Grief and Loss Education: Recommendations for Curricular Inclusion

Transcription

1 Received 03/11/10 Revised 06/15/12 Accepted 06/30/12 DOI: /j x Grief and Loss Education: Recommendations for Curricular Inclusion Elizabeth A. Doughty Horn, Judith A. Crews, and Laura K. Harrawood Currently, the Council for Accreditation of Counseling and Related Educational Programs (2009) does not require course work on grief and loss, and it is possible for counselors to practice without any formal training in the area. The purpose of this article is to highlight the need for additional grief and loss education in the curriculum, provide a brief overview of the current literature surrounding grief and loss, and suggest pedagogical strategies for counselor preparation. Keywords: grief, loss, grief counseling, pedagogy Grief and loss are ubiquitous in the human experience, and the majority of counselors will eventually work with clients facing these issues. In addition to issues related to death and dying, grief and loss as a broad concept encompasses countless facets of human experience, such as normative lifecycle transitions, divorce, substance abuse and recovery, illness, trauma, and career change. Grief and loss course work, however, is not specifically required in most counselor education programs (Breen, 2010), and counselor educators may be reluctant to engage in teaching these courses because of a number of factors, including their own attitudes, religious beliefs, and lack of training (Eckerd, 2009). The ACA Code of Ethics (American Counseling Association [ACA], 2005) is clear in regard to proper training in the determination of professional competence (Standard C.2.), including skills in working with issues of grief and loss (Standard A.9.). However, the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009), which sets professionbased curricular standards for accredited counselor education programs, does not require or address course work specifically related to grief and loss. Although curriculum addressing trauma has been required and some information, such as end-of-life issues, is implied within the Human Growth and Development standards (CACREP, 2009, II.3.a., II.3.f.), grief and loss are not explicitly mentioned in the standards and thus may be overlooked in counseling pedagogy (Eckerd, 2009; Wass, 2004). There is minimal research relating to grief and loss education in the field of counseling or other helping professions. Harrawood, Doughty, and Wilde (2011) identified three themes in a qualitative study of master s students enrolled in a grief and loss course specific to death and dying concerns: increased openness to constructs of death, a greater understanding of their own Elizabeth A. Doughty Horn and Judith A. Crews, Department of Counseling, Idaho State University; Laura K. Harrawood, Professional Counseling Program, McKendree University. Correspondence concerning this article should be addressed to Elizabeth A. Doughty Horn, Department of Counseling, Idaho State University, 1311 East Central Drive, Meridian, ID ( dougeliz@isu.edu) by the American Counseling Association. All rights reserved. 70 Counselor Education & Supervision March 2013 Volume 52

2 beliefs regarding death, and a reduction in their fear of death. These themes show that trainees may be less likely to personalize or project unexamined values and beliefs onto a grieving client or may have less fear when addressing these issues. These findings are consistent with other studies indicating that increased education can have a positive effect on comfort and coping (Bugen, 1980; Ober, Granello, & Wheaton, 2012; Servaty & Hayslip, 1997; Smith-Cumberland, 2006; Wong, 2009). Wass (2004) cautioned, however, that multiple roadblocks to providing grief and loss education should be addressed. These barriers include resistance at the institutional level and failure to acknowledge the need for grief and loss education and a lack of commitment of resources. Literature on practitioner attitudes toward grief and loss further highlight the need for additional training. It is interesting to note that beginning counselors reported that discussing topics related to grief and loss made them more uncomfortable than discussing other presenting problems (Kirchberg & Neimeyer, 1991; Kirchberg, Neimeyer, & James, 1998), and overall levels of counselor empathy toward clients specifically with death-related concerns were found to be low, potentially because of counselors personal factors (e.g., high fear of death) and limited experience and exposure to these client issues (Kirchberg et al., 1998). Ober et al. (2012), however, found that training and experience were significant predictors of counselors knowledge, comfort, and skill levels relating to working with grieving clients. To better understand counselors and counselor trainees level of anxiety in dealing with issues of grief and loss, we distributed a questionnaire to a randomized list of ACA members to investigate their anxiety related to death specifically. These unpublished data indicated that participants (N = 161) who had attended grief workshops significantly demonstrated reduced levels of anxiety in working with death-related issues. It is interesting to note that 83.9% (n = 135) of those surveyed indicated that they had not taken a grief and loss education course as part of their master s or doctoral studies. The prevalence of and attitudes toward grief and loss issues in counseling coupled with professional calls to address these issues in practice and training indicate a need for more exposure to these topics. In this article, we offer suggestions for incorporating grief and loss education into counselor preparation programs. First, we provide a brief overview of the current literature surrounding grief and loss counseling to help frame these strategies. Current Aspects of Grief and Loss Counseling There has been an evolution of thought in the past 20 years surrounding grief and loss in the way counselors conceptualize and treat grief (Doughty, 2009; Humphrey, 2009). Grief counselors have moved away from stage and phase models such as Kubler-Ross s model in favor of a more individualized and complex view of the griever and the grieving process (Center for the Advancement of Health, 2004; Doka & Davidson, 1998; Doughty, 2009; Humphrey, 2009; Martin & Doka, 2000; Neimeyer, 1999; Weiss, 1998; Wortman & Silver, 1989, 2001). For example, there is a current focus on clients using affective, cognitive, and behavioral strategies (Bonanno, Keltner, Counselor Education & Supervision March 2013 Volume 52 71

3 Holen, & Horowitz, 1995; Doughty, 2009; Humphrey, 2009; Martin & Doka, 2000) to connect with the loss, particularly in cases of death (Doughty, 2009; Humphrey, 2009; Klass, Silverman, & Nickman, 1996; Martin & Doka, 2000). Furthermore, counselors increasingly recognize the role of cultural context in the grief experience (Doka & Davidson, 1998; Doughty, 2009; Humphrey, 2009; Martin & Doka, 2000). Counselor educators should be familiar with several grief and loss models that reflect these changes in grief counseling. Each allows for an individual s unique experience and expression of grief as it is informed by his or her personality, experiences, and unique cultural influences. In addition, these models provide a framework for continued adaptation to loss. It should be noted that, although these models embody current ideas, more empirical research is needed to better understand their limitations. Attachment Theory Although originally designed to better understand separation from primary caregivers, attachment theory has become a major influence in understanding and facilitating grief and loss. Bowlby (1980) theorized that the most important attachment an infant has is to his or her mother (later revised to mother figure or primary caregiver) and the quality of this attachment will affect his or her relationships throughout the life span (Parkes, 2001; Stroebe, 2002). Attachment theory is used to aid in the conceptualization of individuals varying reactions to bereavement. Studies show that there are associations between individuals attachment style and bereavement responses (Parkes, 2002; Servaty-Seib, 2004; Wayment & Vierthaler, 2002). Dual Process Model Stroebe and Schut (1999) identified two types of stressors related to bereavement within the Dual Process Model of coping with bereavement: lossoriented stressors and restoration-oriented stressors. Loss-oriented stressors are essentially those that relate directly to loss and the feelings associated with it. These types of stressors include ruminating on the emotions associated with the loss, concentrating on how life had been prior to the loss, and focusing on the circumstances surrounding the loss. Restoration-oriented stressors deal more with the secondary losses associated with bereavement. These stressors include the acquisition of new roles the bereaved person must take on in the absence of his or her loved one, creating a new life without the deceased, and relating to friends and family in new ways. Stroebe and Shut asserted that bereaved individuals go through a process of oscillation between attending to loss-oriented stressors, restoration-oriented stressors, and periods when they do not focus on their grief at all. Meaning Reconstruction When following a loss such as the death of a loved one, many bereaved individuals question their constructed reality and are challenged to reorganize their underlying basic assumptions Given the assault on the individuals worldview, the result is considered a crisis of meaning. The bereaved person 72 Counselor Education & Supervision March 2013 Volume 52

4 may question Why me? Why did this happen? or How can I go on? (Davis, Wortman, Lehman, & Silver, 2000; Servaty-Seib, 2004). Bereaved individuals must reconstruct their personal world of meaning in the absence of their significant other. In fact, it has been said that meaning reconstruction in response to a loss is the central process in grieving (Neimeyer, 1999, p. 67). Meaning reconstruction is a highly individualized and unique process created, in part, by an individual s personality, cultural influence, and previous experience with loss. Adaptive Grieving Styles Martin and Doka s (2000) adaptive grieving styles are reflections of individuals idiosyncratic use of cognitive, behavioral, and affective strategies in adapting to loss. These strategies flow from diverse variables, including personality and culture. Adaptive grieving styles are distinguished through two criteria: the internal experience of loss and outward expression relating to the loss. Martin and Doka asserted that difficulties arise when there may be dissonance between adaptive and natural grieving styles; dissonant responses occur when the griever believes his or her natural adaptive style is not desirable and attempts to adopt the style he or she deems more attractive. In doing so, the bereaved individual may become stuck in the grieving process and develop complications in coping. Styles can be conceptualized as existing on a continuum with the intuitive pattern on one end, the instrumental pattern on the other end, and the blended pattern located in the middle. Intuitive grievers experience and express their grief primarily through affect, marked by a heightened experience and intense expression of emotion and a desire to talk about the loss. Instrumental grievers are less likely to display emotion than intuitive grievers, and Martin and Doka (2000) theorized that the emotional experience may be less intense for instrumental grievers than for intuitive grievers. Also, in contrast to intuitive grieving, the instrumental style of grieving is marked by a more cognitive, behavioral, problem-solving approach. The more prevalent style is blended grieving. Blended grievers naturally experience and express their grief in both cognitive and affective ways yet usually with one style more dominant than the other. What denotes the blended griever is his or her reliance on a variety of strategies that are both intuitive and instrumental in nature. Recommendations for Incorporating Grief and Loss Education Although there is limited empirical research to support the efficacy of a given theory or model of grief counseling over another, Currier, Neimeyer, and Berman s (2008) meta-analysis of studies in grief counseling does indicate that therapeutic interventions are helpful for the bereaved person. Thus, a curriculum for grief and loss counseling could include the following: discussion and critique of classical theories of grief and loss (i.e., stage/phase/task models); the impact of culture, experience, and personality on the grieving process; the understanding of a variety of unique healthy experiences and expressions of grief; understanding that grief work is more than an af- Counselor Education & Supervision March 2013 Volume 52 73

5 fective process; refutation of closure as a necessary process for everyone; recognition of the importance of continuing bonds; and acknowledgment of grief within everyday losses and normative life transitions. Current models for discussion should contain a more biopsychosocial approach to grief (Walter & McCoyd, 2009) and include attachment theory, the Dual Process Model, meaning reconstruction, and adaptive grieving styles. Through the incorporation of various didactic and experiential exercises into the curriculum, students can become aware of their own grief and loss issues as well as learn various techniques to help their clients grief processes. Following are suggestions for incorporating grief education into the CACREP core curriculum. Social and Cultural Diversity Identifying societal attitudes regarding grief and loss. Culture plays an important role in shaping attitudes toward grief and loss and influences the way individuals grieve (Waldrop, 2011). A relevant experience for identifying attitudes within society would be to instruct students to compile media messages about how people grieve in Western and non-western cultures. This could be done using movies, television, commercials, or Internet material. Each could be presented in class and discussed in terms of how the messages might affect an individual s adaptive grieving style and meaning reconstruction after a loss. In addition, the use of film can be an effective instructional tool (Toman & Rak, 2000) and a powerful resource for identifying cultural elements of individuals grief as well as increasing self-awareness regarding attitudes and expectations surrounding loss (Humphrey, 2009). Exploring rituals for grieving. Cultural rituals for grief (e.g., funerals, eulogies) can be discussed as a foundation for the use of more personalized rituals to assist clients in their grief processes. As outlined by Reeves (2011), these personal rituals can be an effective method toward bringing acceptance of a loss, particularly in cases of unresolved and ambiguous losses. Through designing their own rituals, students are given the opportunity to resolve their own perhaps unacknowledged losses as well as to understand their clients need to legitimize their idiosyncratic grief process. Human Growth and Development Creating a lifeline of losses. There are different variations that can be used when creating a lifeline (Humphrey, 2009). The intent of the exercise is to have students examine significant events in their lives in terms of grief, loss, and transition. The length of the lifeline is up to the student or instructor (e.g., last year, last 5 years, life span) and is a way to identify meaningful events that acknowledge how any change in life contains an element of loss. Creation of the lifeline of loss is a way for individuals to identify disenfranchised grief, to reflect on their own adaptive grieving style, and to understand the meanings they may have derived from these losses. Journaling and storytelling about grief and loss. The constructivist view of grief counseling focuses on the struggle of the bereaved person to find meaning in losses (Neimeyer & Currier, 2009). Journaling, storytelling, and the use of 74 Counselor Education & Supervision March 2013 Volume 52

6 metaphor can be a rich source for students in the exploration of their personal attitudes, beliefs, and meanings surrounding their own experiences with loss (Gilbert, 2002; Neimeyer, Torres, & Smith, 2011; Scofield, 2005). Students can be assigned to write about a number of topics, including their thoughts and feelings related to personal losses, their expectations surrounding grief, everyday losses they have experienced, how they have experienced others grief, or the exploration of their spiritual beliefs regarding death and loss. The writings could then be used for a class discussion to reveal variations in individuals efforts to derive meaning from loss. For a more technologically advanced variation, Parikh, Janson, and Singleton (2012) showed that video journaling can be an effective way to facilitate reflection and promote authenticity. Career Development Although it is seldom seen as a grief issue, job loss and career change can be a wrenching experience for individuals and their families (Harris & Isenor, 2011). The experience can include the loss of identity, social status, self-respect, financial security, and their assumptive worldview as well as increased health and psychological issues (Walsch, 2009). As Brewington, Nassar-McMillan, Flowers, and Furr (2004) stated, It is essential for career counselors to identify clients who are grieving and to be prepared to work with a wide range of grief responses (p. 81). A career counseling class could incorporate issues of grief surrounding job loss into the curriculum such that career counseling students would be able to intervene with their unemployed clients in the most effective manner. Addressing these grief responses would also be an excellent opportunity to ascertain the loss- and restoration-oriented stressors that clients use when attempting to resolve crises that involve employment. The incorporation of grief and loss issues into the career counseling curriculum could be accomplished by having students analyze case studies and present a career counseling treatment plan that, as suggested by Sterner (2012), integrates current career counseling theories with existential and grief and loss issues. Another approach might include class exercises in client conceptualization that emphasize clients primary and secondary losses with regard to unemployment and what appropriate interventions might be applied. Helping Relationships Crisis counseling course. Although there are significant differences in crisis intervention and grief counseling, there is evidence that survivors reactions to trauma, particularly in the loss of their assumptive world and altered worldview, can result in complicated grief (Mancini, Prati, & Bonanno, 2011). Although not everyone experiences grief issues after a trauma, crisis counselors need to screen clients for risk factors for both posttraumatic stress disorder and unacknowledged grief reactions following a traumatic event (Mancini & Bonanno, 2006). Mancini and Bonanno (2006) indicated that counselors need to be aware of clients resilience factors that may mitigate maladaptive responses to crises and trauma. A discussion of meaning reconstruction as a potential source of client resilience, as well as the impact of Counselor Education & Supervision March 2013 Volume 52 75

7 adaptive grieving styles on survivors posttrauma processes, would provide students with an understanding of the variations in recovery from trauma. Clinical courses. In practicum and internship, students could be encouraged to view their clients issues through a lens of grief and loss. Doka (2002) pointed out that there are many forms of grief unrelated to death: Separations from almost any form of personally meaningful attachment (e.g., individuals, ideas, possessions, expectations) can result in loss. Some examples are changes in job, hometown, marital status, pets, spiritual beliefs, lifestyle, or property. Helping students identify transitions and separations from attachments may be helpful in better understanding and working with all client issues. Students may be instructed to list all losses inherent in their work with clients and then during supervision discuss how these may affect the client and the counseling relationship as well as students personalization issues. This can help supervisors gauge how well students are able to identify and work with areas of grief and loss and keep these issues integrated into their conceptualization of clients. Group Work In group theory and practice classes, students might engage in classroom experiences that include existential group techniques for grief and endof-life issues (Garrow & Walker, 2001) as well as explore research in group psychotherapy for grief (Joyce, Ogrodniczuk, Piper, & Sheptycki, 2010; Rosner, Lumbeck, & Geissner, 2011). Walijarvi, Weiss, and Weinman (2012) offered a theoretically integrated curriculum-based model for use with grief-related support groups that could be incorporated into this CACREP core area. Through group process, students would have the opportunity to conceptualize group members through the lenses of attachment, dual process, adaptive grieving, and meaning reconstruction. Assessment Because of the highly idiosyncratic nature of grief and the contextual factors associated with it, assessing loss is somewhat problematic. Despite many quantitative measures designed to assess for types of grief (e.g., Texas Revised Inventory of Grief [Faschingbauer, Zisook, & DeVaul, 1987]; Grief Experience Inventory [Sanders, Mauger, & Strong, 1985]; Grief Pattern Inventory [Martin & Doka, 2000]; Inventory of Complicated Grief Revised [Prigerson et al., 1995, 2009]), no comprehensive assessment exists (Neimeyer & Hogan, 2001; Van Heck & de Ridder, 2001). Assignments in assessment could provide students with opportunities to critique various instruments used to assess grief and loss. Research and Program Evaluation Research and program evaluation emphasizes understanding research methods in order to use the most effective measures. Because of the unique nature of grief and loss, it is important to choose methods that recognize the highly individualized manner in which individuals grieve. Counselor educators 76 Counselor Education & Supervision March 2013 Volume 52

8 can encourage students to become familiar with instruments that highlight their clients distinctive grief process as well as use qualitative methods (e.g., case studies, phenomenological studies, ethnographies) that allow for the understanding of each individual s singular experience. Professional Orientation and Ethical Practice The ACA Code of Ethics (ACA, 2005) includes a section on ethical practice regarding end-of-life issues, which discusses the necessity of counselor competence in working with the dying (A.9.a., A.9.b., A.9.c.). Counselors are cautioned to be aware of their own issues regarding death and loss (A.9.b.) as well as those of their clients. Gamino and Ritter (2012) considered it an ethical imperative for counselors to be cognizant of not only their own issues surrounding death and loss, but also their clients level of reluctance to define their presenting issues in the context of grief and loss. A discussion of this section of the ethical code as well as provision of case studies regarding end-of-life issues could easily be incorporated into the ethics curriculum, thus helping counseling students to examine their potential personalization issues to clients end-of-life issues. Discussion and Implications for Future Research We have presented several instructional strategies that can be implemented across CACREP core areas. Although most counselors will deal with issues of grief and loss, it seems that many students are not adequately prepared to do so prior to becoming professional counselors (Eckerd, 2009; Wass, 2004). Beginning counselors discomfort with grief and loss indicates a need for counselor educators to address these issues in the classroom and within supervision. Equally important is an assurance that the instruction given to students is reflective of current trends and best practices. Unfortunately, there has yet to be published a valid and reliable measure to assess counselor competence and comfort levels in working with grief, although Ober et al. (2012) have conducted preliminary research on such a measure. Although a potential for including grief and loss already exists within the counseling curriculum, we acknowledge that there may be barriers to implementing these suggestions for future infusion. One barrier may be a lack of support from colleagues who do not see the need for students to participate in grief and loss education. There are steps the counselor educator can take to address this and other potential roadblocks. First, counselor educators should take every opportunity to educate peers about the far-reaching need for counselors-in-training to receive grief and loss education. When talking to reluctant colleagues, one may find it helpful to reframe grief and loss education as a way to help students work with clients experiencing loss. Although counselors may occasionally work with bereaved individuals, it could be argued that nearly all clients are dealing with issues of loss. In addition, it would be helpful for counselor educators to stay abreast of the current literature relating to grief and loss and take advantage of continuing educational seminars that focus on these issues. Counselor Education & Supervision March 2013 Volume 52 77

9 Several suggestions have been given for educating counselors-in-training about issues of grief and loss. However, the list is by no means exhaustive. It is important for counselor educators to be creative in choosing instructional strategies so that they are a unique fit for their students learning styles, culture, and personalities. Also important is to create environments in which students feel safe to express discomfort and challenges with the subject matter and allow instructors to gauge feelings surrounding the topic. To this end, it may be helpful to include reflection assignments, such as traditional or video journaling (Parikh et al., 2012). Journaling provides a way for instructors to assess how well students comprehend the material presented as well as their comfort level with issues of grief and loss. Hubbs and Brand (2005) suggested that instructors may include more formal evaluations of students journal entries through the use of matrices indicating the depth of responses. Supervision may be another avenue for assessing the effectiveness of teaching strategies and student comprehension. Supervisors who explore students understanding of clients grief and loss issues as well as potential personalization issues will be able to gauge the impact of the instruction given through students awareness, insight, competence, and comfort levels. Future research investigating the benefits and challenges of formal training in grief and loss issues could be beneficial for advocating inclusion in the standards. Preliminary research indicates that a grief course is associated with counselors increased competence with grief issues and lowered anxiety in working with bereaved clients (e.g., Harrawood et al., 2011; Ober et al., 2012). It is important in future research to further understand and develop assessments to measure these relationships and how best to include grief and loss in counselor education. Given that grief and loss are universal in human experience, it seems incongruous that this subject matter is nonexistent in the CACREP accreditation standards. Historically, counselor education and CACREP have made efforts to alter curricular requirements to better prepare counselors to practice in a changing world (e.g., multicultural competencies, crisis and trauma, and social justice issues). Therefore, it would be prudent for counselor education programs to take the initiative in incorporating grief and loss education into the curriculum. References American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: Author. Bonanno, G. A., Keltner, D., Holen, A., & Horowitz, M. J. (1995). When avoiding unpleasant emotions might not be such a bad thing: Verbal-autonomic response dissociation and midlife conjugal bereavement. Journal of Personality and Social Psychology, 69, Bowlby, J. (1980). Attachment and loss: Vol 3. Sadness and depression. New York, NY: Basic Books. Breen, L. J. (2010). Professionals experiences of grief counseling: Implications for bridging the gap between research and practice. Omega: Journal of Death & Dying, 62, Brewington, J. O., Nassar-McMillan, S. C., Flowers, C. P., & Furr, S. R. (2004). A preliminary investigation of factors associated with job loss grief. The Career Development Quarterly, 53, Bugen, L. A. (1980). Coping: Effects of death education. Omega: Journal of Death & Dying, 11, Center for the Advancement of Health. (2004). Report on bereavement and grief research. Death Studies, 28, Counselor Education & Supervision March 2013 Volume 52

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