If we knew how to deal with grief, would we still grieve?
Yes, grief is not a door you want to avoid opening. Nor do you want to deny if you’ve already stepped through it.
However, it is worth knowing what what is in that space and how to use it.
“Grief is not a feeling. It’s a skill.” – Stephen Jenkinson, OrphanWisdom.com
Huh? Didn’t you just spend all of these pages explaining to me that grief is a feeling and a state and an experience and a flavor? You said you can’t force it or rush it because it will happen to me so I don’t have to do anything but now you’re saying it’s a skill? What? I’m too busy crying and sleeping and sitting through annoying social events to follow your steps.
Hey, I get it. Grief is hard! Grief is many things. It is a ‘being’ and a ‘doing.’ This section is about the ‘doing’ part of grief. We hope that the following sections will give you the tools and frameworks to consider how you can use your inherent agency to make meaning from your particular grief.
There are three parts to this section:
- Grief therapies (below): These are summaries of research-based approaches to grief therapy.
- Grief exercises: Activities, writing prompts, thought exercises, meditation prompts, questions, and more.
- How to help someone who is grieving: What to do when someone you care about is grieving.
In the following pages thereafter, we’ll present a curated collection of quotes on grief, an extensive list of organization that can be of help and a massive page of other resources and tools on Grief, Loss, Death and Dying, including videos, links to articles, and books, to finish off this section.
Mental health therapy is centered around the idea that working with a trained mental health professional can provide a space for reflection, sharing, and “unconditional positive regard,” in the words of person-centered therapist Carl Rogers. Therapy comes in many forms: general talk therapy, art therapy, existential therapy, pastoral counseling, mindfulness, cognitive-behavioral therapy, psychiatric interventions, psychodynamic therapy, interpersonal therapy, Gestalt therapy, etc. Many therapists offer “eclectic” modalities, meaning they tailor their approach to the needs of each client. The kind of therapy one pursues, whether in response to general mental hygiene needs or a crisis, is less important than the relationship between client and therapist.
The effects of grief on mental health shows up in therapy offices all the time. Unresolved grief is at the root of 15% of psychiatric referrals (Grief Works, Julia Samuel). Most therapists include grief therapy in their general skill set, while some focus on grief therapy specifically. Some may use one of the approaches described above or below while others might pull together a variety of schools of thought. Regardless of the approach, all beneficial grief therapy shares a common theme of witnessing the client’s grief without judgment or a timeline.
Grief therapy is not required for grieving. It is one tool of many. If you are skeptical about baring your soul to a stranger, consider talking to a physician, therapy-literate friend, or researching online about the pros and cons of therapy. It can be valuable to “shop around” therapists to find one that feels right. Online therapy is also growing and effective. For finding a therapist in the US, check out www.psychologytoday.com. There are also growing options for online therapy, including www.talkspace.com.
The theories below are meant to be loose frameworks for understanding how grief grows and changes. If you find one that intrigues you, consider reading more about it in the links provided. And, if you don’t resonate with any, that’s okay. You are more complicated than any one theory (and there are more than the ones written about here). If you’re frustrated at the whole concept of “explaining” grief, we suggest Megan Devine’s It’s OK That You’re Not OK.
For even more grief theories, check out these on What’s Your Grief: https://whatsyourgrief.com/grief-theories/
Grief Theory: Continuing Bonds
The heart of the continuous bonds model approach to grief is that grieving is not about putting the deceased person in the past and “moving on” to a new life. Grieving is about slowly finding ways to adjust and redefine the relationship with the person who is gone. This allows for a continued bond that changes as you live. Rather than pursuing a linear path towards “closure,” it is normal and healthy to find new ways to engage with the person who is gone. This approach is epitomized in cultures whose customs bring in totems, pictures, names, songs, and memories of the deceased into daily life long after death (check out the movie Coco). Research shows that maintaining relationships with loved ones who have died contributes to more overall life satisfaction in the long term. Continuous bonds can be incorporated into other approaches to grief. What matters is a desire and willingness to…continue the bond!
A few ways to continue bonds with the deceased:
- Share stories about the deceased person with others (old and new acquaintances)
- Eat favorite foods, listen to favorite music, visit favorite places of the deceased
- Incorporate their memory and mementos into significant moments (weddings, graduations)
- Imagine what advice they would give you in challenging situations
- More at the provided link
GRIEF THEORY: Grief Work Theory
(Erich Lindemann, 1940s) and Dual Process Model by Margaret Stoebe and Henk Schut (1995)
The primary text: https://www.ncbi.nlm.nih.gov/pubmed/10848151
Grief work theory is one of the first modern models of grief therapy. Erich Lindemann’s pioneering grief research in the 1940s provided a new foundational understanding of the “tasks” of grief that each person goes through to complete the work of grief:
- Emancipation from bondage to the deceased (i.e. Separating from constant attachment to the deceased – very different from the Continuous Bonds model, see above).
- Readjustment to a new environment in which the deceased is missing. (i.e. Getting comfortable with the new reality).
- Formation of new relationships.
There is certainly some value in other parts of grief work theory; for example, Lindemann cataloged the physical and mental changes that occur in grief and brought attention to the cause of grief work. As grief theory has developed, the following criticisms have been made of grief work:
- The “work” required for moving through the steps is undefined
- There is a lack of sound evidence showing this approach to be universal.
- The steps ignore the agency of the griever in creating their own grief experience.
- There are not enough recuperative breaks.
- It ignores secondary losses.
The Dual Process Model was introduced as a counterpoint to grief work in the 1990s. It posits that grief cycles naturally between the influence of loss-oriented stressors and restoration-oriented stressors. As noted on the What’s Your Grief website:
“Loss-oriented stressors, as DPM defines them, are stressors that come from focusing on and processing the loss of the person who has died and our relationship with that person. This includes everything from looking at old photos, yearning, remembering, imaging what a loved one would say about something, and reminiscing.
Restoration-oriented, on the other hand, has to do with secondary sources of stress and coping. Instead of just thinking about the grief for the person who died, this theory considers the stress of feelings of isolation, having to fulfill tasks that the person who died used to do (like cooking, cleaning, managing finances, etc).”
The “dual” in the process is about the natural oscillation between loss-oriented (confronting the loss) and restoration-oriented coping (avoiding the loss). It is natural and healthy to “take a break” from grieving (or, “find a place to rest in the middle of things,” one of the five invitations.
GRIEF THEORY: 7 Skills from Acceptance and Commitment Therapy
by Steven Hayes, PhD
Steven Hayes, founder of Acceptance and Commitment Therapy, surveyed hundreds of studies around what emotional skills are needed to live with grief. For some, it takes months and for others it takes years. Whatever the timeline, the following seven skills are needed in order to live healthily with grief. The lack of these skills contributes to developing anxiety, trauma, depression, and substance abuse. (Psychology Today article for more information)
7 Steps to move forward with the pain of loss:
1. Acknowledge loss
- Start with a remembrance of some of the positive experiences that cannot now be repeated.
- Embrace feelings of loss
- Numbing ourselves from pain numbs our entire existence and, over time, it means numbing yourself to all kinds of human experience, even the positive things.
- “Be” with your grief for 5 minutes, then 10, then 20, and so on. Pace yourself. After the allotted time period is up, distract yourself. Then, the next time, try for a little longer. “Open your arms to these emotions. It may help to make a list of them and see if over time you are better able to touch the range of feelings.”
- Expand your scope of vision
- Expand beyond painful feelings; do an inventory of what else is there: emotions, thoughts, memory, even the unexpected things. “Welcome reactions that “shouldn’t” belong, life relief, joy, laughter, freedom. These are normal, too.
- Prepare to be overwhelmed
- You may feel numb, crazy, irritated, manic, etc. Your emotions may be a pendulum, but they will not harm you. Step back to see progress over days and weeks, not singularly hard moments or days.
- Watch out for unhelpful thoughts
- Notice self-doubting and self-deprecating thoughts; these are normal too, but not your only thoughts: “I should be over it by now.” “I’m grieving wrong.” “I’ll never get over this.” “Instead of treating them as truths, practice looking at them as reactions to be noticed, not dictates to be followed. If you catch that you’ve been hooked, you can unhook: Try singing such thoughts or saying them very slowly. Recognize that they are there without letting them take control over your actions.”
- Connect with what matters
- Look at the periphery of your immediate grief experience: there is still meaning there. Your pain means you are still alive, and it will also help illuminate what is important to you. Make concrete steps to align your life to your values.
- Take committed action.
- Act. Do. Speak. Volunteer. Address. Express. Create lasting change.
GRIEF THEORY: Narrative Grief Therapy
Dr. O’Malley is a longtime grief counselor and educator based in Fort Worth, TX. Getting Grief Right centers around the idea of approaching loss through the power of storytelling. Using a narrative structure to consider the full past, present, and future of one’s relationship with the deceased becomes a powerful frame for creating meaning out of devastating loss.
O’Malley describes how grief following the death of his infant son influenced his work with clients whose grief stories did not fit into an easy five stages or recognizable path. As a result, he developed a model of narrative therapy that reckons with the lack of closure that stains grief; we grieve because we love, and we continue to grieve as long as we live. There are plenty of case studies in the book to provide examples of how this approach can provide relief.
The book contains a thorough description of the why’s and how’s of pursuing a narrative element in relation to grief. The approach boils down to three “chapters” of a grief narrative. These chapters can be written or spoken aloud during therapy, alone, or in a grief support group:
Chapter 1: Share their story of attachment to the one you lost.
Chapter 2: Talk about the circumstances of death and the immediate aftermath, such as the visitation, funeral, or other mourning rituals.
Chapter 3: Life after loss – that is, the life that is unfolding when you walk through the therapist’s door and the one unfolding for you now. This third chapter will go on for the rest of your life.
The book contains a very helpful appendix with thorough descriptions of how to run a 6-week grief support group. Each meeting includes specific questions for telling a grief story from start to finish. The process of telling one’s story and being witnessed in the telling are powerful tools for finding a space of meaning in an out-of-control situation.
Narrative Grief Therapy: An Overview
The following is a sample structure and questions of each narrative grief meeting.
Meeting 1: Introductions
- Relationship to the person who died
- Why were you drawn to this group?
- What are your expectations?
Meeting 2: Sharing Chapter 1 of the Grief Story – Attachment History
(3 rounds of storytelling)
- Share full story of attachment to person who died
- What did this relationship mean to you? How was the attachment special and unique?
- How did you spend time together?
- What was their greatest joy or sorrow?
- Tell the story of your personality and how it has affected your experience and expression of grief.
- Do you consider yourself methodical or spontaneous?
- Compare and contrast your experience with those of case studies in the book.
- Share your previous experiences with death and in the culture of your family of origin.
- What is your first memory of death?
- Is your family open about expressing loss or morning, or averse to it?
- Does your family have death secrets from previous generations that have created an untold story?
Meeting 3: Sharing Chapter 2 – The Story of the Loss
(3 rounds of storytelling)
- Describe the circumstances of the death
- Sudden or anticipated?
- How did you learn of the death?
- Describe what you remember most about the days and weeks after the death
- Did people gather at your home?
- Was there a service?
- What were the most challenging aspects of your return to daily life?
- Describe the behaviors of others during this time
- Who was there for you during and after the death?
- Who surprised you with their presence or absence?
- How did others, such as acquaintances or coworkers, respond to you in the days and weeks after the death?
Meeting 4: Sharing Chapter 3 – Your Individual Experience
(3 rounds of storytelling)
- Personal changes after the death
- What did you notice about your physical, emotional, and cognitive self?
- What sights, sounds, scents, and touch suddenly remind you of the ones you lost?
- Did you play a specific role with the one who died? Is that a role you now miss?
- Personal expressions of grief (mourning)
- Have you experienced any guilt or regret?
- Have you found ways to be compassionate to yourself? If so, how?
Meeting 5: The Grief Story as It Relates to Your Experience in Your Community
- Looking back, what have been your unmet needs since your loss?
- How often do you hear the name of the one you lost? Is it enough?
- Did you find any comments shocking, offensive, or particularly troubling? If so, how did you respond?
Meeting 6: Review, Summarize, Say Goodbye
- What, if anything, has surprised you about your grief story?
- How would you describe your overall experience with this group?
Grief Theory: The Grief Recovery Model
The Grief Recovery Model (GRM) is a structured approach based on 30+ years of experience and development by John W. James and Russell Friedman. The institute they founded, the Grief Recovery Institute, trains Grief Recovery Specialists around the world in running 8-week grief support groups, 7-week individual treatments, and weekend workshops.
Fundamentally, GRM is based on the idea that unresolved emotions and heartbreak are at the root of “quiet desperation” after a loss – “sometimes feeling good, sometimes feeling bad, but never being able to return to a state of full happiness and joy.” In order to integrate the effects of loss into life (they cite over 40 different kinds of loss, from death to divorce and beyond), one must make deliberate choices to heal the wounds of grief. The resulting recovery path is an action plan: a series of steps aimed at illuminating and healing from incomplete emotional communication. The Grief Recovery Model is related to the grief work model.
Meetings cover a wide range of topics, with specific exercises and homework assignments for each step. Sample exercises and topics of discussion:
- Take responsibility for your reactions. – become an active agent in your grief
- Identify misinformation you’ve been told about grief
- Identifying short-term energy relievers
- Create a “Loss History Graph” to understand your own history and patterns of loss and grief (not just death)
- Gain awareness of incomplete emotional relationship
- Write a “Grief Recovery Completion Letter”
To find a local Grief Recovery Specialist near you: https://www.griefrecoverymethod.com/grief-support-groups
Grief Recovery Specialists (Global): https://www.griefrecoverymethod.co.uk/one-to-one/
The book is quite helpful for grievers looking for actionable exercises.
Grief Theory: Post Traumatic Growth
“For some people, surviving life-changing events can have unexpected consequences. These people found that they felt more resilient, as if they had grown, and had a greater sense of their robustness in the face of adversity – along the lines of ‘If I can survive that, I can survive anything. It also changed their perception of what mattered in life: for most, this meant placing less value on money and status, and more on relationships and the meaning of life. As a result, those people’s relationships tended to deepen and were more satisfying, and they gained a sense of being wiser and more compassionate. Having truly suffered so much, they found that their ability to empathize and sympathize increased, and some experienced spiritual or religious growth as well.” – Julia Samuel, Grief Works
Grief Works contains case studies of grief therapy clients from Samuel’s psychotherapy practice. At the end of the book, she describes the Pillars of Strength: key structures that support grief growth and enable rebuilding. The pillars are:
- Relationship with the deceased
- Relationship with oneself
- Ways to express grief
- Mind and body
Thorough descriptions and exercises of each pillar can be found on their website.
A Post-Traumatic Growth Resource:
Option B by Sheryl Sandberg and Adam Grant
Sandberg and Grant’s website Option B (www.optionb.org) epitomizes the post-traumatic growth model. It is a wonderful and giant resource collection for those going through difficulties in life: grief, loss, divorce, incarceration, illness, abuse, etc. There are stories, essays, and resources for all walks of life. The theme of the site is that regardless of circumstances, we always the ability to grow our resiliency muscles.
And, for proof that there is meaning wherever you make it, look at this Harry Potter grief model: https://whatsyourgrief.com/the-8-horcruxes-of-grief-the-harry-potter-grief-model/
Prolonged Grief Disorder and Complicated Grief Therapy
“Prolonged Grief” is a delineation from the ‘normal’ grieving process, and there is mounting evidence for the case of it being a distinct disorder. (PGD)
The International Classification of Diseases by the World Health Organization describes it as the “persistent and pervasive longing for, or preoccupation with, the deceased that lasts at least six months after loss. In addition, people with the disorder often experience intense emotional pain (such as sadness, guilt or anger), difficulty accepting the death, emotional numbness, a feeling that part of them has been lost, an inability to experience positive mood and difficulty engaging in social activities.”
About 1 out of 10 bereaved people suffer from this.
Although it can be a bit messy to clinically diagnose persistent grief, researchers study have a lot to agree on. The patterns are definitely present. Prolonged grief differs from depression in how people intense longing and preoccupation with memories of their loved one. Depressed people, by contrast, tend to feel muted and sedated, finding it difficult to see value in things.
While identifying this group clearly has been reliable, scientists and therapists are faced with the struggle of identifying Prolonged Grief Disorder in individual, so that they may intervene early.
If you or someone you know may be suffering from prolonged grief, please talk to a professional.
From the APA:
Psychologists and other trained clinicians, including psychiatrists, counselors and social workers, can play a significant role in helping bereaved people move beyond their suffering. “The good news about bereavement is that although it can leave us brokenhearted, it can also break our hearts open to levels of greater compassion. […] And therapists can be in a place to make a great contribution to those positive outcomes.”
Complicated Grief Therapy
Katherine Shear, M.D., Director of the Complicated Grief Program defines ‘Complicated Grief’ in a similar way as to Prolonged Grief Disorder:
“[…]a persistent form of intense grief in which maladaptive thoughts and dysfunctional behaviors are present along with continued yearning, longing and sadness and/or preoccupation with thoughts and memories of the person who died. Grief continues to dominate life and the future seems bleak and empty. Irrational thoughts that the deceased person might reappear are common and the bereaved person feels lost and alone.”
Within Shear’s model, the other three outcomes are:
- Acute Grief – “occurs in the early period after a loss and often dominates the life of a bereaved person; strong feelings of yearning, longing and sorrow are typical as are insistent thoughts and memories of the person who died.”
- Integrated Grief – “the lasting form of grief in which loss-related thoughts, feelings and behaviors are integrated into a bereaved person’s ongoing functioning; grief has a place in the person’s life without dominating.”
- Adapting to Loss – “accepting the reality of the death, including its finality, consequences and changed relationship to the person who died; adapting means seeing the future as holding possibilities for a life with purpose and meaning, joy and satisfaction.”
Diagnosis and Treatment
As with PGD, CG is most often confused with depression. There is solid evidence that treatment for depression is far less helpful than targeted CG treatment so this difference is important.
Shear’s model has a pragmatic, research-tested approach to treatment:
“We use seven core themes in this work, including understanding grief, managing painful emotions, thinking about the future, strengthening relationships, telling the story of the death, learning to live with reminders and remembering the person who died. We work with these themes throughout the 16-session treatment. We use well-defined strategies and procedures. Sessions are structured in a manner similar to CBT. Each session begins with a review of the past week and setting an agenda. We then move to a loss-focused procedure followed by a restoration-focused procedure. The session ends with a brief summary and feedback about how it went and plans for the upcoming week.”
A treatment manual, as well as other therapy aids and resources are available on Shear’s university website, where we sourced this information.
Further Reading on PGD and CGT:
Prolonged Grief Disorder for ICD-11: The Primacy of Clinical Utility and International Applicability
Networks of Loss: Relationships Among Symptoms of Prolonged Grief Following Spousal and Parental Loss
Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11
Complicated Grief Overview for Professionals
Complicated Grief Overview for the Public