A DUAL JOURNEY OF GRIEF: CONSIDERATIONS FOR GRIEVING CLINICIANS WORKING WITH GRIEVING CLIENTS by Shannel Harris BSW, University of Northern British Columbia 2014 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER’S OF EDUCATION IN COUNSELLING UNIVERSITY OF NORTHERN BRITISH COLUMBIA July 2024 © Shannel Harris, 2024 i Abstract Grief is a multifaceted and subjective experience. Despite a considerable body of research on grief and loss, there exists a notable gap in understanding how clinicians navigate their own experiences of grief while attending to grieving clients. Therapists frequently prioritize the welfare of their clients over their own, often feeling an implicit expectation to effectively manage their grief. This can affect the therapeutic relationship and the client directly. It is important to identify this gap in research and address some of the barriers, internal and external, clinicians may face when experiencing grief. In an attempt to address some of these barriers, this project was created. Through conducting a thematic literature review focused on main themes around grief and loss and therapists’ experiences of it and utilizing content analysis to categorize and organize the information in the literature, seven considerations were developed. The seven considerations found in the booklet are: grief, grief theories and therapies: an overview, self-awareness and selfreflection, self-care, things can impact your practice, countertransference, readiness to return to work, and seeking supervision. Information pages and resources are also included. By creating these considerations, this project seeks to provide insights and support for clinicians facing the challenges of managing their own grief in therapeutic settings. ii Acknowledgments I would like to express my deepest gratitude to all those who have supported me throughout the course of this project. First and foremost, I am profoundly grateful to my academic supervisor, Dr. Linda O’Neill, for her invaluable guidance, insightful feedback, and continuous encouragement. Her expertise and patience have been crucial in shaping the direction and quality of this project. I extend my heartfelt thanks to the other members of my committee, Dr. John Sherry and Rebecca Pozer, for their time and knowledge. I am deeply indebted to my colleagues and leadership team at my workplace. The practical and emotional support I received throughout my graduate studies was integral in my ability to successfully complete my program. I am truly grateful to be able to work with the team that I do. Each and every one of them has contributed to my professional practice, my personal wellness, and made me a better clinician. Finally, I wish to express my profound gratitude to my family. To my mom, who has always believed in me and supported my academic endeavors. To my partner, for his unwavering support and understanding throughout this journey. And lastly, but most importantly, to my daughter, who has given me a greater purpose and shown me what it really means to be fully present. Thank you all for your encouragement, support, and for believing in me even when I couldn’t. I could not have done this without each and every one of you and I am eternally grateful. iii TABLE OF CONTENTS Abstract ............................................................................................................................................ i Acknowledgments........................................................................................................................... ii Table of contents ............................................................................................................................ iii Chapter 1: Introduction ................................................................................................................... 1 Significance of the project........................................................................................................... 2 Benefits........................................................................................................................................ 3 Parameters of the Project............................................................................................................. 3 Background of the Project/Personal Location ............................................................................. 4 Overview of the Project............................................................................................................... 5 Chapter 2: Literature Review .......................................................................................................... 6 Grief and Loss ............................................................................................................................. 7 Grief reactions ......................................................................................................................... 8 Typical grief reactions. ......................................................................................................... 9 Complicated Grief. .............................................................................................................. 10 Grief-Related Therapeutic Models Overview ....................................................................... 11 Countertransference .................................................................................................................. 17 Causes of Countertransference .............................................................................................. 18 Impact of Countertransference on Client and Therapist ........................................................ 18 Management of Countertransference Reactions .................................................................... 19 Therapists Experience of Grief and Loss and Implications For Practice .................................. 20 Shifts in Worldview ............................................................................................................... 21 Self-Disclosure ...................................................................................................................... 21 Empathy ................................................................................................................................. 23 Returning to Practice ............................................................................................................. 24 Coping With Bereavement and Addressing Emotional Needs. .......................................... 25 The Role of Avoidance. ...................................................................................................... 26 Expectations Around Returning to Work. .......................................................................... 27 Supervision ......................................................................................................................... 28 Summary ................................................................................................................................... 30 Chapter 3: Project Description ...................................................................................................... 32 Content Analysis ....................................................................................................................... 32 iv Target Audience ........................................................................................................................ 33 Summary of the Project ............................................................................................................. 33 Chapter 4: Considerations for Grieving Clinicians working with Grieving Clients Booklet ....... 35 References ..................................................................................................................................... 73 1 Chapter 1: Introduction Grief and loss are profound experiences that deeply impact individuals' lives, including therapists who navigate these experiences both personally and professionally. The complex relationship of personal grief and professional responsibilities can profoundly influence therapeutic dynamics and outcomes (Doka, 2002). Research by Stroebe and Schut (2001) further emphasizes the dual nature of grief experienced by therapists, highlighting the challenges they face in maintaining emotional boundaries while providing empathetic support to clients. Clinicians have reported both positive and negative experiences when returning to work after a loss. For some, returning is a helpful outlet, giving a sense of purpose, for others, returning to work can feel daunting and full of worry and self-doubt (Givelbar & Simon, 1981; Kouriatis & Brown, 2013; Martin, 2011; Swinden 2021). Kouriatis and Brown (2011) noted the attention paid to client concerns in existing research and how concerns related to clinicians, such as experiencing grief and expecting to work with clients also experiencing grief, is overlooked. They posit this is likely due to the belief held by clinicians that they ‘should’ know how to cope and, as a result, turn their focus onto their client’s concerns. The aim of this project is to provide support and insights for grieving therapists, addressing key themes to consider when returning to work after a loss. These themes include understanding the complexities of grief and loss and their therapeutic modalities, navigating countertransference dynamics, and acknowledging the therapists' own experiences of grief and loss and how they influence their practice. Exploring these themes can hopefully enhance grieving clinicians’ self-awareness, improve client outcomes, and foster a compassionate therapeutic environment. By integrating personal and professional growth strategies, this project 2 will ideally contribute to the well-being of therapists and the quality of care they offer themselves and to grieving clients. Significance of the Project The extensive amount of research on grief and bereavement has led to a deeper understanding of grief and how individuals process it, however there is a significant gap in research related to therapists experiencing a significant loss and how this impacts them in practice (Boyden 2005; De Santis 2013; Dunphy & Schniering, 2009; Kouriatis & Brown, 2011; Swinden, 2021). The therapeutic relationship is widely considered to be the key element in client therapeutic outcomes (Horvath & Symonds, 1991). Often, the focus is on the client experience and how the therapist can best support them. When a client is experiencing grief over a loss, they are likely to seek comfort and guidance from their clinician and lean into the therapeutic relationship as a safe haven to process their grief. However, what happens if the therapist is struggling with their own loss alongside their client? How does this impact the client? The therapist? The relationship? What can be done to help support therapists in their grief while maintaining best practice and continuing to ensure clients are supported? Therapists are not immune to distress, but often, the clients’ experience and well-being is at the forefront of research on the topic of grief (Kouriatis & Brown 2011). Although grief is universal, it’s also unique to everyone, experiencing differences in intensity and longevity of grief (Bonanno & Kaltman, 2001). Considering the lack of research focused on therapists’ grief experiences, despite the immense responsibility they tend to hold, it’s not surprising that some therapists have reported difficulties in returning to work and supporting clients after a loss (Kouriatis & Brown, 2014). By normalizing the grief experiences of therapists and simultaneously acknowledging the uniqueness of individual grief experiences, 3 there is a hope to foster a shift in which more clinicians feel comfortable being open about their needs, ideally leading to a safer environment for therapists to return to their supportive work effectively. This project aims to help that shift by bringing information and awareness to clinicians. Benefits As a therapist who struggled to return to work after my own loss, my hope is that this booklet offers some comfort to others in a similar position I was in. Some other potential benefits for clinicians may be: normalization of grief experiences, gaining more awareness around their own, and others, grief experiences; more awareness on their capacity and ability to return to work; and what they may need in order to return to work effectively. A larger benefit would be at an organizational level where leadership implements changes to ensure more individualized support for clinicians. Overall, the ideal benefits would be for clinicians to gain awareness in some area of their grief and/or practice that will help them to process or hold their grief and practice effectively if they have chosen to return to work. Parameters of the Project Drawing from themes found in the literature, a set of considerations was created. Due to the uniqueness of the grief experience, the title of this project was chosen carefully. ‘Guidelines’ did not feel like an appropriate fit due to the generalizability it’s associated with as there is no one way to grieve. Therefore, ‘Considerations’ was chosen. It is hoped that those reading the booklet will take into consideration, if it fits for them, some of the points from the literature about grief, experiences unique to clinicians, and what other practicing therapists have reported as helping or hindering their grief and/or work with clients. A focus on the overall theme of “grieving clinicians experiences working with grieving clients,” resulted in a literature review 4 centered on relevant topics related to this theme. Through the literature review, other themes began to emerge which informed the considerations used to create this project. This project is intended for individual practitioners. It should be noted that the information presented will likely not fit for all clinicians. Access to supportive resources is an important part of processing grief but something not all clinicians may have. Online resources have been included to help bridge this gap, however in isolated rural communities this could also be a barrier. Supervision has also been reported to be a large mitigating factor in therapist efficacy when returning to work after a loss (Givelbar & Simon, 1981), but adequate and appropriate supervision can also be challenging to find for many (Swinden, 2021). Background of the Project/Personal Location Grief is recognized as a universally felt emotion and one that I have had both the burden and privilege to experience. Prior to my own personal therapy work after a significant loss, I could not fathom ever seeing experiencing grief as a privilege. The grief I experienced was all consuming and brought up other unresolved grief that I had been harbouring. At the time of this loss, I had been actively practicing as a mental health clinician for about four years. I felt doubts in myself as a counsellor as I ‘should’ be able to cope with this grief, I ‘should’ have the tools, but the truth was, I didn’t. It wasn’t until I was encouraged to seek out my own therapy that I really began to understand grief work. I continued to practice counselling through my grief as I came to understand that grief was not finite. It was ever changing, ever lasting, and had become a part of my daily reality. I was learning to live with it, not run from it. As I continued to see clients, I would at times become triggered and my grief would become bigger once again, but it also informed my approach in session. I reflected on what my client needed in the moment, not what needed 5 ‘fixing.’ Often, it was connection, empathy, validation, space to be heard free of judgment or unsolicited advice. I found peace in something I had fought so hard to escape when I was in the midst of my strongest grief, being present. My hope is that this project provides other clinicians with something that will help them through their grief journey. Overview of the Project Chapter one illustrates why I have chosen this project and how I hope it will assist grieving therapists while practicing with grieving clients. In chapter two, a literature review provided the themes of the project which include: grief and loss (including types and theories), countertransference, and existing research on therapists’ grief and loss experience. Chapter three outlines the overall project. Chapter 4 includes the completed booklet, titled: “A Dual Journey of Grief: Considerations for Grieving Clinicians working with Grieving Clients.” Throughout the project, “clinician,” “counsellor,” and “therapist” will be used interchangeably, however in the actual finished booklet, “clinician” will be the sole term used to make it feel more accessible to a wider range of helping professionals. 6 Chapter 2: Literature Review Grief and loss have been a focal point for study and therapeutic modalities, however there is a lack of research focused on the grieving therapist and how this affects their practice with grieving clients, therefore there is also a lack of research on how to support these therapists. Transference and countertransference have also had considerable attention and how countertransference is viewed has grown and shifted over time. Countertransference is unavoidable in therapeutic work, especially when considering grief experiences, and has historically been seen as something to be avoided (Freud, 1953). More contemporary views encourage clinicians to address and work through it instead, seeing it as being inevitable and detrimental if not effectively managed (see for example Hayes et al., 2018; Hayes, Gelso & Hummel, 2011; Hayes, Yeh & Eisenberg, 2007; Rosenberger & Hayes, 2002; Ulman, 2001). Literature on countertransference in the context of grief and loss will be focused on due to the nature of the project, the focus on therapist grief and loss. Studies on the experience of grieving therapists and what this means for their professional practice are sparse and often anecdotal; however, they do provide some insight into the challenges, needs, thoughts, and feelings these bereaved therapists experience. It is accepted that the therapist is a fundamental tool in therapy which makes understanding the impact of loss on a therapist and their practice vital. Horvath and Symonds (1991) concluded from their metaanalysis on the therapeutic working alliance and psychotherapy outcomes that the impact the therapeutic relationship has on the success of therapy is a key predictor in how successful therapy is. Considering this, there should be a larger focus on supporting therapists when returning to work after a loss to mitigate impacts on the therapeutic relationship for both the therapist and client. 7 This literature review includes a brief overview of grief and loss, including types and how it is often pathologized, as well as some of the methodologies and theories that have emerged. A discussion on countertransference and how this may impact therapy, including in the context of grief and loss, is included. Finally, studies focused on therapists who have experienced a personal loss and its impact on their practice is discussed. It should be noted, however, that due to the wealth of information around grief and loss, countertransference, and general therapists’ experiences, the literature utilised is not exhaustive but is meant to offer a representation of trends and main ideas in these areas. Grief and Loss The study of grief and loss has been extensive. Since Freud’s (1953) original publishing of Mourning and Melancholia in 1917, the definitions and types of grief have been extrapolated to include a wide array of grief experiences and presentations. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) tries to recognize grief as a normal part of life while acknowledging the challenges that can come with unresolved and complicated grief by distinguishing between grief reactions (e.g.: “normal grief” from depressive episodes and “Persistent complex bereavement disorder”). In the counselling field, it has led to many different theories and methodologies for working with grieving individuals. From Kubler-Ross’s (1969) five stages of grief to Shear’s (2005) Complicated Grief Therapy, there is no shortage of viewpoints on how grief can be explored. A discussion around normal/typical and complicated/disordered grief reactions as well as different theories and approaches to grief is included to provide context and understanding of grief and how it may be addressed in a therapeutic setting. 8 Grief is often thought of as losing a loved one through death. Although this is true for many, it is not the only cause for grief as it can be experienced through other losses as well. Doughty et al. (2011) argue that “all client issues involve elements of grief and loss” (para. 1). Neimeyer (2001) addresses the reciprocal relationship change has with loss, “Loss and grief are integral parts of life, with all changes in our lives involving loss and all losses in our lives requiring change” (p. 3). Clients often seek therapeutic support due to changes in their lives, including experiencing a new medical diagnosis, a change in life circumstance, various adjustment difficulties, breakdowns of relationships, mood concerns, loss of an important person, to name a few. These experiences include mourning some aspect of their lives and often has an impact on personal schemas, with many re-evaluating their thoughts and beliefs depending on the circumstances of the loss (Doughty et al., 2011). Grief reactions Grief is a universally recognized emotion that virtually all people experience at some point in their lifetime. Due to the universality of grief, there has been much debate around the pathologizing of grief and grief reactions. Attachment theory explains how individuals develop different attachment styles which can influence how they cope with grief (Bowlby, 1980). Unsecure (anxious, avoidant, or disorganized) attachment styles may lead to more challenges in the grieving process than someone with a secure attachment style. Neimeyer et al. (2002) proposed a model where attachment theory was the basis for whether an individual experienced complicated grief or uncomplicated grief. If an individual was securely attached to the deceased person, their self, happiness, and survival was posited to be unthreatened resulting in uncomplicated grief: an ability to accept the loss, find meaning in life, and maintain connections to others. Whereas unsecure attachment led to self, happiness, and survival being threatened 9 which led to separation and traumatic distress which were reported as symptoms of complicated grief. Typical grief reactions. Typical grief reactions are recognized across cultures. A person’s worldview about death and dying and how mourning is carried out informs how grief is experienced and processed, which can vary from culture to culture and person to person (Doughty et al., 2011). Bui (2018) summarizes the acute grief phase as a ‘normal’ reaction. Frequent thoughts about the lost loved one, yearning, intense emotional pain and “pangs of grief,” social withdrawal, loss of interest, emotional lability, emotional dysregulation, and being easily triggered, are described as aspects of this acute grief phase. “Normal” grief reactions are often characterized as occurring up to six months immediately following a loss, with complicated grief being characterized as symptoms that continue after six months to a year; however hesitations around blindly accepting these timeframes without taking cultural and other individual differences into account remain (American Psychiatric Association, 2013; Bui, 2017; Bonanno & Kaltman, 2001; Neimeyer et al., 2002; World Health Organization, 2021). Although there can be cultural differences in how grief is expressed, these are common experiences reported when grieving (O’Connor, 2019; Neimeyer et al., 2002; World Health Organization, 2021). Bonanno’s (2001) review of grieving processes found four types of “disrupted functioning” that bereaved individuals experience in the year after a loss: cognitive disorganization, dysphoria, health deficits, and disruptions in social and occupational functioning. Positive experiences after a loss, such as positive changes in identity and thought content, were reported by Bonanno (2001) who also found that the positive experiences had a positive correlation to the health outcomes of participants a year after the loss. Neimeyer et al. 10 (2002) also speak to evidence of personal growth after grief that bolstered positive perceptions about life’s meaning. Complicated Grief. Complicated grief, abnormal grief, prolonged grief disorder, and persistent complex bereavement disorder are all names used to describe a grief experience that is severe, prolonged, persistent, and unshifting that causes the individual significant distress (American Psychiatric Association, 2013; Bryant, 2014). Abnormal or complicated grief tends to develop when there is limited social supports and coping skills, substance abuse, other life stressors present, a history of mental health concerns, or when grief is due to the death of a child (O’Connor, 2019; Waller et al., 2016). The DSM-5 is used in clinical settings to diagnose mental disorders depending on varying criteria (American Psychiatric Association, 2013). With each edition and revision, the DSM tends to include/exclude criterion and diagnoses depending on recent research. Grief and loss experiences, specifically the diagnosis of complicated grief, or prolonged grief disorder, has been debated for some time and ultimately was not included in the newest edition of the DSM. It has been argued that the inclusion of a complicated grief diagnosis would benefit individuals who are struggling with grief and loss for extended time periods with a significant or severe interference in their daily functioning as they may be better able to access professional supports with a formal diagnosis and mitigate depression misdiagnosis (Bryant, 2014). It has also been found that labels, such as diagnoses, can provide comfort and understanding to some (Bryant, 2014). Hesitations around including this as a stand-alone disorder center on possible risk of ‘normal’ grief reactions being labeled as pathological, “the challenge for the diagnosis of prolonged grief is balancing the benefits of identifying those who are suffering persistent 11 significant mental health problems following bereavement and not falsely labeling normative grief responses as pathological” (Bryant, 2014, p. 23). O’Connor (2019) compiled a literature review on grief and how the body reacts/adapts. Negative effects on mortality and general wellness were observed in those who were struggling to adapt to a loss, they were reported to have immune system deficits and more significant and long-standing changes in different biomarkers versus those who reportedly had a more “normative adaptation to loss” (O’Connor, 2019). Poorer cognitive testing and functioning were also noted in those considered to be experiencing complicated grief. O’Connor (2019) suggests continuing to study the effects of grief on mind and body in order to better understand the larger body systems that can be impacted by grief rather than just focusing on psychological effects. At times, wanting to help someone who is grieving alleviate their pain is contradicted with the worry or fear that their grief will become pathologized (Bui, 2018). An understanding of grief reactions and their severity can be beneficial to clinicians in order to best support their clients, and themselves. Taking individual experiences and symptoms into account, while acknowledging cultural factors, may help a clinician determine whether grief is shifting into complicated grief where further intervention may be warranted. However, as noted, this can be a fine line to traverse so as not to pathologize ‘normal’ grief or miss a more significant mental health concern. Grief-Related Therapeutic Models Overview There is no shortage of grief theories. Attachment theory and cognitive stress theory are currently the main influences for grief research, which underpin the discussed theories; however, there is not one standard grief theory or therapy (O’Connor, 2018). Due to the abundance of theories on grief and grieving, for the purposes of this review I focused on providing an 12 overview on a few of the influential grief-related theories: Kubler-Ross’s five stages of grief (Kubler-Ross, 1969), Bowlby’s attachment theory (Bowlby, 1980), Worden’s tasks of mourning model (Worden, 2018), Neimeyer’s meaning reconstruction theory (Neimeyer, 2001), Stroebe and Schut’s dual-process model (Stroebe & Schut, 2001), and Shear’s complicated grief therapy (Shear, 2010). It is important to note that this is not an exhaustive review of grief theories, however some of the more common among the literature relating to grief and bereavement (see for example Doughty et al., 2011; Hamilton, 2016). These theories and therapies, when used in grief and loss counselling with grieving individuals, have been shown to help prevent grief from becoming complicated and help to mitigate grief responses that are detrimental (Waller et al., 2016). Incorporating evidence-based interventions and approaches is not only crucial in general but also holds significant importance in bereavement counseling (Waller et al., 2016). Although there is evidence for the efficacy of specific grief therapies, it is important to consider individual uniqueness in terms of how grief is expressed and worked through. Studies have found that being present, walking alongside the individual, honoring their experience and story, remembering the person who died, being open and unafraid of grief-related emotions, refraining from advice when not asked for it, and simply listening were some of the most helpful aspects of support grieving individuals reported receiving (Cacciatore et al., 2021; Goldsworthy, 2005; Waller et al., 2016). Research on grief has come a long way since Freud (1957) discussed “grief work” in Mourning and Melancholia. Freud posited that to work through grief, ties had to be broken between the bereaved and the deceased. Although some tenets from Freud are still acknowledged by researchers, such as some of the mental and physical effects, readjusting to life without the deceased and creating new meaningful relationships, others have been opposed to some of his 13 ideas, such as the process needing to occur as quickly as possible (see for example: Larson & Hoyt, 2009; Schut, 2010). Elisabeth Kubler-Ross’s five stages of grief is arguably the most well-known of these theories. Kubler-Ross (1969) developed the stages as a result of work with terminally ill patients. Although this model was developed for people who are terminally ill, the stages are still widely recognized and often referenced within the topic of grief. She defines the five stages as: denial and isolation, anger, bargaining, depression, and acceptance. She posits that, as a person grieves, they work through each of these stages, not necessarily in a linear fashion. However, KublerRoss’s stage theory has been critiqued and it has been argued that there is not enough empirical evidence to support her assertions (Bonanno, 2001; Neimeyer et al., 2010). John Bowlby has been a key influence in many grief theories due to the insights his work on attachment theory have provided on how people experience grief and cope with it. Bowlby (1980) originally focused on children’s attachment to primary caregivers and how those relationships affected individuals’ ability to form emotional bonds. The attachments to caregivers were seen as offering a secure base where children could both explore the world and have a safe relationship to seek comfort when needed. In relation to grief, Bowlby (1980) outlined four phases individuals work through to both enable a detachment of the lost loved one and to continue the bond (in order to ‘adjust’ to the loss). The first phase is characterized by feelings of numbness or shock that “usually lasts from a few hours to a week and may be interrupted by outbursts of extremely intense distress and/or anger” (Bowlby, 1980, p. 84). Second, the individual experiences feelings of yearning for their lost loved one. Disorganization and despair follow, with reorganization and detachment as the last phase. Those who are grieving may start to adjust to life without their loved one, while still feeling the impact of the loss. Attachment 14 theory is, overall, focused on the profound impact important relationships have on individuals which are significantly disrupted when a loved one is lost, but also focuses on the lasting connections with that person. J. William Worden (2018) first introduced the concept of “Tasks of Mourning” in 1982 as an adjunct to other grief theories that existed at the time. Worden (2018) describes his tasks as less passive than some of the other phase- and stage- based theories in that it “can give the mourner some sense of leverage and hope that there is something that he or she can actively do to adapt to the death of a loved one” (p. 43). The four tasks include: accepting the reality of the loss, processing the pain of grief, adjusting to a world without the deceased, and finding a way to remember the lost loved one while embarking on a new life without them. In this model, the individual grieving is seen as an active participant working through their grief rather than just experiencing it in a passive way. Robert Neimeyer, a social constructivist in the field of thanatology, developed the “Meaning Reconstruction Model” that focuses on how individuals cope with the experience of loss and make sense of it by emphasizing that individuals actively construct their own understanding of reality (Neimeyer, 2001). The key concepts of Neimeyer’s (2001) model are: the reconstruction of loss (confronting the emotional impacts of loss, reassessing beliefs and assumptions, creating a new sense of identity, and adapting to changes as a result of the loss), the use of narrative approaches to retell stories of loss and explore thoughts, feelings, and beliefs about it, maintaining emotional connections with the lost loved one and the recognition of cultural factors and how they impact the experience of loss. Margaret Stroebe and Henk Schut first introduced the Dual Process Model of Coping with Bereavement in the late 1990s “in an attempt to integrate existing ideas rather than [create] 15 an altogether new model” (Stroebe & Schut 2001, p. 395). This model describes two broad types of stressors: loss-orientated (focus on processing the loss experience) and restoration-oriented (secondary stressors that are consequences of experiencing a loss) (Stroebe & Schut 2001). Stroebe and Schut (2001) believe that a grieving individual alternates between avoiding aspects of loss and confronting them and that “oscillation between the two types of stressors is necessary for adaptive coping” (p. 395). Positive and negative meaning (re)construction occur in both lossoriented and restoration-oriented pathways. Positive meaning (re)construction includes: “positive reappraisal, revised (constructive) goals, positive event interpretation, expressing positive affect;” whereas negative meaning (re)construction includes: “rumination/wishful thinking, revised (unconstructive) goals, negative event interpretation, ventilating dysphoria” (Stroebe & Schut 2001, p. 397). Engaging in both loss-oriented and restoration-oriented coping allows grieving individuals to find a balance between attending to their emotional needs related to the loss and adapting to the changes in their daily lives. M. Katherine Shear’s complicated grief therapy is a specialized therapy designed to assist those struggling with complicated or prolonged grief. Complicated grief therapy came as a result of limited efficacy shown in treating complicated grief responses with standard treatments (Shear et al, 2005). This grief-specific therapy utilizes aspects of interpersonal psychotherapy, cognitive-behavioral therapy, and motivational interviewing (Shear et al., 2005; Shear, 2010). It is structured, often consisting of 16 sessions over four months and uses a general framework of psychoeducation, journaling, involvement of a support person, increasing interpersonal functioning, creating personal goals, encouraging self-care, revisiting the death, revisiting avoided places/activities, working with memories and pictures, and imagining conversations with the lost loved one (Shear, 2010). In Shear et al.’s (2005) study comparing complicate grief 16 therapy and interpersonal psychotherapy, they found that participants who received complicated grief therapy showed a greater reduction in symptoms and improvement in overall functioning and quality of life than the interpersonal psychotherapy group. Waller et al. (2016) compiled a systematic review of evidence for grief counselling and found Complicated grief therapy to be effective in reducing grief symptoms however noted that further exploration into the efficacy of this therapy was needed. Generally, those who seek out counselling support due to grief have been struggling with significant symptoms and likely a significant impairment in their daily lives. Those experiencing "normal" grief reactions may not seek out or need therapeutic support. Studies suggest that those who are not experiencing maladaptive grief symptoms may not benefit from counselling support the same as those having significant difficulty (Schut, 2010). There has been some debate around the efficacy of grief-centred therapies (see for example: Larson & Hoyt, 2009; Niemeyer et al., 2010; Schut, 2010). Some studies have used participants who could be considered in the ‘normal grief’ category who have been recruited for a specific study versus having sought out grief specific therapy on their own accord, these ‘found’ participants often report no change in symptoms at follow-up check ins (Schut, 2010). Studies that have used participants who have either sought out therapy or report a more significant impairment due to grief have consistently reported an improvement in grief-related symptoms like those discussed above at 6-month, 9month, and 12-month intervals (Neimeyer, 2010; Waller et al., 2016). While there is a multitude of theories and therapeutic approaches addressing grief and loss, it appears that the most significant determinants of therapeutic outcomes are the unique factors presented by the client and the therapeutic rapport established with the therapist (Bonanno, 2001; Cacciatore et al., 2021; Goldsworthy, 2005; Waller et al., 2016). Being present 17 with a client and walking alongside them in their journey through grief may prove more useful than any specific modality. However, this can create challenges when the therapist is also navigating their own experiences of grief and loss. Countertransference Freud (1959) first identified countertransference by describing the phenomenon of unconscious reactions in the therapeutic relationship. Countertransference has since been described and defined in different ways in the decades since Freud’s conceptualization. Four different notions of countertransference have been used in the literature: classical, totalistic, complementary, and relational (see for example Hayes et al., 2011; Rosenberger & Hayes, 2002). However, for the purposes of this literature review, a more integrative definition will be used. The causes of countertransference, the impacts it can have on therapy, and a discussion on managing countertransference will be included. Hayes et al.’s (2007) article on countertransference in bereavement therapy discusses the universal agreement that therapists’ experiences and well-being impact the therapeutic relationship and that countertransference is an expected part of therapy. In addition to Freud’s (1959) definition of countertransference as unconscious defensive reactions by the therapist, Hayes et al. (2018) further identify countertransference by the internal and external reactions (conscious or unconscious) that are a result of unresolved conflicts which arise when triggered by some aspect the client brings into therapy. It is argued that countertransference in therapeutic relationships is inevitable due to the humanness of the therapist; there are bound to be unresolved conflicts that a client will eventually touch upon in some capacity (Hayes et al., 2007; Hayes et al., 2011; Hayes et al., 2018). Despite the often negative connotations attached to countertransference, it can also provide insight into the 18 dynamics in the therapeutic relationship and enhance the effectiveness of the therapeutic process (Heimann, 1950). Causes of Countertransference What causes countertransference to arise can be multifaceted and is dependent on the individual, however, client factors alone are not reliable indicators (Rosenberger & Hayes 2002). The level of resolution around therapist issues has an impact on levels of countertransference. Research shows a correlation between how countertransference impacts clients and the therapeutic relationship depending on how resolved, or unresolved, therapist concerns are (Hayes et al. 2007; Hayes et al. 2018; Rosenberger & Hayes 2002; Heimann, 1950; Ulman, 2001). Ulman (2001) researched specific situations where aspects of the therapists’ private lives were inadvertently exposed to their clients. The purpose of this study was to assist therapists in being better able to anticipate how they may react in the face of countertransference as the client becomes more aware of their personal life and begins to discuss topics with commonality to their therapist. Ulman (2001) reported that this sudden imbalance in the relationship impacted the therapists’ ability to maintain their therapeutic stance. If a therapist is struggling with unresolved grief over a loss, a client coming into session to discuss their own grief will likely evoke countertransference responses within that therapist. Impact of Countertransference on Client and Therapist Countertransference can affect the therapist, the therapeutic relationship, client perceptions of the therapist, and sessions. Clients tend to be impacted more by overt countertransference behaviour as they may not be aware of what impacts the therapist unless the therapist acts it out in session, e.g.: by avoiding topics brought up by the client (Rosenberger & Hayes 2002). However, the therapist may perceive themselves as untrustworthy and/or less 19 effective if experiencing countertransference regardless of client awareness (Rosenberger & Hayes 2002). Although the client may not be made explicitly aware of countertransference and may not sense any apparent shifts in therapy, therapist perception will still influence the sessions in some way. In relation to grief, Hayes et al. (2007) found that therapist empathy, credibility, the working alliance, and session depth were all affected in some degree that was dependent on whether the therapist had resolved their own grief, with empathy the most affected. Dependent on the level of resolution around the therapists grief and loss, the client experienced the therapist to be more or less empathetic, available, and understanding towards them. “In the realm of bereavement therapy, therapists can function as wounded healers in that losing a loved one and working through the emotional pain of missing that person can serve as a basis for enhanced empathy with clients who are also dealing with the death of a loved one” (Hayes et al., 2007, p. 351) if that therapist is working to acknowledge and resolve their grief and can recognize it’s potential impact. Management of Countertransference Reactions If countertransference is an inevitable reality for therapists, then management of countertransference reactions is an important aspect of maintaining best practice. Hayes et al. (2018) found that the better therapists were able to manage their countertransference reactions, the better the psychotherapy outcomes were. The main factors mitigating these reactions are selfawareness around the therapists’ own triggers and unresolved issues, maintaining healthy boundaries, engaging in personal therapy, receiving clinical supervision, and practicing self-care (Hayes et al., 2018). 20 However, theory alone is not sufficient to mitigate countertransference reactions, the therapist must possess the ability for self-reflection in order to effectively manage countertransference. Self-insight, anxiety management, conceptual skills, and ability to repair are some characteristics that may make therapists better able to mitigate negative countertransference effects (Rosenberger & Hayes, 2002). The more empathic capacity the therapist has, the more open they will be to their feelings around countertransference, making empathy one of the key pieces to effectively managing countertransference reactions and practicing more effectively (Hayes et al., 2011; Rosenberger & Hayes 2002). Therapists Experience of Grief and Loss and Implications For Practice Most studies related to therapist bereavement have focused on therapists’ experiences with grief around the death of a patient/client to suicide or terminal illness (Kouriatis & Brown, 2014). Yet, studies focused on therapist personal loss experiences outside of client loss, and how these affect the therapist personally and professionally appear generally limited to unpublished dissertations and anecdotal accounts (see for example Boyden, 2005; Bozenski, 2006; Johnson, 2011; Millon, 1981; Stebbins, 2015; Vamos 1993). Kouriatis and Brown (2011) argue that the lack of research on this topic may be due in part to the focus placed on clients by helping professionals, and the lack of recognition of their own experiences and how they impact the work. Although most of the focus appears to be on how therapist practice is affected, some studies do give attention to the personal impact therapists experience outside of their work with clients. However, it is important to note that due to the reciprocal nature of the therapeutic relationship, it can be argued that the personal effects inevitably impact the therapist’s professional work. There are both positive and negative effects discussed; factors that enhance 21 practice and therapist perception of themselves, and those that are reported to hinder it. The role of self-disclosure, the depth of empathy and the therapeutic relationship, avoidance of deeper topics or connections, fears, mitigating factors for grief, factors that increased therapist difficulties in coping and practicing, difficulty in knowing when to return to work, are discussed. Kouriatis and Brown (2013) argue that whether grief has a positive or negative effect on the therapeutic relationship is largely determined by the existence or absence of commonalities in the loss experience and/or coping strategies used. Shifts in Worldview Worldviews and personal schemas tend to shift in some way after experiencing a loss. However, for practicing therapists, there can be specific shifts related to how they practice and how they see clients and client issues that have implications both for their practice and for the therapeutic relationship. Papadatou’s (2000) model of how health professionals grieve when faced with a patient death includes two factors, lifestyle and work style, which speak to the individual’s respective schemas and beliefs. It is proposed that, due to these factors, the professionals’ personal experience with loss is a major contributor to how they experience grief which is further implicated by their work style – their workplace’s views and values. How a therapist, and how their workplace, views and experiences grief can significantly impact and shift therapeutic work. Becvar (2003), in discussing the loss of her son, reported a shift in how they view death and life, “I not only lost my fear of death but also achieved a much greater appreciation for life” (p. 470). Self-Disclosure Both positive and negative effects of therapist self-disclosure of grief on the client and therapeutic relationship have been reported (Millon, 1981; Swinden, 2021; Tsai et al., 2009). The 22 decision on whether to self-disclose about their personal loss or not was made based on therapist clinical judgment around the therapeutic alliance and if the disclosure would help serve the client and therapeutic relationship versus just the therapist (Givelbar & Simon, 1981; Swinden, 2021; Tsai et al., 2009). Choosing to self-disclose in an appropriate way “can enhance the intimacy of the therapeutic relationship and establish the therapeutic relationship as more similar to outside relationships” (Tsai et al., 2009, p. 7). If the therapist felt the relationship would be negatively affected by the disclosure, it would have other negative effects on the client, or if the therapist judged the client as not being in an emotionally safe space to hear the disclosure, they chose not to share (Swinden, 2021; Tsai et al., 2009). Vamos (1993) reflected on their account of selfdisclosure around a personal loss and its impact on a subset of clients stating, “looking back, I have no doubt that my decisions were dictated more by my own difficulties than by technical considerations” (p. 304), reporting a few of their clients suffered negative impacts due to their self-disclosure (or lack thereof). One client reportedly felt abandoned due to a cancelled appointment and no information given as to why, and another client became preoccupied with the therapist’s loss which significantly impacted their sessions. Some of the positive effects of self-disclosure found were its ability to shift therapy into areas that may have been previously avoided, more trust towards the therapist, seeing the therapist as more 'human' due to a normalization of emotionality, and modeling of effective and appropriate communication (Tsai et al., 2009; Vamos, 1993). However, it was also reported that disclosure could cause some clients to avoid certain topics due to fears of overburdening their therapist, some clients may believe the therapist as less able to help them due to being perceived as functioning at a lower level than before the loss, and worry around if their therapist is able to 23 be fully present and in the moment with the client due to preoccupation with their loss (Tsai et al., 2009). Empathy One aspect that was found across several studies on therapist bereavement and experience working with grief, was the impact personal loss had on therapist empathy and compassion towards clients and client stories. As with other aspects of therapist experience described here, there are also both positive and negative affects on therapist empathy reported in the literature. Empathy is a key ingredient to an effective therapeutic relationship. Rogers (1957) describes empathy as a condition in which therapists meet in order to be effective and help to facilitate positive change and/or understanding within clients. He further defines empathy as the ability to “sense the client's anger, fear, or confusion as if it were your own, yet without your own anger, fear, or confusion getting bound up in it” (Rogers, 1957, p. 99). Being able to ‘walk in another’s’ shoes and value their experience without conveying a minimization of it through an implied ‘sameness’ or complete understanding – which we cannot have as each experience is unique – is a way in which empathy can live in the therapeutic space. Rogers (1957) posits that “When the client's world is this clear to the therapist, and he moves about in it freely, then he can both communicate his understanding of what is clearly known to the client and can also voice meanings in the client's experience of which the client is scarcely aware” (p. 99). Hayes et al. (2007) looked at how clients perceive their therapists in relation to therapist grief and found that there was a correlation between the amount of grief the therapist was experiencing and how empathetic they thought the therapist to be. The more grief the client sensed the therapist was feeling, the less empathetic the therapist appeared. This echoes Givelbar and Simon’s (1981) study that reported how sensitive clients can be to their therapist’s mood and 24 how shifts in empathy are often picked up on by the client. Stebbins (2015) reported, in a personal account of his own grief, that he struggled to maintain an “other focused empathic objectivity” (p. 30) resulting in pausing his practice, but that through his own healing he was able to “experience the power of empathic understanding” (p. 31) which led to feelings of hope about the future and led him to offer therapeutic support in areas of bereavement. Many studies shine a positive light on how empathy is impacted because of therapist personal loss and grief. There is a reported increase in, or more profound feeling of, empathy towards clients after the therapist experiences loss (Bozenski, 2006; Broadbent, 2011; ColaoVitolo, 2006; Givelbar & Simon, 1981; Kouriatis & Brown 2014; Swinden, 2021). In Givelbar and Simon’s (1981) study, a client commented about their feelings of being more understood after the therapist had experienced a loss which aligns with Kouriatis & Brown’s (2014) report of therapists’ feeling better able to ‘walk alongside’ their clients after experiencing a loss. Due to the nature of therapeutic relationships and what the therapist brings to it as an individual, it’s postulated that a therapists personal loss experience may serve as an important resource and source of connection rather than a detriment (Dunphy & Schniering, 2009). Returning to Practice Coping with bereavement and the accompanying stressors, addressing emotional needs, the role of avoidance, expectations around returning to work and what that work should look like, the benefit of and need for supervision, are some of the factors to consider when assessing readiness to return to practice. Some therapists report returning to work too early and struggling to be effective where others report their return to work as a helpful strategy in distraction and finding bigger meaning. Both make a strong case for reflection and awareness around one’s own readiness to continue the work after experiencing a loss. 25 Coping With Bereavement and Addressing Emotional Needs. Becvar (2003) outlines several internal stressors and external factors related to grief that contribute to an already stress laden field. Helplessness, hopelessness, intense emotions contrasted with a desire to be effective, and strain on spirituality, are among some of the internal stressors. Whereas external contributors include lack of support or understanding from colleagues, longer term involvement with clients, and difficulty in processing issues due to confidentiality constraints. Not allowing an appropriate amount of time or a safe space for grieving to occur can also contribute to therapists feeling as though their grief should be ‘hidden’ or they should be able to cope in isolation (Becvar, 2003; Givelbar & Simon, 1981; Swinden, 2021). Therapists reported worrying that the act of grieving may be problematic in the workplace. They worried they may experience emotional flooding or detachment with clients, their feelings would negatively impact the therapeutic relationship, difficulties with differentiation and overidentification may arise, possibility of conscious or unconscious avoidance of certain topics, and worry around their ability to stay present and engaged (Givelbar & Simon, 1981; Kouriatis & Brown, 2014; Swinden, 2021). One of the more striking concerns brought up by Givelbar and Simon (1981) was the potential for a therapist to “designate one of his or her patients to be a replacement for the lost object” (p. 148) and encourages therapists to reflect on this, especially with new clients seeking services after the therapist returns to work. Becvar (2003) proposes six factors to mitigate the potential of personal grief experiences affecting practice: realistic expectations around time frames and needs when grieving, “mourning spaces” to assist in processing grief prior to working with a client’s grief, maintenance of professional boundaries, time to attend services and funerals, self-care, and space for a holistic approach to one’s grief. Attunement and reflection of emotional states and vulnerability were 26 described as ways therapists could alleviate some of their worries around their personal grief experiences affecting practice. Kouriatis and Brown (2013) reported their participants felt that grief not only affected them psychologically, but cognitively, physically, and relationally as well. These therapists reported that what helped them cope with these effects were having professional and personal support from others, continuing to live their lives and function amidst their grief, engaging in a process of creating meaning out of their loss, and seeing clients. They reported seeing clients as helpful as it gave them a purpose and a reprieve from their grief. The knowledge they possess as therapists was reported to be a ‘powerful’ and ‘containing’ experience. For some therapists, they found that having time and space away from work and seeing clients was the best form of selfcare, however the majority reported finding satisfaction in the work they were doing with clients and the added avoidance from the preoccupation of the loss was seen as positive. The Role of Avoidance. Avoidance has been reported as both adaptive and maladaptive in the literature on therapist grief experiences and also in some of the grief theories discussed above (e.g.: Stroebe and Schut’s (2001) dual-process model). Tsai et al. (2009) argue that avoiding emotional needs can negatively affect the therapeutic alliance, especially when clients are attuned to their therapists and able to tell when the therapist is not fully present. In addition to avoiding their own emotional needs, therapists may also avoid certain topics or emotional affects presented by their clients, either avoiding topics that remind the therapist of their own emotional state or giving significant, unwarranted attention to a client’s grief experience (Givelbar & Simon, 1981; Kouriatis & Brown 2014). However, some therapists report that their loss experience and ability to share some of this experience with their clients helped foster 27 exploration into areas that the therapist may have previously avoided and/or felt the urge to avoid prior to their loss (Kouriatis & Brown 2014; Tsai et al., 2009). Martin (2011) argues that this avoidance can be dangerous. He posits that avoidance of our emotions and experiences, our ‘humanness,’ drives us deeper into the realm of outcomesbased work versus relationship-based work. The more we avoid and ignore the human parts of ourselves, the more we tend to focus on fixing and curing problems, “we convince ourselves that the only thing that matters is outcomes, and forget the basic context of all our lives mortality” (p. 11). Papadatou’s (2000) model suggests a balance of avoidance in relation to grief is healthy and adaptive. By experiencing and avoiding grief, the therapist gains a sense of control through finding meaning in loss and recognizing that they are ‘finite and vulnerable in the face of death’ (p. 69). As with most grief and loss experiences, how the therapist processes it is dependent on the impact it had on them (physically, mentally, socially) and the personal and professional supports available to them. Expectations Around Returning to Work. Many expectations follow a practicing therapist. Expectations from themselves, their organizations, other professionals, and clients. Grief does not trump these expectations, however it may necessitate a, possibly temporary, shift in them. Worden (2009) argues that it is important for therapists to explore and acknowledge their own experiences of grief and loss in order to become a more effective therapist. In aligning with Worden (2009), it would be valuable for therapists to explore this prior to their return to work to assess their fitness to practice and the effects their loss had and any lingering effects that may come up. Awareness around grief may help mitigate issues that come up around readiness to return to practice and expectations around returning. 28 Many therapists have reported a personal or professional push to return to work prematurely. Financial concerns, personal feelings and expectations on when they ‘should’ be okay to return, loneliness, societal and social pressures, and an urge to return to ‘normal’ were some of the reported reasons therapists returned to work despite not feeling fully ready (Givelbar & Simon, 1981; Martin, 2011; Swinden, 2021). Fears around appearing ‘fragile’ to clients, not being able to contain their grief, and the focus shifting from client to therapist were reported upon therapists’ return to work (Kouriatis & Brown, 2014; Swinden, 2021). This was combined with not having enough support or guidance around their fitness to return to practice which left some unsure of how to move forward. Returning to work after a personal loss proved to be a positive and helpful experience for many. Martin (2011) discussed one of the therapist’s accounts of returning to work after the loss of her son. For this therapist, counseling offered a ‘refuge,’ it was something she reported feeling confident in doing and allowed some normalcy to return to her life. Others described working as coping, that it mitigated their loneliness and isolation and that their identity as counsellors were tied with their ability to provide support and safety to their clients despite their own vulnerability (Kouriatis & Brown, 2013; Swinden 2021). However, Givelbar and Simon (1981) provide a word of caution around returning to work before examining grief and loss while feeling the acute impact as it can negatively impact both therapist and client. Therapists should feel safe to be able to voice their needs without the burden of guilt for what they decide. Supervision One of the main themes to come out of the literature on this topic is the need for, and benefit of, supervision. Killian (2008) argues that the psychological health and wellbeing of 29 counsellors and therapists is paramount to being an effective counsellor. However, not all supervision is created equally. Characteristics of supervision that have been found to be most helpful to therapists and clinicians include: adequacy, appropriateness, supervisor competence, collaborative engagement, and use of a person-centred approach (Falender & Shafranske, 2004; Falender & Shafranske, 2007; Sutter et al., 2002). Swinden’s (2021) study highlighted concerns around inadequate supervision. The therapists interviewed discussed the systems-focused supervision they received upon their return to work after a loss and how this did not meet their emotional needs. The supervision received was more focused on case management (e.g.: client numbers) versus the therapists’ emotional states. The therapists’ felt attempts to communicate how they were doing in relation to their loss experience was dismissed, creating uncertainty around how their fitness to practice was being assessed. Overall, this study showcased a need for supervision that is more supportive and less based around numbers. This does not appear to be a new phenomenon either, Givelbar and Simon (1981) also reported finding that the experience of a personal loss and its effect on the therapist was also sparsely and inadequately discussed in supervision. Although supervision is an integral part of practicing in a safe and supportive way (both for the therapist and the client), it appears to become an even greater need in times of increased stress, like when experiencing the effects of a loss. Therapists working after loss reported adequate supervision as being vital to coping with their grief and working as a ‘safeguard’ for both therapist and client (Broadbent, 2011; Kouriatis & Brown, 2014; Martin, 2011). However, access to supervision was not the only concern. Therapists reported the need, and sometimes difficult task of, self-awareness and the responsibility around what they needed to bring to supervision (Kouriatis & Brown, 2014). 30 As grief and loss can be experienced as a result of any change or shift in someone’s life, self-awareness around therapist thoughts and feelings about loss and how they react to it are needed to be able to effectively practice. Being present and ‘walking with’ clients through their grief can become a harrowing process when the therapist is attempting to work through their own grief process. If therapists returning to work after a loss were to have access to adequate and appropriate supervision, practice self-awareness around emotional states and readiness to return to work and utilize social supports they may be better able to effectively practice if still grieving. Summary In 1993, Vamos explored their personal experience of grief and how it affected their clinical practice. They reported they were unable to find an article that discussed the issues of a bereaved therapist. This “contributed to loneliness” in their grief and to an “uncertainty in terms of how to provide adequate information to patients while protecting herself at a time of great vulnerability” (p. 304). Although there has been an increase in research around this topic since Vamos’ account, there is still a clear gap in this area identified by several researchers and, most recently, by Swinden (2021). Kouriatis and Brown’s (2013) study attempted to help fill some of these gaps but still suggested future research to focus on impacts surrounding therapists who are working with clients struggling with similar issues of grief and loss. They also noted how this may uncover other areas to explore, including looking at possible overidentification and any other benefits or challenges that could possibly emerge due to this unique dynamic. Grief is not linear nor is it finite. In a profession where relationships are paramount and our humanness is a key component in these relationships, the lack of research on therapist grief and bereavement and how this plays out in sessions when the client is also experiencing grief is a significant gap. The likelihood that Vamos’ (1993) experience of loneliness and uncertainty (due 31 to a lack of literature on the topic) is an isolated one, is highly unlikely. Shared experience can be a source of knowledge and comfort and more research is needed to support grieving therapists in their practice with grieving clients. Until then, this project will attempt to further normalize grief and the unique needs of a grieving individual to empower grieving therapists to feel safe to seek supports they need. 32 Chapter 3: Project Description The following project was developed, in part, in response to the lack of research on how therapists who are grieving work effectively with clients who are also actively grieving. It was also developed as a response to my own grieving process as a therapist who returned to work with clients who were also grieving. These considerations were informed by a thematic literature review that included an overview of grief and loss and therapeutic modalities tailored to grief and loss, countertransference, and therapists experience of grief and loss and how their practice was impacted. The completed project is titled “A Dual Journey of Grief: Considerations for Grieving Clinicians working with Grieving Clients” (Chapter 4). Content Analysis An inductive approach to content analysis was used. Content analysis is often used in the nursing profession, specifically in the psychiatric community (Elo & Kyngäs, 2008). Content analysis works to summarize information by analyzing the content of texts to identify patterns, themes, or trends (Elo & Kyngäs, 2008). Literature relating to broad themes was sought out and from it, other categories began to emerge, with subcategories within them. This is demonstrated in the literature review where the themes for this project were pulled from. Elo and Kyngäs (2008) speak about the two phases in content analysis: the preparation phase and the organizing phase. In the preparation phase, I determined broad themes in order to narrow down my search for literature. The organizing phase consisted of grouping and categorizing the key literature that was collected on each topic and consolidating it into the larger themes outlined in Chapter 2. The literature review was conducted looking at main themes around the topic of grieving therapists’ experiences working with grieving clients. These themes were summarized into the following categories found in the booklet: grief, self-awareness and reflection, self-care, possible 33 impacts on practice, countertransference, readiness to return to work, and seeking supervision. An outline for the final booklet was created, including relevant themes, headings, and content that would be included in the final project. A list of references is attached to the booklet for those who would like to access further information. Additional resources, including online resources, local counselling supports, and emergency contacts, were included at the end to help support individuals seeking more information and/or more immediate supports. Target Audience This project was designed for helping professionals experiencing grief. As Kouriatis & Brown (2011) suggest, due to the professional role therapists play, more attention is directed towards clients and client wellbeing rather than therapist wellbeing. Although there is an emphasis on working with grieving clients and readiness to return to work, an attempt was made to make it somewhat more generalizable to any therapist experiencing grief, whether returning to work or not. It would also be beneficial for supervisors to be aware so they can better support the clinicians they supervise. Summary of the Project Grief is universal. As helping professionals, therapists are often focused on their client’s wellbeing more so than their own. However, therapists are not immune to grief. Maintaining a professional standpoint, being present, and practicing effectively can be influenced and impacted by the therapists’ personal experiences. If a therapist is actively grieving while continuing to work with clients who are also grieving, this grief may show up in sessions and impact the therapeutic relationship. To best support practicing therapists, more attention needs to be given to the experiences of these therapists to shed more light on this unique phenomenon. If it’s inevitable that we all experience grief in some form, at some point, in our lives, then we need 34 more supports for helping professionals who will likely both experience grief and support a client experiencing grief, possibly simultaneously. 35 Chapter 4: Considerations for Grieving Clinicians Working with Grieving Clients Booklet 36 Considerations for Grieving Clinicians Working With Grieving Clients SHAN NEL HARRIS. M. ED 37 There is no fix for grief, no one-size-fits-all approach. Every encounter with grief is unique. Take from this what you need and leave behind what you don't. -S 38 Dedication.... Introduction Considerations 2 3 4 5 6 6 6 6 GRIEF Risk factors/warning signs for prolonged grief disorder GRIEF THEORIES AND THERAPIES: AN OVERVIEW Kubler-Ross’ Five Stages of Grief Bowlby’s Attachment Theory Worden’s Tasks of Mourning Model Neimeyer’s Meaning Reconstruction Theory 7 Shear's Complicated Grief Therapy 8 Stroebe and Schut’s Dual-Process Model 10 SELF-AWARENESS AND SELF-REFLECTION 11 Attachment Styles 12 SELF-CARE 13 THINGS THAT CAN IMPACT YOUR PRACTICE 14 COUNTERTRANSFERENCE 16 READINESS TO RETURN TO WORK 16 The Issue of Self-Disclosure 16 Workplace Culture What Were Some Things that Other Therapists Reported When Returning to Work? 17 18 SEEKING SUPERVISION 19 Info Guides Conceptualizing Grief: Metaphors 20 21 Common Misconceptions about Grief Grief is not Reserved for Death 22 23 29 30 Crisis Support 30 Online Resources 31 Local Counselling Resources and Grief Support 32 References Journal Pages Resources. 39 This is for every helping professional who has endured grief. May you never fear that your grief is too burdensome or less valid than others. 1 40 As helping professionals, we often put the needs of others before ourselves, knowing in some part of our mind that this is actually less helpful than how it appears on the surface. The therapeutic relationship is just that, a relationship. Reciprocal. Our wellness as helping professionals can have a direct impact on the therapeutic relationship. Despite the expectations held by ourselves and others around how clinicians ‘should’ function, reality supersedes expectation and we must allow ourselves the same grace we give those we serve. Grief is universal and can be all encompassing. The following considerations have been compiled to offer information, support, and guidance, if it fits for you. Most research has highlighted client experiences of grief, this is an attempt to highlight clinicians’ needs in the face of grief, especially when returning to work supporting clients. This booklet is intended for any helping professional experiencing grief. For those reading, I hope this is informative and helpful, but most of all, I hope you find grace for yourself among the hard things. 2 41 Considerations FOR GRIEVING CLINICIANS WORKING WITH GRIEVING CLIENTS 3 42 Grief “When death is the water and love is the raft, grief is the oar - let it move you through” -Alex Klingenberg Grief is normal. And it's painful. The vast majority of people will experience grief at some point in their lives. Feelings of loss, yearning, anger, frustration, sadness, and disruption can all come and go during the journey of grief. “Loss and grief are integral parts of life, with all changes in our lives involving loss and all losses in our lives requiring change.” -Neimeyer Although grief is normal, it can become problematic if it is longstanding and having a significant impact on your day to day functioning. The next page includes some things to look out for that may require seeking further support. While there are many theories and therapeutic approaches addressing grief and loss, the most important things are the therapeutic relationship and the unique, individual factors the client brings in. Being present with a client and walking alongside them in their journey through grief may prove more useful than any specific modality, so just allow time and space to process. 4 43 6i lef RISK FACTORS FOR PROLONGED GRIEF DISORDER • Losing someone close: If you've lost a family member, partner, or child • Sudden or traumatic loss • Not enough support • Past mental health issues • If you've had a tough time with grief in the past, it might make grieving now more difficult • If the loss is confusing or doesn't have closure, like a missing person, it can make grieving harder • Some personality traits, like being very attached to someone, can make grief more intense WARNING SIGNS OF PROLONGED GRIEF DISORDER • Unable to stop feeling really sad and missing the person intensely • Continuously thinking they'll come back, even months later • Inability to stop thinking about them causing disruption in your life • Avoiding places or things that remind yoi of them • Feeling like you don't have any emotions or don't care about things • Inability to think about the future or make plans • Avoiding friends or activities you used to enjoy • Having trouble sleeping and bad dreams about the person you lost • Feeling really angry, guilty, or hopeless because of the loss *lf you are concerned about what you are experiencing, please reach out to a trusted support or to one of the resources listed at the back of this booklet.* 5 44 Grief Theories 8 Therapies: A Brief Overview KUBLER-ROSS'S FIVE STAGES OF GRIEF • Stages: denial and isolation, anger, bargaining, depression, and acceptance. • Originally developed as a result of her work with terminally ill patients. • Kubler-Ross argued that individuals work through these stages during grief, often jumping between different stages in a non-linear way. contrary to popular belief. BOWLBY’S ATTACHMENT THEORY • Focuses on the profound impact important relationships have on individuals which are significantly disrupted when a loved one is lost, but also focuses on the lasting connections with that person. Four phases with a goal of both detaching from • the lost loved one and continuing the bond in a new way: 1. Numbness/Shock 2. Yearning for the lost loved one A k 3. Disorganization and despair 4. Reorganization and Detachment A WORDEN S TASKS OF MOURNING MODEL • In this model, the individual grieving is seen as an active participant working through their grief V rather than just experiencing it in a passive way.V*\ \ • Four tasks: o Accepting the reality of the loss o Processing the pain of grief ° Adjusting to a world without the deceased ° Finding a way to remember the lost loved one while embarking on a new life without them. 45 Grief Theories 8 Therapies: A Brief Overview NEIMEYER’S MEANING RECONSTRUCTION THEORY • Focuses on how individuals cope with the experience of loss and make sense of it by emphasizing that individuals actively construct their own understanding of reality. • Key concepts: o The reconstruction of loss (confronting the emotional impacts of loss, reassessing beliefs and assumptions, creating a new sense of identity, and adapting to changes as a result of the loss). The use of narrative approaches to retell stories of loss and explore thoughts, feelings, and beliefs about it. o Maintaining emotional connections with the lost loved one. o The recognition of cultural factors and how they impact the experience of loss. o SHEAR'S COMPLICATED GRIEF THERAPY A specialized therapy designed to assist those struggling with complicated or prolonged grief. Complicated grief therapy came as a result of limited efficacy shown in treating complicated grief responses with standard treatments. It is structured, often consisting of 1 6 sessions over four months and uses a general frame¬ work of psychoeducation, journaling, involvement of a support person, increasing interpersonal functioning, creating personal goals, encouraging self-care, revisiting the death, revisiting avoided places/activities, working with memories and pictures, and imagining conversations with the lost loved one. 46 Grief Theories 8 Therapies: A Brief Overview STROEBE AND SCHUTS DUAL-PROCESS MODEL • This model describes two broad types of stressors: Loss-orientated (focus on processing the loss experience). ° Restoration-oriented (secondary stressors that are consequences of experiencing a o loss). • Stroebe and Schut believe that a grieving individual alternates between avoiding aspects of loss and confronting them and that moving between each enable them to effectively cope. Engaging in both loss-oriented and restorationoriented coping allows grieving individuals to find a balance between attending to their emotional needs related to the loss and adapting to the changes in their daily lives. • Positive and negative meaning construction and reconstruction occur in both loss-oriented and restoration-oriented pathways. o Positive meaning construction includes: positive reappraisal, revised goals, positive event interpretation, expressing positive affect o Positive meaning reconstruction includes: constructive goals o Negative meaning construction includes: rumination/wishful thinking, revised goals, negative event interpretation, ventilating dysphoria o Negative meaning reconstruction includes: unconstructive goals 8 47 Grief Theories 8 Therapies: A Brief Overview This is not an exhaustive list of theories and therapies, it is brief overview of some that are common in current literature (see "References"). These theories and therapies, when used in grief and loss counselling with grieving individuals, have been shown to help prevent grief from becoming complicated and help to mitigate grief responses that are detrimental. Incorporating evidence-based interventions and approaches is not only crucial in general but also holds significant importance in bereavement counseling. Although there is evidence for the efficacy of specific grief therapies, it is important to consider individual uniqueness in terms of how grief is expressed and worked through. Studies have found that being present, walking alongside the individual, honoring their experience and story, remembering the person who died, being open and unafraid of grief-related emotions, refraining from advice when not asked for it, and simply listening were some of the most r’ helpful aspects of support grieving individuals reported receiving. / 9 48 Self-Awareness 8 Self Reflection You may notice shifts in how you view grief and loss, and/or death and dying. Other shifts in your worldview may occur as well. Some clinicians experiencing grief have reported an increase in empathy towards their clients and less avoidance around difficult topics. But it’s also possible you may question your efficacy as a helping professional and become more avoidant of certain topics. As each experience is different, self-reflection and self-awareness are key to being able to accurately assess where you’re at and what you need. Effectively communicating this to your support team is an important next step, especially if you’re needing connection. Some ideas on how lo do this: Speaking to a safe person Journaling Personal therapy Mindfulness practices Meditative practices Journaling Journaling can be an outlet for emotions that can be difficult to express. Being able to release our emotions can help reduce stress and promote well¬ being. Journaling can also be a self-reflection tool. Writing about experiences, behaviours, and reactions can help you reflect on your experiences. You may begin to notice patterns and triggers that affect you. There are five journal pages included towards the end of this booklet (pages 24-28). 10 49 Self-Awareness 8 Self-Reflection Attachment Shies: Attachment styles can influence how we cope with grief. Those with unsecure attachment styles can have more challenges in the grieving process than those with secure attachment. It can be helpful to reflect on your own attachment style and how it influences your response to stress. The chart below is a brief overview of different attachment styles, (see “Grief Theories and Therapies” for more information on attachment theory and grief.) Anxious (Preoccupied) Self-Assured, Direct, Resonsive A voiduni (Dismissive) Self-reliant, Distant Self-doubting, Sensitive Fearful (Disorganized) Self-sabotaging, Unpredictable, Isolated 11 50 Self-Care We often encourage self-care for our clients but can have a hard time with it ourselves. Finding balance, especially in the midst of grief, can be a challenge. Self-care refers to something we do, intentionally, to help improve (or maintain) our mental, physical, and emotional health. It promotes stress reduction, self-compassion, and overall health. What is this for vou? It doesn't have to be anything extravagant. It can simply be allowing yourself to feel how you feel, without judgment. Find ways to honor your feelings and where you are at. What works for others may not work for you and that’s okay. Trying to find a balance between distraction and feeling, avoiding and processing, can feel like an impossible task. Take it one step at a time. 12 51 Things that can impact your practice Your own emotional stale and vulnerability J Attunement and reflection of your emotional state and vulnerability can help relieve some worries around grief affecting clients. Not giving yourself enough time to grieve, or a safe space to grieve, can affect how you view your grief. It may feel like it needs to be hidden or that you ‘should’ be able to cope on your own, without support. Some clinicians report returning to work and helping clients gave them a sense of purpose and meaning and was helpful in their grieving process, where others felt they needed the extra time away from work and clients to be able to be most effective when they returned. Avoidance: Confrontinor Are 7you avoiding? r) rO T, Avoidance can arise both with your own grief experience and within sessions. Some argue that balancing processing it is the most helpful way to work $ grief with avoiding through it. In session, avoidance of certain topics due to grief or another trigger, can have detrimental effects. Avoiding your own emotional needs and also avoiding certain topics or emotional affects in session can have negative impacts, just as paying too much attention on a certain event or emotional state (e.g.: a loss) can also be detrimental. Self-reflection and self-awareness, combined with supervision (see page 18), can help you to find where avoidance may be coming up for you and how it could be impacting you and your clients. 13 52 Conn lei 11 'tn isfei’ei ice Countertransference refers to a clinician’s feelings or reactions toward a client. When clinicians begin to feel or act in ways that are influenced by their own personal experiences or emotions, rather than solely focusing on the client's needs, they are experiencing countertransference, which can affect the session and the therapeutic relationship. This can happen consciously or unconsciously and is argued to be inevitable in therapeutic relationships. Since it is seemingly inevitable, it felt important to include in it’s own section. So, be aware for this to pop up at some point! It may have already, but it isn’t always a bad thing. Acknowledging and addressing countertransference has been shown to strengthen therapeutic alliances. Whul causes counlerii wsference? Simply put (or not so simply...), unresolved issues are the leading factor in a clinician experiencing countertransference. Another reason to practice self-awareness and seek supports if needed to process any unresolved feelings or concerns. 14 53 Counlerlransference continued... Managing countertransference is important as it can cause avoidance of certain topics in sessions and clinicians may question their efficacy even if the client has no awareness of countertransference. Clients also do sometimes notice and have reported feeling their therapist was less empathetic, less available, and less understanding towards them. Managing countertransference in an effective way facilitates better outcomes in therapeutic settings. How can you manage it? Gaining awareness around your triggers, finding safe outlets for your grief, having a support network you can reach out to, doing whatever you need to continue your grief journey. Empathy was found to be another key piece to managing countertransference. Be as empathetic as your capacity allows, and be sure to be empathetic to yourself first and foremost. “The reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal, and you will rebuild yourself around the loss you have suffered. You will be whole again, but you will never be the same. Nor should you be the same, nor would you want to." -Elizabeth Kubler-Ross 15 54 Readiness io return to work How do you know if you’re ready to return to work? This question may not have a definitive answer, but here’s some things to consider before making your decision... The issue of self disclosure Depending on how much was shared with clients about your absence, questions may arise when returning to work. Being prepared for the possibility of these questions and reflecting on how you would like to answer them can be helpful. Be mindful of how much you share and ask yourself who you are sharing the information for. If it is for the client and would not be harmful or detrimental to them or the clinical alliance, then share at your discretion. However, if it may be harmful in any way, it is best to only share what is absolutely necessary. It would be helpful to seek supervision around this prior to seeing clients. Workplace Culture Consider what your workplace culture is like and who your support team at work is. If you are able to, seek supervision and request it fit for your needs (e.g.: more personally focused versus numbers focused). Time to heal can be a luxury that some don’t have access to. If this is the case, and you must return to work before you feel fully ready, do your best to create a back to work plan that fits your needs. Consider your capacity and how much you can take on when you return, start small and work your way up. Allow yourself as much grace as you can. 16 55 Readiness io return to woi’k What were some things other therapists reported when returning to work? Some therapists report going back to work soon after a loss as positive, where others felt that they needed more time away and that going back earlier would be detrimental to themselves and clients. Some felt pushed to return too quickly, sometimes because of their workplace, other times because of financial constraints. Some felt pushed by society or social circles. Others were lonely or felt they were ‘expected’ to return because they ‘should’ be fine. Some did find comfort in returning to work and enjoyed the normalcy of it and feeling like they had purpose. A note about expectations There will always be external expectations, and some will always be impossible. You can’t always manage others’ expectations, but you can manage your own. Allow yourself time and space to grieve in whatever way you need. 17 56 Seeking Supervision Seek supervision when returning to work and continue to have regularly scheduled supervision. Supervision should be a safe space to focus on your emotional wellbeing and not just on client numbers. Discuss how you are doing and where you are at in an open and honest way with a supervisor you feel safe with. In order to be most effective, supervision should be adequate, appropriate, collaborative, person-centred, and conducted by a competently trained supervisor. If you don't have access to safe and adequate supervision. I encourage you to look into finding a clinical supervisor who can meet your needs. Inadequate supervision can lead to poorer outcomes for clinician and client. Peer supervision can also work in a pinch, however more ongoing supervision with a trained supervisor is ideal. 18 57 Info Guides HANDOUTS & INFOGRAPHICS 19 58 Conceptualizing Grief: Metaphors Grief is like a sharp rock in the stream of your life. At first, when you step on the rock, it’s painful. As time goes on, the stream gently smooths the rock, and you find yourself noticing less and less that the rock is there. When you do notice it, although you feel the edges, they are still smoother than before. But there will be days when the rock turns and exposes more sharp edges, pangs of grief ringing up when you step on it once again. As the stream ebbs and flows, so will your grief. the Jar represents our capacity to cope, the pompoms represent our grief and loss experience(s). Our grief does not go away, but our capacity grows and shifts to accommodate it. The ball in the box in our loss. There is a grief button on the top of the box, when pressed, it activates feelings of grief and loss. When loss is recent, the ball is quite large, hitting the grief button often. As time progresses and we process our grief, the ball shrinks and hits the button less often. Our grief remains, but occupies less space than it once did. 59 60 "Here s the thing: every loss is valid. And every loss is not the same. You can't flatten the landscape of grief and say that everything is equal. It isn’t.” -Megan Devine DISENFRANCHISED GRIEF: "grief that society (or some element of it) limits, does not expect, or may not allow a person to express... Disenfranchised grief may isolate the bereaved individual from others and thus impede recovery.” -APA Dictionary of Psychology Grief Cent be experienced because of... Loss of a job Moving Milestones in life Loss of community Loss of identity Loss of friendships Relationship break-ups or shifts Change in self Any change where there is a sense of loss 61 Journal Pages 23 62 S3 63 92 64 zs 65 82 66 67 Resources CRISIS, ONLINE, LOCAL, REFERENCES 29 68 Local Crisis Support: Northern BC 24 Hour Crisis Line: 1 (888) 562- 1214 YOUTH SUPPORT: 1 (888) 564-8336 (24 hour access) Online Chat: northernbccrisissuicide.ca (4pm to 10pm) Text helpline, text talk to 686868 Provincial Crisis Support: Online Chat Service for Youth: YouthlnBC.com (Noon to 1 am) Anywhere in BC 1 -8OO-SUICIDE: 1 800 784 2433 (24 hour access) 310Mental Health Support: 310 6789 (no need to dial area code) (24 hour access) In Case of EMERGENCY: Call 91 1 - Police, BC Ambulance Go directly to The University Hospital of Northern British Columbia (1475 Edmonton Street, Prince George, BC) Online Resources What's Your Grief This website provides resources, including articles, podcasts, and online courses, to help individuals navigate grief and learn coping strategies. www.whatsvourrief.com Grief Healing This website, run by grief educator and author Marty Tousley, offers articles, books, and online support for those grieving the loss of a loved one. www.griefhealing.com/ Grief.com This website offers articles, videos, and resources on grief and loss, as well as information about David Kessler's books and workshops. www.grief.com 69 Locul Counselling Resources and 6rief Sipport Prince George Hospice Palliative Care Society (PGHPCS) Hospice offers information and support to those experiencing grief. There are various group and events offered. More information can be found on their website: www.pghpcs.ca Hospice House 3089 Clapperton St, Prince George. BC, V2L-5N4 250-563-2481 PGHPCS Admin Office 1 506 Ferry Ave, Prince George. BC. V2L-5H2 250-563-2551 The Healing Centre at the Prince George Native Friendship Centre No charge counselling service for all populations. More information an be found on their website: www.pgnfc.com/programs services 1(500 - 3rd Avenue (3rd Floor). Prince George. BC. V2L 3G6 Phone 250-564-4324 | Fax 250-614-7728 Community Counselling Centre (CCC) Low-cost counselling service provided by Master's of Education in Counselling students and supervised by trained clinical counsellors. More information can be found on their website: www.communitvcounsellincentre.com #206 - 181 1 Victoria Street. Prince George. BC. 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