre-loss state, considering

grief

 as a life crisis where balance can be re-achieved, and failing to attend to the

spiritual aspects of

grief

. Companioning for these goals involves several tenets, Wolfelt says, including learning

from the client, discovering the gift of silence, and listening with the heart (Wolfelt,

2007).

Using this perspective focuses the counselor on facilitating client grieving needs

(Wolfelt, 1997). These needs form a structure for the relationship, but meeting them

is not a linear or "led" process. Rather, within the relationship with the counselor,

maintaining a companioning model helps the client to meet the needs of "acknowledging

the reality of the death, embracing the pain of the loss, remembering the person

who died, developing a new self-identity, searching for meaning, and receiving ongoing

support from others" (p. 2). Meeting these human needs will lead to healing and reconciliation,

what Wolfelt describes as "the new reality of moving forward in life without the

physical presence of the person who died" (p. 135).

CAN GRIEF COUNSELING PROMOTE GROWTH?

In their research on trauma and growth, Tedeschi and Calhoun (1995) described characteristics

that make an event

traumatic

: being sudden, unexpected, and uncontrollable; and producing continuing, sometimes

lifelong, effects. A recent interest in psychology has been to examine the positive

rather than the pathological aspects of human functioning. Research suggests that

through times of hardship, stemming from stressful life events or trauma, individuals

have experienced "benefits" or have grown. Posttraumatic growth (Tedeschi & Calhoun,

1995) has been defined as experiencing positive growth following

traumatic life events.

An increasing number of studies have begun to examine positive psychological outcomes

of trauma. Linley and Joseph (2004) found that posttraumatic growth has been documented

in a wide variety of human events: cancer, the Oklahoma City bombing, sexual assault,

plane crash, and combat. Of particular interest is a study by Davis, Nolen-Hoeksema,

and Larson (1998) in which persons who lost a family member to death were interviewed

before and after the loss. The authors considered two ways participants thought about

the event: making sense of the loss (e.g., the participant accepted the death as

fate or God's will) and finding something positive in the experience (e.g., improved

family relationships). Those participants who either found benefit or made sense

of the loss were less distressed six months after the death and experienced better

adjustment.

Coping strategies may influence which individuals adjust better during and after

trauma. Psychosocial coping resources may protect against depressive symptoms, and

social support (perceived or actual) is thought to enhance psychological well-being

by fulfilling the need for a sense of coherence and belonging, thus counteracting

feelings of loneliness (Bisschop, Kriegsman, Beedman, & Deeg 2004). Relationships

between coping and posttraumatic growth have been reported. In Tedeschi and Calhoun's

posttraumatic growth model (1995, 2004), coping plays an important role in the ability

of individuals to adjust after a

traumatic

 event and ultimately experience and perceive growth. In a review of coping and posttraumatic

growth among cancer patients, Stanton, Bower, and Low (2006) identified eight studies

that used multiple coping strategies. They found that posttraumatic growth was more

commonly associated with approach-oriented coping strategies (e.g., active acceptance)

than avoidance strategies.

Spirituality and religion also play major roles in how individuals cope with trauma

and adversity. Both have been linked to a range of positive health outcomes, including

reduced depression and lower risk of substance abuse (Larson & Larson, 2003). Pargament,

Koenig, and Perez (2000) found that individuals cope differently depending on their

perception of God, other spiritual beings, or religion. The trend toward understanding

spirituality and religiosity as a resource in

traumatic

 situations has prompted the need for further research on how religiosity impacts

such phenomena as coping and posttraumatic growth.

The spirituality of individuals experiencing traumatic

 events has been found to change as a result of the events (Tedeschi & Calhoun, 1995,

1996; Tallman, Altmaier, & Garcia, 2007). Such spiritual or religious changes are

thought to be a major component in changes in the life perspectives/philosophies

growth domain. In a study of women who survived sexual assault, individuals reported

becoming more spiritual (Kennedy, Davis, & Taylor, 1998), and increased spirituality

was related to increased well-being after the assault. Tedeschi and Calhoun (1995)

state that "the degree to which religious beliefs can help survivors assimilate

traumatic

 events and grow from their difficulties seems a promising area for investigation"

(p. 117).

Finding benefit is a significant outcome for grieving clients. Whether individuals

are assisted in finding benefit through expressive approaches (King & Miner, 2000;

Smyth & Pennebaker, 2008), where participants write about their trauma or their emotions;

"benefit reminding" approaches (Tennen & Affleck, 2002); or enhancement of active

coping (Antoni et al., 2001) may not be as important as simply having the client

participate in a process where meaning found through grieving is articulated and

integrated into her overall view of the loss.

CONCLUSION

This article and others in this section have had as the overall goal the description

of ways counselors can effectively conceptualize, empathize with, respond to, and

assist a grieving client--much-needed but very difficult work. Indeed, counselors

who work regularly with grieving clients can suffer from compassion fatigue or even

secondary traumatization. However, the promise of counseling with grieving clients

is the possibility of impacting a person in both the present and the future, and

perhaps also improving the health and well-being of the client's children and other

family members. It is not a task to be taken lightly. In her memoir of the year after

her husband's death, Joan Didion (2006) writes of her ambivalence over her recovery

from

grief:

 I did not want to finish the year because I know that as the days

 pass, as January becomes February and February becomes summer,

 certain things will happen. My image of John at the instant of his

 death will become less immediate, less raw. It will become

 something that happened in another year.... I know why we try to

 keep the dead alive: we try to keep them alive in order to keep

 them with us. I also know that if we are to live ourselves there

 comes a point at which we must relinquish the dead, let them go,

 keep them dead. Let them become the photograph on the table. (pp.

 225-226)

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Elizabeth M. Altmaier is affiliated with The University of Iowa. Correspondence concerning

this article should be directed to Elizabeth M. Altmaier, Department of Psychological

and Quantitative Foundations, The University of Iowa College of Education, 360 Lindquist

Center, Iowa City, Iowa 52242-1529. E-mail: elizabeth-altmaier at uiowa.edu.

Table 1. Grief Domains and Definitions

 Domain Definition

 Physical symptoms Somatic and physiological

 reactions

 Cognitive Difficulties remembering,

 difficulties learning, or thinking

 Uncertainty over Loss of meaning of life and

 future pessimism about the future

 Denial Not accepting the loss, with

 responses including shock and

 numbness

 Interpersonal Changes in interpersonal

 interaction reactions, needs, and

 relationships

 Emotional response Range of internal feelings

 related to the loss

 Injustice of loss Frustration over the loss,

 feeling as though the loss was

 not deserved, shattered

 assumptions of a "just world"

 Symbolic rituals Behaviors with symbolic

 meaning an individual may

 engage in during the grieving

 process

 Continuing bonds Continued emotional,

 cognitive, and behavioral

 links with the deceased

 Benefit finding Positive changes about the

 self as a result of the

 experience of loss

Questia, a part of Gale, Cengage Learning. www.questia.com

Publication Information:

Article Title: Best Practices in Counseling Grief and Loss: Finding Benefit from

Trauma. Contributors: Elizabeth M. Altmaier - author. Journal Title: Journal of Mental

Health Counseling. Volume: 33. Issue: 1. Publication Year: 2011. Page Number: 33+.

COPYRIGHT 2011 American Mental Health Counselors Association; COPYRIGHT 2011 Gale,

Cengage Learning

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