Denial. You’ve heard about it, even referred to it with clients and perhaps with yourself. For Elizabeth Kubler Ross, MD, a woman who got the world talking about death and loss, denial was the first of five stages she found to be true anchors for the dying, but these carefully observed stages were not meant to help relieve or define grief for the survivors who live with the loss.

Survivors go through a different movement and for them, denial can affect potent therapeutic outcomes. Unless a blatant loss is described by a client, it is easy for a therapist to miss grief and its grip in the early phases of therapy.

As someone who has studied and specialized in grief therapy for 25 years, I asked my colleagues how they approach grief with clients. Below, their answers, and the lessons I’ve learned along the way.

How Other Mental Health Professionals Are Asking Clients About Grief

The experience of loss can come from many different threads – not just the death of a loved one. Loss can be felt after a divorce, a traumatic injury or accident, and even as the result of the ongoing pandemic, in which a sense of normalcy has been removed from so many lives. Grief also likes to hide, often masked as or quietly running alongside other mental health disorders.

In fact, missed grief in the sacred therapy room is more of an issue than clinicians think. No matter how many years you’ve had in the chair, how many folks have passed through your office, or how much great training you’ve completed, grief and its cohort of issues often get booted into other categories of mental illness or distress. I see it as one of the primary issues walking through my door, often veiled as anxiety, depression, anger, and even erectile dysfunction and vaginismus.

In most of my sessions, while anxiety or depression may seem to be the most prevalent and disturbing concern to the client, I quietly wonder where the grief is and how to best uncover it so that it can be properly heard. Recently, I began to wonder how my mental health professional peers address this obstacle.

So, I sent out a quick, informal survey to 28 colleagues. I asked:

Do you assess for grief as a primary issue even if the client has not suggested a history of loss and/or grief response? In other words, do you discuss grief no matter the story told? And if you do, when in the professional relationship do you bring up the conversation?

Of the 28 therapists, all of whom engage in talk therapy (as opposed to CBT, DBT or CPT), 10 said they wait until something about loss presents itself, essentially brought up by the client. I interpret this response as grief being somewhat of a taboo subject, sometimes making a therapist uncomfortable until the client or conversation leads them in that direction.

Ten of my colleagues shared how they didn’t mention grief but instead discussed the presenting issues, like anxiety or depression, and helped clients stay focused on responding to the symptoms through self-talk and staying present in the face of their issues. The remaining therapists (8) said they use an initial history of grief to help them sort out where presenting issues may be arising from.

How Can We Improve Our Approach to Grief?

Change the Terminology

I understand that it’s not easy to broach these conversations. But there are ways to become more comfortable with the grief conversation as part of an initial assessment. For instance, you can add a mini-assessment to the assessment you already do, in the style which you are already comfortable, by asking clients about yearning, hunger, desire, and loss. The term “grief” does not have to be directly mentioned – yet.

Imagine asking the client on the first meeting to “Keep your story safe until you feel a sense of trust for me. Please, for you and to protect you, don’t share your story.” Allow the client to be curious about the moves you are making. Let them know you see them and let them see you. Grief doesn’t like to come out and play so easily. But as a therapist, you will get the basic information you need, and after that – perhaps in the next session or two – you can ask them what they are yearning for. You will find that their desire uncovers what they have lost and then, together, you can unfold and treat that loss, that grief.

Address Personal Loss

I also recommend taking time with yourself to see how you may respond to questions about your own yearning, desire, hunger, and loss. What do you hear? Do you notice where the grief lies?

Some people may attempt to create a collaborative alliance with their grief. In other words, by identifying its presence, naming it with precision, and taking the time to be with it, the grief knows you are willing to meet it halfway. Others may take note of their grief – perhaps there’s an aroma in the air that leads back to a memory of loss – and yet, they collude to leave it there, deal with it “later,” or ignore it.

As part of my informal survey, I also asked colleagues:

How has your own relationship with grief and loss affected your desire or ability to go into that territory with clients?

Of the 28, 12 said they had marginally worked through their own losses. This surprised me, especially because it seemed through their own admission, a choice was made to ignore the potential effect this could have on their work with clients. Their own avoidance may well have colluded with a client’s desire or inability to face and dissect grief and its non-linear way of showing up. Alternatively, the presenting issue may have directly related to a loss and they did not see a need to assess for the characteristics of grief.

I was happy to hear from the 8 colleagues who used grief as part of an initial assessment, that because of their own deep work around grief and loss (some of whom had lost a parent or gone through a tough divorce), a crisp realization evolved into a broader lens of understanding how grief can interrupt, undermine, or inform the therapeutic process.

By defining grief for yourself and by remembering what got you into the field, you can forge a path that will help you to be more than adept at helping and healing your clients. So often, it is our own pain, disillusionment, or dilemmas that define the professions we choose. In the same manner, it must be our own work – entering the depths of our personal psyches – where we see the transformation of ourselves into therapists and the transformation of our clients through our guidance.

Expand Your Definition of an Emergency Therapy Session

Getting comfortable with grief also requires you to get comfortable with the emergency of the clients’ psyche sitting in front of you – whether it’s in person or via a screen. We know that by the time someone picks up the phone to make an appointment, they are already feeling desperate, afraid, and alone. They are yearning for something they may not have words to describe or imagine. By the time they are face to face with you, they’ve likely reached a point when their trauma, anxiety, anger, or fear is causing obstacles in their relationships, their routines, and their self-embodiment.

So, keep in mind that the emergency sitting before you is deeper than you might think, which is why coming into a session with an added repertoire can reap more information than you might expect.

Once you’re prepared, you can put your observation skills to work. Watch what happens with a client when you offer a grief perspective – or a yearning perspective. See what kind of conversation opens up when the question asked is not what is expected.

Specific Signs of Grief to Look For

Here are a few grief cues I have picked up on over the years.

Life or Lifestyle Changes: Big and Little “G’s”

Listen for what I call the Big G’s and the Little G’s – the G stands for grief. The Big G’s are the incidents where grief is obvious. Loss of a loved one, loss of a job, loss of a relationship, or an ongoing physical or mental illness are obvious examples of the Big G effect.

The Little G’s are small, yet when unnoticed, can accumulate. Getting teased at work, having a broken leg, or a fight with a friend all seem like Little G’s. However, if over time they affect the client’s ability to socialize, exercise, or go to work, the Little G effect can lead to a Big G.
If the Little G’s happen in a short period of time, they can also reap Big G responses.

Talking about Purpose

You can also consider whether an individual’s state of mind, sometimes seeming fractured or lost, may be emblematic of a grief state. When you hear about a lost sense of purpose, for example, which can be attributed to a depressive state, is it made more intense because of grief?

In my professional experience, this is often the case. Lost purpose is not only a common circumstance but one in which grief can be easily overlooked. Upon hearing and assessing for symptoms of depression, you will treat the depression, yet what if you also treat the grief? They often exist in parallel and just because a depression lifts does not mean the grief is no longer raging for the client. Grief is as important to name, understand, and treat as is the presenting issue. (More on sources of purpose and meaning.)

Lingering

One cue of lingering grief may be the client’s resistance to leave therapy when you believe they have finished. If you think of grief as the psyche’s state of emergency, then anyone who walks through your doors is in that state. For the client, their internal sirens are clanging, ringing, loudly banging to be seen. The client wants to be untethered from the emotional pain. Yet, they may rely on it, as well.

Overall, as modern human beings, we have learned to compartmentalize our lives. We may have had a fight at home with a partner or kids, yet, whatever happened before seeing the client, needs to be put into our secret compartment so the work can be done. Your clients have secret compartments, too. More than ever, however, when I approach a client with the question of yearning, it almost always leads to a history of losses in their life and how they coped or, more accurately, are still coping. This is where you come in.

Professional Takeaways

  • As a therapist, it’s important to get comfortable with grief and the early conversations that go with it.
  • Grief is tricky. How you face its potency as a clinician – with your own understanding of loss – is part of uncovering the grief in the therapy room.
  • Grief can be present even when a client is not describing a big or broad loss – the fact that they are seeing you means grief is there.

 

Looking for more strategies? Learn about the addition of prolonged grief disorder to the DSM-5. Plus, Edy Nathan walks an author through her own grief and loss in this series on our sister consumer site, Psycom.

Last Updated: Dec 16, 2020