Working with Bereaved Clients: Some Guiding Principles
When I tell people that I work with people who have ‘lost’ loved ones, a common response is to say ‘I couldn’t do that...isn’t it really depressing, all that talk about death?’ Clients themselves may sometimes say something very similar.While some degree of sympathy is inevitable, which, in turn, may give rise to a measure of depression, the overwhelming feeling (and I’m sure I speak for as majority of my colleagues) is one of being privileged to be taken into a stranger’s confidence about their innermost fears, anger, yearning, guilt and many other grief responses. I’ve had several clients tell me things that they’d never told another living soul, usually because of the fall-out they fear would result; they may be ashamed of what they’re revealing in confidence and are able to reveal it precisely because I am a stranger with no social or emotional connection to the deceased or anyone else known to him/her or to the client. (This is why, if we suspect that we might know the client or the deceased relative/friend, we must declare this and are unable to work with that client.) More commonly still, the client feels they cannot share their grief with another family member – or even close friends, especially if they knew the deceased well – for fear of adding to his/her own grief. So the client is trying to protect others (especially surviving children – of any age) by concealing their true grief reactions. Inevitably, it’s not just individual members who are affected by the death: the family as a unit is fundamentally changed and the individual members have to adjust to this new family unit.
Being a stranger also means that I can be non-judgemental (in technical, Rogerian terms, display unconditional positive regard): if I have no emotional investment in any of the relationships in which the client and the deceased are embedded, then I have no need or reason to react emotionally myself to anything the client may disclose (except at the most general level of being a fellow human being). This, in turn, means that I can offer myself as a sounding-board: the client can hear themselves put their grief into words without having to worry about my approval/disapproval, offending me, upsetting me etc. (Partly for this reason, when meeting a client for the first time I tell them that they should feel free to say anything they want to – and in any way they want to; ‘there’s no censorship in this room’). Many clients might swear quite commonly in their everyday conversation, and to have to check this with me might inhibit the expression of their grief. Even for the infrequent swearer, strong emotions can often be best expressed through ‘naughty words’.
Being given permission to express themselves freely is one facet of a more general, and fundamentally important, principle of bereavement support, namely, that the client is ‘in charge’ of the grief work that they undertake. Related to this is the principle that everyone’s grief is unique (because the relationship with the deceased was unique), which is one of the reasons that relatives find it so difficult to give and receive support to and from each other. Although many clients who come to Cruse have been signposted by their GP, it is the client who has to make the initial contact with Cruse; self-referral is critical because that’s the biggest single step on the client’s grief ‘journey’ and they must be in charge from the very start. It sometimes emerges that the client was pressurised by relatives to contact Cruse (perhaps to unburden themselves from the responsibility of supporting the client) and that s/he is doing it more for them than for themselves. Fortunately, this doesn’t necessarily mean that they cannot benefit from their Cruse experience.
The belief in the uniqueness of every individual’s grief implies that it’s very difficult to predict how s/he will react to the bereavement: we often don’t know how we will react until it happens. This is why stage accounts of grief (best known being that of Elizabeth Kubler-Ross) are so discredited: stages imply a predictable order of responses, a theoretical ‘straitjacket’ that every individual is meant to fit into. Clients sometimes have a very basic familiarity with this theory, as evidenced by asking ‘Shouldn’t I have got over the shock by now?’ or, more sweepingly, ‘Shouldn’t I be over it by now?’
Used as more of a guideline than a straitjacket, stages of grief can still be useful if, for no other reason, to act as a kind of checklist of feelings, cognitions and behaviours that fall under the heading of ‘grief’. This, in turn, relates to another major principle, namely, normalizing the client’s grief. One of the major forms of support that we can offer bereaved people is to reassure them that what they are experiencing is grief – and not the signs of ‘going mad’. Quite apart from the pain of losing a loved one, grief can itself by very frightening, bewildering, and disorientating. Feelings of panic and fear can be overwhelming, often accompanied by physical symptoms that can be mistaken for a heart attack or something equally serious.
As Colin Murray Parkes says in his psychosocial transition theory (PTT), bereavement (especially if this is sudden and traumatic) challenges our assumptive world (i.e. everything we took for granted (‘normality’) before the death). The world – our world – will never be the same and we have to re-define ourselves, our very existence. Clients need to be told, as many times as necessary, that this is how grief feels and, in appropriate language, that grief is the price we pay for loving someone (they represent two sides of a coin). Part of this normalisation of the client’s grief is to say that there’s no timetable: different individuals need different amounts of time to begin coming to terms with this dismantling of their assumptive world and the construction of a new one, one that doesn’t have the loved one in it.
However, this definitely doesn’t mean that we have to totally remove the loved one from our thoughts and feelings if we’re to get on with the rest of our lives and form new relationships (as the concept of ‘grief work’, derived from Sigmund Freud’s psychoanalytic theory, maintains). Indeed, part of that adjustment process should involve forging a new relationship with the loved one, keeping them alive within you (in your memories and ongoing love) at the same time as learning to live without them. Neither should exclude the other. When, for example, parents set up a charity in the name of their child who has died, they are very much keeping their child’s memory alive but by helping others in the world where that child is no longer flesh-and-blood.
What would concern me as a bereavement supporter is if a client throws themselves totally into, say, setting up a charity, or making significant changes in their life (such as getting rid of all his/her clothes and other possessions, moving house, embarking on new social activities) at the expense of allowing themselves to feel the pain of grief. Equally, clients may become ‘stuck’ in their grief, so overwhelmed by it – and over a significant amount of time – that they’re unable to ‘move on’/’move forward’ with their lives. In the terminology of Margaret Stroebe and Henk Schut’s dual process model, the first client is restoration oriented (to the exclusion of the loss orientation), while the second client is loss oriented (to the exclusion of the restoration orientation). Both are displaying an unbalanced (and, hence, unhealthy) way of coping with their bereavement: ideally, there should be oscillation between the two orientations.
Typically, as common sense would predict, clients begin by focusing on the loss orientation (relating to the primary loss of the death of the loved one): they may still be in shock, still coming to accept the fact of the death, still consumed by, say, the anger they feel towards the medical staff whom they see as having failed to do all they could for the deceased. (Here, I wouldn’t try to establish whether the client is justified in feeling angry, but rather just give them time and space to vent that anger and explore how it might be linked to other feelings – and other people. For example, anger towards the medical staff may be displaced from the deceased, whom they may feel, unconsciously, has let them down and abandoned them.) Sometimes, however, clients come preoccupied with secondary losses, i.e. the fall-out from the death (such as financial, legal, and other practical concerns). It may be that these need to be addressed (both in the support sessions and the client’s everyday life) before real grief work can begin, i.e. before any oscillation between the two orientations can take place.
As well as being non-judgemental, Rogers argued that counsellors/supporters should display congruence (authenticity or genuineness).Part of what this denotes is that the counsellor/supporter must show themselves to be a ‘real’ human being, with real emotions. More than once, I have a shed a tear while listening to a client’s story and I acknowledge that this happening at the time; this is meant to reassure the client that I’m fully ‘with’ them, that my attention and my ‘humanity’ are directed at them and no one or nowhere else. However, were I to start weeping when the client is weeping, I’d be crossing a line from ‘professional’ helper (all Cruse supporters are volunteers) to a sympathetic, caring person; while these are crucial qualities in themselves for supporters to possess, they should be implicit in working with clients, not made visible in a way that could interfere with the grief work. For a client to see the supporter getting upset would inevitably inhibit the client’s ability to freely express their thought and feelings.
This illustrates another fundamental principle, namely, setting boundaries , both for the client and the supporter him/herself. Boundaries represent safeguards, ways of emotionally protecting both parties. To take another example, there should be no physical contact unless this is initiated by the client (as in a handshake or, sometimes, usually at the end of the work together, a hug). Again, the client may sometimes ask the supporter about his/her personal life (such as ‘Have you experienced bereavements yourself?’ or ‘Do you have any children?’). The rule here is that any self-disclosure on the part of the supporter should be minimal, just enough not to be seen as rude or discourteous; it should (usually) only ever be a response to a client’s question (comparable to the client putting their hand out to shake the supporter’s hand). Other examples include time-keeping (informing the client that there are only a few minutes left in the session and ending it at the appointed time - but not abruptly). Confidentiality and anonymity are two other fundamental boundaries that may only be crossed in exceptional, and extreme circumstances.
Boundaries are intended to remind both parties about the nature of their respective roles: these are as much about what the relationship is not (e.g. friends, spiritual guide/guidee) as what it is (a bereaved person seeking support from another who is trained to support such people). The supporter’s training is based on a range of basic principles used widely in counselling and psychotherapy and part of their obligation to the client, and to Cruse as an organisation, is to receive regular supervision (an experienced Cruse supporter who has undertaken additional supervision training). It is in supervision (and sometimes in the required ongoing professional development) that the supporter is able to offload the inevitable mix of negative feelings that client work produces, as well as to problem-solve and receive guidance when challenges arise.
Finally, the greatest gift the supporter can offer the client is the opportunity to tell their ‘story’ and to be listened to without being judged. In their everyday lives, clients typically have to adapt what they say about their grief according to the person they’re speaking to and the situation. Bereavement support cuts through those restrictions, allowing the client to be as honest as they can ever be about their true thoughts and feelings. In giving their sorrow words, clients can begin to properly understand their grief: when we articulate our grief, we know better what we’re dealing with, we bring it out from the shadows into the light; when this happens, we can begin building a new life around our grief which will always stay with us, rather than believing that we have to banish it from our hearts and minds.