The wound of psychosocial loss will also heal if
   (1) unnecessary contaminants such as unreasonable guilts and resentments can be worked through;
   (2) the individual is prevented from feeling isolated and helped to feel connected to others; .. and
   (3) the person can be helped to tap into the psychological "nutrients" that come from some kind of positive outlook on life.

Whether as therapists or in the role of friends, we can help those who are bereaved meet these healing conditions through the use of a number of principles of grief counseling. Many people who suffer a major loss fail to complete their process of grieving because one or all of the three aforementioned conditions cannot be met. Unexpressed feelings of self-condemnation, social isolation, and the loss of a sustaining philosophy of life represent tragically unnecessary additional burdens to the inevitable losses in life. Yet it is not inevitable that those who suffer losses must also suffer the additional burden of lowered self-esteem or feelings of being alone and disoriented. This is analogous to a wound becoming infected, allowed to gape open, or the body lacking nutrients necessary to heal.

While the death of a close relative, beloved spouse, or friend is the prototype of the grief experience, any type of loss can precipitate some degree of mourning. The death of a pet, moving away from friends, retirement, graduation, and many other role shifts can have significant psychological implications. Anticipating a loss, such as the spectre of one's own death, also involves a number of these principles. Special problems arise with situations involving the death of a child or the suicide of a significant other .

Most people in our society change roles in life with little support or chance for ventilation. Many assume that no support is available, or they have attitudes that won't let them make use of the caring and listening of friends. One of the reasons for this is that we are only beginning to fully appreciate how grief work can heal and to learn methods for promoting that healing. We can advance these concepts in our society as a way of preventing unresolved grief and emotional disturbances that arise out of it. In the following sections I will present the principles of grief work in three general categories: ventilation, empathy, and re-integration.

Ventilation

The facilitator of grief work must use discretion in offering reassurance. Simply being genuinely present with those who are grieving often communicates the most powerful form of support. It isn't necessary to find things to say to "make them feel better." Platitudes about how the situation may work out for the better can actually be counter-productive. Instead, being present involves a willingness to tolerate and even empathize with the pain. This suggests to the suffering person that the loss is real, appropriately painful, and emotionally disorganizing, and that the grieving person is not "crazy." This quiet "being with," this willingness to listen and care, also communicates confidence that with the support of a relationship, healing will occur.

It is important that we ensure that this natural psychological process is given adequate time and attention. This is perhaps the main principle of grief work. People tend to avoid their feelings using a wide range of defensive maneuvers. We can focus on the deeper dynamics of the grief work by helping the grieving person talk about the pain, the loss, the past, the future, the personal meaning, and all the feelings and ideas and memories and crushed dreams. Often the grieving person will spontaneously bring up most of the topics that need to be addressed. If a block appears to hinder the expression of feelings, it may be helpful to gently facilitate the bereaved's expression of thoughts, memories, and emotions. Yet in general it's enough to trust the silences and to allow the process to proceed at its own pace. This recognizes that it's normal for people who are suffering a loss to "seal over" for periods of time, during which they don't have a need to talk or be emotional. The image of the abiding midwife is a good model to keep in mind. The goal is to facilitate the natural process of the soul's working through of its own dilemma, that of accepting the inevitable while reorganizing the psyche so that it can go on in life. Watching for the cues and acting only when needed, then, is the key to grief work.

A ‘Check-List' of Themes

  1. Discuss the circumstances of the dying process itself. (If the loss involves an event other than death, modify these questions to fit that situation.)

  • Was the dying sudden or prolonged, expected or unexpected, involved with suffering or rather peaceful?

  • Did the dying person have sufficient opportunities to "say goodbye," and in turn, did all who would be suffering from the loss have a chance to say goodbye?

  • Was anyone "clinging" to the dying person out of a lack of capacity for independence or misplaced sentimentality? (This can have a negative impact on all concerned.)

 2. Review the frustrations, resentments, or appreciations regarding the diagnosis, treatment, and overall medical care given the person who has died.

  • Are there lingering questions regarding whether all that was possible was done, not only in caring for the dying person, but also in consideration of the family?

  • Did the physicians control the patient's pain or discomfort adequately? Did the family and the medical staff communicate effectively? Was there an understanding as to when excessive medical interventions would be withheld?

  • Did the dying person know his condition?  Was there any  deception practiced by the family or doctors?  Was there any  avoidance of important discussions because people were trying to keep up a false front?

  • On the other hand, were the relatives/bereaved allowed to express their feelings of fear and sadness or were there pressures for them to maintain a facade of cheerfulness and hope in the period prior to the death?

  • Were the key family members allowed to participate in some helpful way so that they could feel some effectiveness in coping with the grieving process?

  • Did the dying person suffer from depression and/or a loss of self-esteem because of fear of becoming a "burden," or from any other reason?

 3. Discuss the impact of the illness associated with the loss. Consider issues such as financial cost, reduction or support of the social network, problems of nursing or household care.

 4. Throughout the role-transitions of the illness, the dying, and the period following, many big or little decisions were made. Talk about any guilts, resentments, regrets, and frustrations. Help the bereaved forgive and understand the limitations of available information in those situations.

 5. The bereaved may feel guilty about the relationship between the lost person and the bereaved, regarding not having done "enough" in some way.  These also need to be brought out into the open.

 6.  Focus on any feelings of shame for having been "too emotional" or perhaps "not emotional enough."  Guilt over being weak in any way or for having particular feelings need to be reviewed in the open conversation of the interpersonal context, where the healing of support can modify the pain of confession.

 7. Discuss the process of grieving itself. Often, the bereaved need to talk about unfinished feelings regarding the funeral, the memorial service, the availability or effectiveness of support, and other experiences. For many people the traditional approach to rites of passage may be emotionally unsatisfying or sometimes even quite disturbing. Religious themes are often stirred up, and of course there are also feeling aroused about family members, those who seemed to be given preference, and other matters of protocol.

  • Were there opportunities to express emotions at the funeral or were there pressures to suppress emotion?

  • Talk about the physical status of the bereaved--feelings of fatigue, confusion, and various aches, pains, or flare-ups of psychosomatic illnesses.

  • Review the use of alcohol, drugs, or other anxiety-relieving agents and how they might have been excessively utilized (or pridefully avoided).

 8. Review the dimensions of loss in concrete terms: empty furniture, photos, unfinished tasks, unfamiliar roles to take on that the other person always filled, etc.

   • Include resentments, dissatisfactions, and burdens involved in relating to the other person--often some sense of relief, triumph, and escape blends with guilt in coping with the many facets of loss.
 
   • Review fond memories and encourage the bereaved to talk about the lost person's virtues, amusing idiosyncracies, etc. (This will be discussed further below.)

 9. What is the spiritual impact of the loss? Has it shaken--or confirmed--the faith of the bereaved? Either way, discussion is often helpful. Even if the loss has been coped with by a deepening of faith, it's important for the bereaved to witness to and affirm their beliefs to an understanding audience.

 10. Consider the social impact of the loss. How have activities changed? Have some friends fallen away or been unable to offer effective support, or has the person who is grieving not known how or been willing to ask for help?

  • Have relatives or friends or the bereaved himself expressed ideas about how one should be "strong" or how showing feelings is a sign of "weakness"?

  • Is the bereaved under pressure to resume working or assume child-care roles? Or, on the other hand, are others, in their attempts to be helpful, in fact over-protecting the bereaved? Such over-protective maneuvers actually infantilize those who are supposedly "helped," thus interfering with that aspect of grief work that involves feeling one's own activity in getting on with life.

 11. If the dying person was unwilling to die, their "holding on" maneuvers can be interpersonally stressful to those who witness the dying process. It leaves them with a subtle sense of guilt, as if the bereaved "should have done more to help." Also, the confusion attendant to a lack of clarity about the nature of dying tends to actually intensify the sense of loss. Therefore, review if there were any fears of death, clinging to relationships, or continuing rage at unfinished business. These themes can also be concerns of the bereaved, projected onto the lost person.

 12. Do family members or the social network harbor residual anger? Blame and defensiveness can become major obstacles to a clean resolution of the grieving process.

 13. The socioeconomic status of the people involved, wealth or poverty, fame or obscurity, or degree of popularity can also distort the grief process. These variables should be acknowledged and discussed.

Of course these are meant to be general guidelines, and other questions could also be asked. Aside from the facilitator having some general framework for working with the bereaved, though, the basic principle of grief work should be that of simply listening reflectively and letting the grieving person choose the topic and pacing of the exploration to suit his or her individual needs.

A Brief Note on Depression

Empathic Support

It's important that the grief facilitator not take sides, but be open to all aspects of emotion: Both the need to avoid thinking about the loss and the need to talk about it in detail-- even to repeat a story--are part of the real needs of grieving. One of the best ways for helping persons to become aware of their real feelings is to imagine what you would feel like in the same situation. When appropriate, you can extend empathic imagination to also include consideration of the experience of the deceased.

One useful concept is the recognition that our minds consist of many parts of ourselves; the feelings of some parts may seem to contradict the feelings of other parts. Mixed feelings about complex situations or a significant other person are quite normal. Indeed, a common error is to address people as if they have only one predominant feeling, and the other feelings are only "defenses" or disguises. This view of the personality as a perfectly unified entity is erroneous. Increasing evidence suggests a more refined and flexible view of the nature of human experience is more realistic.

Hence, a practical and effective approach to grief work consists of addressing the bereaved in terms of "parts of you."  Reply, in a reflective manner, "Part of you feels that you can't go on," instead of "You feel that you can't go on." This gives the other person more room to agree without having to feel that this is a full formulation of the present state. A "parts of you" statement can lead the bereaved to say, "Yes, although another part of me knows that I will go on."

Re-Integration

In psycho-dynamic terms, the healing of loss occurs through the process of internalization, in which the bereaved symbolically takes into the self the best parts of the lost person or situation. This may involve either conscious or unconscious memories and associations. The sense of self is built up from many elements, one of which is the person's set of relationships, and when a significant loss is experienced or anticipated, there's a potential for filling in that gap and shoring up the vulnerability through a variety of pathological mechanisms. In addition to denying the loss, it's possible to unconsciously incorporate representations of the lost person, even including some negative elements, such as the physical symptoms or judgmental behaviors.

It's healthier to make this process conscious, for in helping the bereaved to explicitly choose what to take in and what to leave out tendencies to engage in primitive defenses can be converted to more mature coping strategies. People have a profound ability to creatively elaborate symbolic images and statements which can serve to integrate the feelings associated with the loss. Consciously generating a matrix of chosen words which complement the images of the lost person serves to foster a synthesis of rationality and emotion.

For example, in some situations the bereaved continues to carry some unconscious and magical fantasies that the lost person or situation can still somehow satisfy certain needs. In such cases, grief work would involve the bereaved re-owining those needs, and beginning to consider how they could be met from other people or in other ways. Imagining the lost person validating this process, saying to the bereaved, "You deserve to have those needs met," facilitates this healthy transformation of loss into affirmation.

One of the more valuable goals of grief work is assisting the bereaved to internalize the best elements of the lost person or situation. To this end, help the bereaved ask three key questions:

  • What specific experiences have been shared? The idea here is to avoid mere generalities and instead to recall memories with as many concrete associations as possible. Help to make the imagery vivid by asking evocative questions so both the bereaved and the listener can picture the situation clearly. For example, the bereaved might say, "He was just...great..." and you might ask, "Tell me a time when he did something great that you especially remember." "Oh, I remember once we walked on the beach and he picked up the most amazing pieces of driftwood...I still keep them over my mantlepiece."

  • What has the person who has died given to the bereaved? Again, the idea is to move from tendencies to be vague to spelling out specific qualities and experiences. "He taught me to stick with a project until I was successful." "I find myself playing the same games with my kids that she played with me."

Sometimes this can be indirect, arising out of the lost person's limitations or weaknesses. "He could never be affectionate, and he was the lonelier because of it. It taught me to value affection."

Gifts can also be thought of in terms of meaning. Help the persons who have suffered loss to name several qualities which they will take into the rest of theirlives.

  • What has the bereaved meant to the person who has died? Help the bereaved imagine the relationship vividly enough to realize that he or she gave something of value to the lost one. This is an important psychological step, for it affirms the value of the one left behind. One experiences a sense of effectiveness by becoming aware that one has meaningfully affected another person. It suggests that there is a potential for a bereaved persons to share their loving, giving, or other qualities with others.

Sometimes it is helpful to do a kind of role playing, with the bereaved speaking to the imagined lost other person in an "empty chair." This technique, found in Gestalt therapy and derived from psychodrama, allows the bereaved to symbolically experience the "final encounter." I've found that it's especially helpful to pose the aforementioned three themes in the form of questions in the fantasized or role played dialogue.

The facilitator has the bereaved ask the imagined lost other a question; then the bereaved, reverses the roles, actually getting up and sitting in the empty chair, and enacts what s/he imagines the lost person might say. After this, staying in that other role, the lost person asks the same question, and again, by changing parts, the bereaved answers the question from his or her own viewpoint. The questions are, "What do you especially remember that we shared together?" "What have I meant to you?" The answers are discovered from within.

Summary

One of the major tragedies in our culture is that the experience of loss is compounded by the bereaved unnecessarily feeling guilty, isolated, and unfinished. This paper suggests some approaches that can help people suffering the pain of a significant loss to internalize the best elements of the relationship and renew their commitment to life. Often it's helpful for a therapist to include many friends and family in the grieving process mentioned above, depending on the wishes of the bereaved. The emerging field of "thanatology" reflects our willingness to address more honestly the problems of death, dying, and bereavement.  By emphasizing a renewed integration on a healthier level, we can help those dealing with a major loss to shift toward a new direction in life. Moreover, knowing the principles of these approaches helps all of us to communicate more openly before our relationships eventually must come to an end. Integrating a vivid awareness of the inevitability of loss in our lives stimulates a re-evaluation of our priorities and a shift of attitudes towards ourselves, others, and life in general.