Techniques of Grief Therapy

Creative Practices for Counseling the Bereaved

Robert A. Neimeyer

• Publisher: Routledge
• Year: 2012
• Print ISBN: 9780415807258
• eBook ISBN: 9781136519758
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Techniques of Grief Therapy is an indispensable guidebook to the most inventive and inspirational interventions in grief and bereavement counseling and therapy. Individually, each technique emphasizes creativity and practicality. As a whole, they capture the richness of practices in the field and the innovative approaches that clinicians in diverse settings have developed, in some cases over decades, to effectively address the needs of the bereaved. New professionals and seasoned clinicians will find dozens of ideas that are ready to implement and are packed with useful features, including:

• Careful discussion of the therapeutic relationship that provides a "container" for specific procedures
• An intuitive, thematic organization that makes it easy to find the right technique for a particular situation
• Detailed explanations of when to use (and when not to use) particular techniques
• Expert guidance on implementing each technique and tips on avoiding common pitfalls
• Sample worksheets and activities for use in session and as homework assignments
• Illustrative case studies and transcripts
• Recommended readings to learn more about theory, research and practice associated with each technique

Part I

Framing the Work

1

Presence, Process, and Procedure

A Relational Frame for Technical Proficiency in Grief Therapy

Robert A. Neimeyer

In an important sense, it is not a question of what grief therapy techniques do for a bereaved client; it is the question of what bereaved clients (and therapists) do with the techniques that counts. And so it seems appropriate to open this book with a consideration of the broader relational framework that provides a “container” not only for our client’s grief, but also for the specific procedures we offer to express, explore and ease the experience of loss. My goal in this chapter is therefore to suggest that therapeutic presence provides the “holding environment” for a responsive grief therapy, within which attention to therapeutic process attunes the therapist to that unique juncture where a client’s need meets his or her readiness for a particular intervention in a particular moment of interaction. Nested within these larger and more ample containers like Russian dolls, specific procedures have a potentially powerful place in the overall project of counseling or therapy. Divorced from these larger contexts, however, stand-alone techniques lose much of their potency; they become merely a random concatenation of methods whose relevance to a particular loss remains uncertain, uncoordinated and unconnected to the durable thread of coherence that characterizes effective therapy.

My goal in these pages is to frame these issues, in keeping with the spirit of the broadly humanistic and specifically constructivist tradition of psychotherapy that is my home base (Neimeyer, 2009a). I trust, however, that readers from many disciplines will recognize the counterparts of these concepts in their own traditions, be they analytic, systemic, cognitive behavioral, spiritual or simply grounded in their intuitive sense of the common factors that tend to underpin healing human interactions, across and beyond the counseling professions as such. I will begin with the most fundamental of these factors, therapeutic presence, and progress to process and procedure in turn.

PRESENCE

Therapy begins with who we are, and extends to what we do. That is, bringing ourselves to the encounter, as fully as needed, is the essential precondition for all that follows, that distinctive blend of processes and procedures that broadly defines a given therapeutic tradition and more specifically defines our own therapeutic style. Here, I want to emphasize the foundational quality of therapeutic presence, the way in which the offer of full availability to the client’s concerns, undistracted by other agendas, grounds the work by offering a reflective audience to the telling and performance of the client’s grief narrative, allowing both (or in the case of family or group therapy, all) participants to take perspective on current conundrums in fresh ways.

Attending from self to other

In this conception, the presence of the therapist does not “crowd out” attention to the client, or even compete with it in a direct sense, as in implying that therapists should be particularly self-disclosing in their work, or offer clients object lessons from their own lives and losses. Instead, it more typically implies a kind of from–to attention, as the therapist attends from his or her sense of self to the person of the client. It is precisely this form of “personal knowledge” that is described by the philosopher of science Michael Polanyi, in which the knower holds him- or herself in subsidiary awareness while retaining a focal attention on the other (Polanyi, 1958). For example, in one memorable grief therapy session I found myself conducting a (minimally) guided imagery exercise with a client who was grieving the loss of her mother (Neimeyer, Burke, Mackay, & Stringer, 2010). Inviting her to close her eyes with me, I asked her to scan her body for a felt sense (Gendlin, 1996) of how she was holding the loss, slowing the pace of my instructions to encourage a “loosening” of her meaning-making from the more clipped, “tightened” discourse of our previous therapeutic conversation (Kelly, 1955/1991). What emerged was remarkable: with a beatific smile she quickly gestured toward the space around her head, and described a radiant, warm light that seemed to be coming to her from above, beginning to shroud her head and shoulders. Noticing tingles of warmth rippling down my own spine and into my body, I then invited her to allow the light to enter her and envelop her body more completely. As she did so, she brightened still more, nearly laughing, and described a delightful tickling in her abdomen, a sensation strongly reminiscent of how her mother would tickle her when she was a little girl. As we closed this period of inward attention, she described the remarkable sense of peace and connection to her mother that she felt and voiced a clear conviction that her mother was with her still, but in an oddly spiritual/corporeal way. I would argue that my own sympathetic “channeling” of the client’s experience—something that occurs for me in the great majority of sessions at cognitive, emotional, and often palpably physical levels—represents precisely the sort of from–to knowing that usefully orients me to the client’s position and to potentially therapeutic “next steps” in our work together.

Relating respectfully

In keeping with the collaborative, reflective and process-directive approach that is central to a meaning reconstruction approach to grief therapy (Neimeyer & Sands, 2011), the stance of the therapist is one of respectful, empathic engagement in the client’s evolving narrative of self and world. The therapist does not decide what meanings will be reconstructed and which will be reaffirmed in the wake of loss, but instead assists clients in recognizing incompatible old meanings or constructs and works with them as they endeavor to find alternatives. Significantly, this is not typically a very “cognitive” process in the usual sense, as the assumptive world that is challenged by profound loss scaffolds our core sense of identity, purpose and relationship. In particular, for clients with deeply disturbed personal histories, the heart of psychotherapy may consist in offering them a reparative relationship in which they are able to risk letting the therapist have access into their core understanding of self (Leitner & Faidley, 1995). The creation of this role relationship (in which one person attempts to construe the deepest meaning-making process of another) is vital, as both client and therapist seek to establish a reverential relationship that acknowledges the uniqueness of the other. This reciprocal connection does not necessarily imply that the therapist discloses personal content in the therapeutic relationship—although this is not precluded when clinically or humanly indicated. But it certainly makes room for the disclosure of the therapist’s process responses to the client’s behavior (e.g., feeling moved by a bereaved client’s courageous acknowledgement of his profound loneliness, or feeling distanced by a client’s shift toward apparently superficial content), which can play a useful role in fostering client awareness and enhancing the intensity of the therapeutic connection.

Although this sort of receptive presence might seem to have mystical overtones, it can be rendered in other terms as well. Among the most adequate is Buber’s evocation of an I–Thou relationship with the other (Buber, 1970), which presumes an essentially sacred attribution of full personhood to the other, in contrast to an I–It relationship which casts the other as simply an object to be acted on for our own purposes. In more secular terms it also resonates with the cardinal role of therapeutic empathy, genuineness and unconditional positive regard given particular emphasis by the honored tradition of humanistic psychology, and most especially by Carl Rogers (Rogers, 1951). But I find that Polanyi’s description adds usefully to such formulations because it highlights the necessary presence of the self in the relational knowing that is therapy, as the implicit ground from which our awareness is directed to the explicit figure of the client’s words or actions. Interestingly, I think that the self of the therapist functions in a similar way for the client as well, as he or she attends from the therapist’s questions or instructions to his or her own material. Thus, for both, the therapist’s presence serves as a clarifying lens that brings into greater focus (inter-)personal patterns and processes that are more difficult to observe in the client’s private reflections. Contributions to the present volume that underscore the importance of mindfulness in both therapist and client clearly resonate with this conception.

Some relevant data

Interestingly, empirical research on a large number of bereavement and end-of-life professionals accords with the centrality of therapeutic presence as a foundational feature in responsive grief therapy (Currier, Holland, & Neimeyer, 2008). Responding to open-ended questioning about how they helped bereaved clients make sense of their losses, nearly half (41.2%) of the participants discussed ways that they practice presence with mourners by emphasizing the quality of the relational environment as a crucial determinant of meaning-making. In particular, 16.0% of the participants explicitly stressed the quality of the relationship with the bereaved, noting that “I let the client know that they can tell me anything” and “I provide for my patients and their families a safe holding environment.” About a quarter of the sample (26.1%) highlighted the relevance of empathic attunement. Examples of responses that fell within this second basic category included: “Listen, listen, listen;” “I attempt to validate the patient’s feelings;” and “Being present to their pain.” Lastly, 15.1% of the participants emphasized the centrality of respect and not casting judgment. For instance, practitioners shared that “[meaning-making] is all dependent on the degree of the client’s readiness” and “I try to go to where the person is in their journey rather than where I might want them to be.” By offering a safe container for the client’s grief and its expression, therapists offer the precondition for its transformation as well.

PROCESS

If therapist presence sets the stage for psychotherapeutic work, process is the medium in which the drama of therapy unfolds. Extending this metaphor, an effective grief therapist attends to unfolding action in the consulting room much as a director might attend to a theatrical performance, with the crucial exceptions that the director him- or herself is also an actor on the stage, and there is no script for the enactment! Instead, in the improvisational theatre that is counseling, the therapist subtly directs the process by attending to signals of possible extension, elaboration or intensification of the action or emotion in promising directions, sometimes through explicit instructions or suggestions, but more commonly through her or his own responsiveness to the client’s “lines” or performance. This attention to the unfolding “give and take” of interaction is what opens the possibility for timely suggestions regarding therapeutic techniques, like many of those included in this volume.

Following the affect trail

A basic orientation to process carries several implications for the practice of grief therapy as a moment-to-moment transaction between two (or more) people. The first can also be stated as a guiding principle: Follow the affect trail. That is, significant emotion, even (or especially) when subtly present, typically defines the growing edge of the client’s experiencing—the shadow of sadness that portends looming loss, the static of anxiety that announces a sense of abandonment, the spark of pride that attends a client introducing us to stories of a deceased loved one. In each instance the feeling tone underpinning the client’s experience in the moment is palpably present in his or her language of gesture, proxemics, verbal, co-verbal and nonverbal expression. Simply articulating this implicit emotion and inviting elaboration (“I notice that your jaw is trembling as you say that. What’s happening for you right now?” or “If those tears could speak, what would they tell us?”) is often enough to deepen the client’s self-awareness, prompting symbolization of new meaning as a precondition to its further negotiation. Contributions in subsequent chapters that focus on sensing, labeling and modulating significant emotion accord with this principle, as do those that foster attention to the body as a locus of felt meanings.

At some points, however, emotion and other modalities (such as imagery or narrative) can be so closely inter-braided that drawing forth one automatically brings with it the other(s). An illustration of this arose for me in a recent session of therapy with a lonely client grieving the death of her father after a long lapsed relationship that recently had been rekindled (Neimeyer et al., 2010). Altered by her statement that she felt like there was “a sheet of Plexiglas” between herself and others, I asked her to close her eyes and visualize that Plexiglas and her relation to it. As she did so, she described it as an “octagonal enclosure” in which she found herself alone, with others as shadowy figures passing by on the outside. When I enquired whether the enclosure had a ceiling of some sort, she replied that it did not, that it was open at the top. Visualizing the scene myself, and getting more details of her positioning in relation to the walls (“sometimes touching them, but never able to get through”), I inquired as to their height. She responded without hesitation: “Eight feet.” “Hmm …” I wondered, “Eight feet, and eight walls in the enclosure … Does the number eight have a special significance for you?” Immediately my client burst into tears with a slight gasp, and responded, “Yes—my father died on the 8th!” The seemingly unbreakable, unbridgeable walls in which she felt encased were the walls of her grief, cutting her off from other human contact. Elaborating the image a bit more, she described the enclosure as an aquarium and herself as the fish observing and being observed by a world beyond her reach. She eagerly accepted my suggestion as the session ended that she might write a short metaphoric story with the title Life in the Fishbowl as a means of extending the image, its associated feelings and meanings into our conversation the following week.

Whether emotion is given attention in its pure physical expression or in the way it resonates through a significant story or image shared in therapy, it is viewed as being rich in significance from a meaning reconstruction standpoint. For example, personal construct theorists interpret emotions as clues to incipient shifts in our core constructs for maintaining a sense of self and relationships (Kelly, 1955/1991), as when a client’s anxiety in the aftermath of loss suggests that he or she is confronting life as a bereaved person without the necessary means of anticipating or making sense of it. More generally, this conception views emotion as a form of intuitive knowing (Mahoney, 1991), rather than as an irrational force to be brought into line with rational evaluations of a situation. In this way we need not see affect, even negative affect, as a problem to be eliminated, controlled, disputed, minimized or simply coped with through distraction, but rather respected as a source of understanding to be validated and explored for what it says about what a client now needs. Several of the expressive interventions outlined later in this volume resonate with this conception.

Privileging experience over explanation

A corollary to the principle of following the affect trail is that all therapeutic change is initiated in moments of experiential intensity; all the rest is merely commentary. That is, potent grief therapy interventions need not be heavy-handed, but they entail ushering a client in...

Table of contents

• Cover Page
• Half Title Page
• The Series in Death, Dying, and Bereavement
• Title Page
• Copyright Page
• Contents
• List of Figures and Tables
• Prologue
• Acknowledgments
• Part I Framing the Work
• Part II Modulating Emotion
• Part III Working with the Body
• Part IV Transforming Trauma
• Part V Changing Behavior
• Part VI Restructuring Cognition
• Part VII Encountering Resistance
• Part VIII Finding Meaning
• Part IX Rewriting Life Narratives
• Part X Integrating the Arts
• Part XI Consolidating Memories
• Part XII Renewing the Bond
• Part XIII Revising Goals
• Part XIV Accessing Resources
• Part XV Grieving with Others
• Part XVI Ritualizing Transition
• Part XVII Healing the Healer
• Epilogue
• List of Contributors
• Index