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Grief Perspectives
Scholar's Corner
Resource Review
Your Professional Library

When Grief is
"Just One More Thing"

by William G. Hoy
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 assessingpotential 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,,, 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,, 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 (1), 43-59.
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
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.

Resource Review
While we often talk about the importance of evidence-based practices and the value of staying abreast of new developments in the field, one wonders exactly how a busy professional caregiver ever finds the time to “keep up?” This is a fair question. The database to which I have access through the Baylor University Library indexed 1,942 articles in peer-reviewed journals on the keyword “bereavement” published in 2017 alone. This number could be easily multiplied if one expands the search terms to include “end-of-life care” and other related words. Is it any wonder we are drowning in a sea of information?
In this column, I have often recommended subscribing to the alert services of the important journals in the field. However, that can still overwhelm one with content. So, as I receive in my email box those journal alerts (usually in the form of the table of contents from the newest issue), I scan them for the sub-specialties in which I am most interested. I speak and teach often on issues related to ceremonies, cross-cultural awareness, end-of-life spiritual issues, and complicated grief so I pay particular attention to those articles. I am learning how to better ignore articles outside my interest area.
The following journals are some of my favorites, the ones to whose free alert service I subscribe. By unsubscribing from those I do not continue to find useful, I can add new journals of interest, never allowing the number of journal alerts to which I subscribe exceed a dozen or so; even this many results in one or two email “alerts” most weeks.
Journal of Illness, Crisis, and Loss
Journal of Loss and Trauma
American Journal of Hospice and Palliative Medicine
Journal of Religion and Health
Death Studies
Omega: Journal of Death & Dying
Members of the Association for Death Education & Counseling do not need to subscribe to Death Studies and Omega at the publishers’ websites. Members automatically receive these tables of contents when new issues are published, along with free online access to the journals as a standard member benefit.
Your Professional Library
Lukas, S. (2012). Where to start and what to ask: An assessment handbook(enhanced edition with audio CD). New York: Norton.
The “first interview” with a person one intends to help always proceeds with two goals in mind, social worker Susan Lukas asserts: that the client’s story is heard in his or her own words and that the client perceives that his or her beliefs are understood by the counselor. Most books I have read and classes and workshops I have attended on “assessment” discuss the primary goal as getting “the facts;” Lukas seems to think that we will get all the facts we need if we will attend to these two more basic goals.
The author begins this most helpful book to introduce the psychotherapeutic assessment appointment. From this philosophical framework, she provides hundreds of strategies, considerations about counseling room furniture and layout, and assessment questions, all arranged in chapters on interviewing adults, children, couples and families. Interspersed throughout are helpful chapters on assessing for suicidal and homicidal ideation, considerations on the medical status of the client, assessing for substance abuse and sexual abuse, and many other important issues.
Written for students as they prepare for the first field placement, the book provides dozens of practical ideas and new insights of help to experienced clinicians. Though its first edition was published 25 years ago, it is still a fine, practical resource.
Research that Matters
Wall‐Wieler, E., Roos, L. L., & Bolton, J. (2018). Duration of maternal mental health‐related outcomes after an infant's death: A retrospective matched cohort study using linkable administrative data. Depression and Anxiety, 35(4), 305-312. doi:10.1002/da.22729
The Anxiety and Depression Association of America ( focused its April 2018 issue of its journal, Depression & Anxiety, specifically to the mental health of women and children; this research study fits nicely into the theme. A child’s death is a known risk factor for complicated grief especially for mothers. However, measuring the actual prevalence of distress has been an elusive project.
Canada’s national health care system yields incomparably rich health data because every citizen’s records are linked through the system. These researchers at University of Manitoba were able to link data on every Manitoban with specific health data. After de-identifying the data, they were able to include in their cohort every mother and child born in Manitoba over a 12 year period. This provided a means to conduct a whole-population study on every birth and to examine the medical responses of mothers to any infant deaths (birth to one year) during the period. Then, the researchers were able to compare mental health diagnoses, treatment, and pharmaceuticals prescribed for the non-bereaved mothers and the bereaved mothers. In typical studies of this type, data is based on sampling techniques and self-report measures.
When comparing all the available data, the researchers found that mothers who suffered the death of an infant were five times more likely to be diagnosed with depression than the non-bereaved mothers. When examining the medical records, researchers found that the increases in depression remained high during the first year and then returned to baseline soon after. While the bereaved mothers had significantly higher levels of anxiety, these differences appear to be in the six months prior to the child’s death. This might be related to the infant’s impending death, perhaps due to known birth anomalies at or soon after death and the mothers’ awareness of the likelihood their child would die.
Clearly, a study like this has significant limitations in that all data was collected from population and medical records. Though medical utilization is likely higher in Canada because of universal care, mental health diagnoses do not tell the whole story on bereavement distress. Only a portion of bereaved mothers would meet the diagnosis for a mood disorder or anxiety disorder and physicians do not always conduct a thorough assessment using accepted clinical criteria to make that diagnosis before prescribing an antidepressant or anxiolytic medication. It is significant, however, that the mental health symptomatology did seem to return to baseline levels by the end of the first year in the majority of cases, lending support to the critical nature of support in the first year after an infant’s death.
GriefPerspectives is published monthly by Grief Connect, Inc. Copyright ©2017. All rights reserved, including publication or distribution in any form, electronic or printed. For reprint permissions or suggestions for content, please email us at
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