|Loss is no respecter of persons, and as such, often comes to those for whom there is already a long list of psychological issues and relational difficulties. A significant loss will almost undeniably make worse a pre-existing Panic Anxiety Disorder, Major Depression, or Generalized Anxiety Disorder. Substance abuse can be intensified after a loss and common sense indicates that a physical abuse-characterized relationship is likely to be made worse in the emotional upheaval of early grief.
While these issues are important in assessment for therapeutic services, they become essential to uncover in the screening process before people attend bereavement support groups and participate in other supportive activities implemented by non-clinicians (Hoy, 2016). I have resolutely held for years that non-clinicians provide incredibly important peer-support services for grieving people and nothing has changed my conviction about the role of volunteers in these roles.
However, an increasingly complex mental health environment and a continued narrowing of services to people who are clearly psychologically disabled means that bereavement support centers, faith communities, hospices, and schools have increasingly taken referrals for people with bereavement issues complicated by significant pre-existing psychopathology. This underscores my long-held conviction that bereavement volunteers should be supervised by experienced professionals with a deep understanding of psychopathology. As a matter of practice at the hospice bereavement center where I provided clinical and program oversight for more than 15 years, we implemented a policy for a clinician to pre-screen potential support group participants.
Here are some important considerations for assessing and addressing these problems. The first three are specifically about assessing
potential issues and the last three are about addressing
them, though most would agree that the therapeutic dialogue always involves elements of both.
Inquire about previous counseling experience
. One question I like to ask in my initial phone interview with a caller is whether she has had experience with a counselor before. This simple question often reveals long-standing struggles with depression, anxiety and other potentially grief-complicating concerns. Follow-up questions about when those conversations occurred, who the therapist was, what the nature of the “problems” were, and how they were resolved can provide rich insight into the potential client’s appreciation for mental health services as well as preliminary data about the nature of pre-existing diagnoses and treatment.
Hear the client’s description of the pre-loss emotional life
. One vital area of discussion in the screening and assessment phase of therapy focuses on how the client perceives his/her emotional life to have been before the loss and how things have changed. The answer to this question has often revealed a long history of abuse, addiction to substances and details about attachment disorders that reach back to early childhood. In response to my simple question, “Would you tell me a little about how things were emotionally for you before your mom died?” one client responded by saying, “I was never able to measure up to her standards.” Obviously, this response invites a follow-up prompt such as, “Please tell me more…”
Investigate the client’s use of medications
Today’s mental health professional absolutely must have an understanding of pharmacology, and fortunately, internet tools make this easier than ever. In addition to being aware of the trade and generic names of the common psychotropic medications (antidepressants, tranquilizers and anti-psychotics), mental health practitioners need to also be aware of common cardiac, endocrine and anti-hypertensive medications, since their use can often complicate emotional regulation. In addition to getting to know a local pharmacist on whom you can rely as a “consultant,” you may want to consider keeping a link on your smartphone and desktop computer to trusted sources like epocrates.com, drugs.com, medscape.com, or MedlinePlus. There are also courses on psychopharmacology available in live seminars and online training programs. Our job is not to become pharmacists or physicians but to better understand the factors that complicate bereavement (Patterson, Albala, McCahill & Edwards, 2010).
Assume a holistic approach to care
. In my History of Medicine course, students discover that holistic care has been waxing and waning in medicine for about 2,500 years; the Greek physician, Hippocrates is the first we know to have specifically addressed it. Sadly, many healthcare professionals reach first for the prescription pad when dealing with a patient with some likely mental health condition such as depression or panic anxiety, sometimes without even a thorough assessment. Of course, we might ask exactly how a physician is supposed to thoroughly assess a patient’s physical and psychological symptoms in a visit lasting between five and ten minutes.
Equally important is remembering many psychological symptoms are made better or worse by diet, exercise, spiritual practices, sleep and other lifestyle choices. Assuming a holistic approach to care means realizing that massage, chiropractic care and nutritional counseling can be as important and effective as any other intervention in helping reorient the body’s natural healing properties. Therapists must always cultivate relationships with holistically-minded physicians, clergy, health and wellness consultants, and practitioners of complimentary models of healthcare treatment (such as massage, guided imagery in music, and acupuncture with their evidence-based research findings).
Utilize solution-focused strategies where appropriate
. Solution-focused grief therapy helps clients develop a desired vision for a future where the presenting problem is solved, and as such, tends to focus much more on the present circumstances of the client’s life than long-term, historical issues. At first glance, this appears to be counter-intuitive when a bereaved person presents with specific diagnosed mental health conditions. Solution focused approaches do not ignore the client’s history or pain, but rather, allows the therapist to join with the client to create a pathway to his or her intended goal (well-being) by building on client strengths, resources and cognitions. Even when using outside resources, the client takes the lead in defining which resources will be used and how they will be useful (Trepper, et.al., 2010; Walter & Peller, 1992).
Maintain good supervision and collegiality
No amount of experience in counseling is sufficient preparation to allow one to provide “Lone Ranger” service. Instead, therapists who have grown in the wisdom of
experience attest to the importance of finding one or more colleagues with whom to discuss cases and provide mutual learning. Counselors with less experience always benefit from ongoing supervision, even after the necessary period of supervision leading to licensure or certification is ended.
Therese Rando (1992/93) suggested more than 25 years ago that the onslaught of complicated grief was just beginning and her words now seem clearly prophetic. In a world of growing need and shrinking resources, counseling with people experiencing loss is difficult work. Effectively working with people whose grief is deeply complicated by pre-existing psychopathology is especially so.
Hoy, W.G. (2016). Bereavement groups and the role of social support: Integrating theory, research, and practice
. New York, NY: Routledge.
Patterson, J.E., Albala, A.A., McCahill, M.E. & Edwards, T.M. (2010). The therapist’s guide to psychopharmacology: Working with patients, families and physicians to optimize care, revised edition.
New York: Guilford.
Rando, T.A. (1992/93). The increasing prevalence of complicated mourning: The incidence is just beginning. Omega, 26
Trepper, T.S., McCollum, E.E., De Jong, P., Korman, H., Gingerich, W., & Franklin, C. (2010). Solution focused therapy treatment manual for working with individuals.
No city: Solution-Focused Brief Therapy Association. Accessed free from http://www.sfbta.org/researchDownloads.html
Walter, J.L. & Peller, J.E. (1992). Becoming solution-focused in brief therapy
. Leviitown, PA: Brunner/Mazel.
Wiger, D.E. (1997). The clinical documentation sourcebook
. New York: John Wiley & Sons.
The Author: For more than three decades, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide effective care. After a career in congregation, hospice, and educational resource practice, he now holds a full-time teaching appointment as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas.