Best Practices in Counseling Grief and Loss: Finding Benefit from Trauma

Altmaier, Elizabeth M
Journal of Mental Health Counseling; Jan 2011; 33, 1; ProQuest Psychology Journals
pg. 33

Journal of Mental Health Counseling

Volume 33/Number 1/January 2011/Pages 33-xxx

Best Practices in Counseling Grief and Loss:

Finding Benefit from Trauma

Elizabeth M. Altmaier

Grief may be a primary presenting concern of clients or may form a background to another presenting
concern. In either case, use of best practices in assessing and treating grief is essential. In this article I
review what best practices are in general and in assessment and treatment. I also evaluate ways lo mea
sure grief and describe domains of the grief experience. The article also discusses controversies within
the literature on grief counseling, including the potential for deterioration after treatment. It concludes
with a view of counseling grief that promotes finding benei
f t from trauma.

This special section describes the devastating impact of loss on the life of a
person. However common it may be, loss causes significant individual griev
ing, which in tum can impair emotional, cognitive, and behavioral functioning.
Throughout this special section we have emphasized the difficulties caused by
the crisis of loss and the experience of bereavement, such as the potential of
complicated grief and the special case of parentally bereaved children. We have
also noted the importance of culture-based counseling issues related to grief.
More important, however, is a larger perspective introduced by Harvey, who
defined loss as a "fundamental human experience" (Harvey, 2002, p. 2) from
which we can grow and learn to understand others, help others, and develop our
own courage to live with pain. It is critical to keep this positive view of grief in
mind when considering best practices in counseling those who are grieving
because it treats counseling as facilitating growth rather than simply mending
loss.
In this article I focus on the evidence that underlies assessment and treatment,
and on practices that should be considered in counseling the grieving client.
Thinking of grieving within the context of posttraumatic growth will define
alternative counseling approaches.

Elizabeth M Altmaier is affiliated with The University of Iowa. Correspondence concerning this
article should be directed to Elizabeth M Altmaier, Department of Psychological and Quantitative
Foundations, The University of Iowa College of Education, 360 Lindquist Center, Iowa City, Iowa
52242-1529. E-mail: elizabeth-altmaier@uiowa.edu.

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IMPLEMENTING BEST PRACTICES: FROM RESEARCH EVIDENCE TO

COUNSELING EACH CLIENT

What are best practices? Though the term has been adopted widely, its usage
is not agreed upon-much like terminology related to grief. Concisely, best
practices, a term borrowed from the business world, suggests that there is a par
ticular technique, approach, or method that when used with a particular target
is more effective (reaches its goals) and efficient (uses fewer resources) than
other techniques, approaches, or methods. It also suggests that there are data
available to influence the decision to use this particular technique. Within the
mental health field, other terms that denote a similar emphasis on using data to
make decisions on assessment and treatment are evidence-based practice and
empirically supported treatment.

One approach to understanding best practices is to focus on outcome data

gathered in clinical trials of a particular treatment (empirically supported treat
ments). Many consider these studies to be the best basis upon which to select a
treatment. Advocates of empirically supported treatment argue that although a
treatment is only one of several influences on client outcome, it is the influence
that a counselor in training can most readily learn and the influence that can be
most easily studied scientifically (Norcross, Beutler, & Levant, 2005).
There are two other sources of data to inform treatment choice. One is clini
cal lore-the accumulated experience of many practitioners transmitted
through personal testimony, continuing education, client reports, news cover
age, and so on. Unfortunately, clinical lore has the drawback of promoting
treatments later shown to be ineffective or less effective than alternatives. Fad
diets might be the health counterpart to selection of counseling approaches
predicated on clinical lore.
Another data source is the counselor's own personal clinical experience. A
seasoned counselor can recall similar clients, similar desired outcomes, similar
contexts, and so on-memories that can inform a present treatment decision.
Unfortunately, clinical experience can fall prey to the biases that influence
human memory, such as confirmation bias, which emphasizes previous suc
cesses and overlooks previous failures. Another bias is the availability heuris
tic, where clients who are memorable for any reason are prominent images in
the counselor's memory, while less memorable clients fade.
An alternate view of counseling effectiveness is the primacy of the counselor
within the interpersonal relationship. In this view, treatments are essentially
equal in their effectiveness, but it is whether the counselor is, for example,
warm or rejecting, sensitive or insensitive, astute or ignorant that most influ
ences outcomes. When data are sought to support treatment decisions, the per
sonhood of the counselor is typically overlooked although it accounts for as

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Altmaier I BEST PRACTICES IN GRIEF

35

much of the outcome as treatment. Wampold (Norcross et al., 2005), for exam
ple, argues that overlooking the personhood of counselors in research on best
practices, particularly research that focuses on the treatment as the sole or pri
mary influence on outcome, causes two types of misattribution: First, it inflates
the effects attributed to treatment and thereby creates a false sense of confi
dence in a treatment when the counselor may be the agent for change. Second,
a focus on treatment alone creates an impression that counseling is a package
of techniques that can be delivered impersonally-a gross misunderstanding of
the deeply human enterprise of counseling.
Alternatively, the counselor-client relationship may be the primary source of
influence. Lambert (Norcross et al., 2005) notes that when clients are asked
about their counseling experience in qualitative and retrospective studies, the
relationship with the counselor is typically cited as the primary reason for
change: clients feel understood, valued, appreciated, supported, and so on.
Technique and theoretically based explanations of treatment outcome (e.g.,
change in dysfunctional cognitions) are almost never mentioned.
Last, the fact that clients are active agents in their own improvement and
change cannot be overlooked. Rather than being a passive recipient of a treat
ment, the client elaborates on the insights of counseling outside the session,
works the information and insights into her life, and through self-healing and
self-determination mechanisms creates a medium for effective outcome.
In summary, the background of best practices is important in selecting coun
seling approaches for a grieving client, keeping in mind that there is contro
versy over whether grief counseling is appropriate for everyone, only for
persons seeking treatment, or only for persons experiencing complicated grief.
Moreover, though in general some counseling approaches may seem to be
effective, research should not imply that the personhood of the counselor, the
relationship of client and counselor, or the client's own self-healing processes
are insignificant aspects of change.
BEST PRACTICES IN GRIEF ASSESSMENT

Although grief is a universal phenomenon, it has not been adequately con

ceptualized. As the accompanying articles note, the lack of consistency in
defining grief has led to inconsistency in the development of grief measures. In
what follows I describe the most prominent of these measures. They were cho
sen because they (a) are the most widely used; (b) focus on grief, rather than
broad psychiatric symptoms; (c) assess normal, not complicated, grief; and (d)
consider grief across all possible losses, rather than a specific loss, such as the
loss of a child. (See Stroebe, Hansson, Schut, & Stroebe, 2008, for more com
plete coverage of conceptual issues in the measurement of grief.)

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GriefMeasures
Texas Revised Inventory of Grief (TRIG ; Faschingbauer, Zisook, & DeVaul,
1987). The TRIG, probably the most widely used measure of grief, is a brief
measure with two subscales: Current Grief and Past Disruption. Items, created
based on a review of the literature and the clinical experience of the authors,
contain sentences of personal description to which the participant responds on
a five-point scale (I =completely false to 5 =completely true). Because of the
contrasting temporal nature of the two sections, the developers assert that the
two scores can be used to assess progress in grieving.
Niemeyer and Hogan (2001) summarized the psychometric qualities of the
scale. Internal consistency ranged from . 77 to .87 for the Current Grief subscale
and .86 to .89 for Past Disruption. For the original Texas Inventory of Grief,
Faschingbauer (1981) reported an exploratory factor analysis study in which
items were retained with factor loadings greater than .40. Though there are few
data on validity, the widespread usage of the scale provides considerable com
parative data for users.
From a construct validity perspective, there are several concerns about the
TRIG. The Current Grief subscale contains three items related to crying (e.g.,
"I still cry when I think of the person who died"). There is considerable over
lap of this subscale with depression: items assess sadness, loss of interest in
previously pleasurable activities, irritability, and sleep problems. Finally, the
scale fails to incorporate constructs that have been both theoretically and
empirically associated with grief (e.g., guilt, hearing the dead person's voice).
Grief Experience Inventory (GEi). The GEi was designed to be sensitive to
the longitudinal process of grief (Sanders, Mauger, & Strong, 1985). Items
derived from the literature are presented as self-descriptive sentences to which
the participant responds true or false. Scoring is similar to that of the Minnesota
Multiphasic Personality Inventory: there are three validity scales: Denial,
Atypical Responses, and Social Desirability; nine clinical scales: Despair,
Anger-Hostility, Guilt, Social Isolation, Loss of Control, Rumination,
Depersonalization, Somatization, and Death Anxiety; and six "research" scales:
Sleep Disturbance, Appetite, Loss of Vigor, Physical Symptoms, Optimism
Despair, and Dependency.
Niemeyer and Hogan (2001) summarized the psychometric properties of the
scale. Internal consistency is rather poor, with six of the nine clinical scales
having an alpha coefficient below .70. Sanders et al. (1985) present a factor
analysis with three dominant factors that do not correspond to the scale's struc
ture-the largest factor seems to measure depression. Validity data (Sanders et
al., 1985) reveal that the clinical scales differentiate between bereaved and non
bereaved persons and yield higher scores for persons who indicate they are
having difficulty accepting the loss of the loved one.

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Altmaier I BEST PRACTICES IN GRIEF

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Core Bereavement Items (CBI). Burnett, Middleton, Raphael, and Martinek

(1997) describe their CBI as a "scale of core bereavement items that could be
used to assess the intensities of the bereavement reaction in different commu
nity samples of bereaved subjects" (p. 51). Their items were formulated from
focus interviews with recently bereaved adults and a review of the literature.
After selecting 76 items, the authors used factor analysis to narrow the pool to
seven subscales. Validity studies further reduced coverage to 17 items in three
subscales: Images and Thoughts (e.g., "Do images of the lost person make you
feel distressed?"); Acute Separation (e.g., "Do you find yourself missing the
lost person?"); and Grief (e.g., "Do reminders of the lost person, such as pho
tos, situations, music, places, etc., cause you to feel a longing for him or her?").
Items are responded to on a four-point frequency scale with anchors indicating
increasing frequency.
Niemeyer and Hogan (2001) report reliability and validity data for the CBI;
coefficient alpha was estimated at .91 for the scale as a whole. Middleton et al.
(1998) noted the following validity data: bereaved parents scored higher than
bereaved spouses, who in turn scored higher than bereaved adult children.
There are no factorial validity data.
Hogan Grief Reaction Checklist (HGRC). The most recent scale (Hogan,
Greenfield, & Schmidt, 2001) was explicitly intended to "delineate normal
grief' (p. 2) and in particular to avoid blurring grief with symptoms like depres
sion or anxiety. Hogan et al. also used an empirical method of scale develop
ment, obtaining and analyzing interview data from bereaved adults, to identify
six categories: Despair, Panic Behavior, Blame/Anger, Disorganization,
Detachment, and Personal Growth. Initially focus groups analyzed items that
were then given to a community sample of adults who had experienced the
death of a family member. Factor analysis revealed six factors that corre
sponded to the initial categories; items with loadings of .40 or greater were
retained.
Hogan et al. (2001) present alpha coefficients ranging from .79 to .90 for the
subscales and .90 for the whole measure. They suggest using a total score for
the 61 items. However, although this scale is presented as useful for general
grief, the final set of instructions pertains to the death of a child for parents
rather than as a general grief measure.
In assessing grief it is important to remember that no single measure captures
all its manifestations. Counselors might well consider assessing domains of
grief rather than the general concept of grief because clients will have differing
experiences and may well be expressing their grief within different domains
across time.
Schoulte and Altmaier (2008) analyzed grief measures to identify a consen
sus of domains that encompass the experience of grief. After a thorough review

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of the literature that yielded all relevant inventories, superordinate grief

domains and definitions were determined via qualitative content analysis of all
items on these inventories (see Table 1 )
.

Table 1. Grief Domains and Definitions

Domain

Definition

Physical symptoms

Somatic and physiological reactions

Cognitive difficulties

Difficulties remembering, learning, or thinking

Uncertainty over future

Loss of meaning of life and pessimism about the future

Not accepting the loss, with responses including shock

Denial

and numbness
Interpersonal interaction

Changes in interpersonal reactions, needs, and

relationships

Emotional response
Injustice of loss

Range of internal feelings related to the loss

Frustration over the loss, feeling as though the loss was
not deserved, shattered assumptions of a "just world"

Symbolic rituals

Behaviors with symbolic meaning an individual may

engage in during the grieving process

Continuing bonds

Continued emotional, cognitive, and behavioral links with

the deceased

Benefit finding

Positive changes about the self as a result of the

experience of loss

One approach to grief assessment is for the counselor to assess each domain,
either through clinical interviewing, published measures, or client self-reports.
The use of diaries, journaling, and drawing can supplement the experience of a
particular domain in addition to measures or conversation. In any assessment,
client reactions should be normalized because there are socially perceived bar
riers to showing grief.
As Schoulte describes (above, pp. 11-20), cultural context is also necessary
to assessment. Inquiring about social and cultural expectations is a fruitful way
to transition to discussing the influence of family and culture. Questions as sim
ple as "What do you think your family's expectations are of you at this time?"
can help a client explore what may be hidden influences on the grief experi
ence.
BEST PRACTICES IN THE TREATMENT OF GRIEF

Is grief counseling effective? Although intuitively it would seem that provid

ing a supportive environment in which to grieve-in the presence of an
empathic counselor, with gentle encouragement to consider the role of the
deceased in the client's life-would promote adjustment, there is controversy
about how effective grief counseling is. Larson and Hoyt (2007) have summa
rized the empirical evidence for and against it. Two particular sources of

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Altmaier I BEST PRACTICES IN GRIEF

39

concern for them are the possibilities of a deterioration effect after treatment
and of a minimal positive outcome.
Two researchers who conducted meta-analyses have argued that clients who
received grief counseling may end up worse off than they began: Fortner
(1999) cited a rate of 37% of clients deteriorating after treatment; Niemeyer
(2000) found a similar rate, 38%. Larson and Hoyt (2007) studied the two meta
analyses in detail and concluded that the rates of deterioration found were based
on a statistic that may have been defined erroneously. Specifically, Fortner
(2008) notes that an error in his dissertation text may have led to confusion
about the calculation of the deterioration rates he cited.
A second criticism is that the outcomes of grief counseling, expressed as an
effect size, are not large enough to warrant confidence in such treatment.
Reviews considered by Larson and Hoyt (2007) established an effect size (.11
to .43) lower than the .80 typically obtained in estimates of counseling outcome
(see Wampold, 2001, for discussion). Schut, Stroebe, Van Den Bout, and
Terheggen (2001) concluded that "based on the evidence to date, outreaching
primary prevention intervention for bereaved people cannot be regarded as
being beneficial in terms of diminishing grief-related symptoms, with a possi
ble exception for interventions being offered to bereaved children" (p. 731).
Taking this perspective, however, ignores the four views of the influence on
counseling effectiveness previously discussed. The current controversy rests on
the treatment technique alone; what is not known are outcome effects attribut
able to the person of the counselor, the characteristics of the client, and their
relationship. The widespread acceptance and promotion of groups such as
Compassionate Friends (for suicide survivors) and online groups such as
MyGriefSpace.net suggests that at least some grieving persons find support
from compassionate others to be of help.
There is preliminary evidence that persons with complicated grief may
achieve better outcomes than clients with normal grieving responses. Shear,
Frank, Houck, and Reynolds (2005) compared two treatments for complicated
grief, interpersonal therapy and a new treatment for complicated grief. This
new treatment focused on ways in which to "retell" the stories associated with
the loss so as to reduce distress and increase positive memories. Both treat
ments produced improvement in the target symptoms of complicated grief
(assessed by an inventory of complicated grief), but the new treatment was
found to be more effective.
Overall, the best conclusion regarding the efficacy and effectiveness research
on grief counseling is that the matter is still unresolved. Considering solely the
treatment, which is the basis of outcome research in this area, yields a conclu
sion that counselors should continue to strive to provide counseling to persons
in need while gathering data on effectiveness and efficacy. The Association of
Death Education and Counseling has posted a statement on research efficacy

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and the findings related to deterioration that promotes this balanced approach
(ADEC, 2008).
INTERVENTION STRATEGIES

One way for counselors to begin thinking of grief counseling strategies is to

utilize the perspective described above on the domains of influence on client
outcome. Because of the importance of the personhood of the counselor, in this
section I consider first qualities that ensure that a counselor will be an effective
helper for grieving persons. (Here I rely heavily on the thoughtful writings of
the director of the Center for Loss and Life Transition, Alan Wolfelt [1998].) A
framework for those qualities consists of empathic presence, gentle conversa
tion, available space, and engaging trust. Within empathic presence are quali
ties of listening, silence, and support. Many grieving persons will need to tell
and retell stories associated with the loss. Empathic listening, accepting and
encouraging the expression of feelings, and allowing pain to be expressed
freely are critical.
Gentle conversation avoids cliches and easy answers. Telling grieving clients
that they will "get over it," "better days will come," or "the darkest hours are
just before dawn" is demeaning. The best response may be "I am sorry. Tell me
more about it." A gentle conversation allows opportunities for remembering.
Memories can be encouraged through pictures, drawing, and other expressive
modalities.
Counselors should strive to provide available space for the client. Helping
the client find support and encouragement from other sources as well as coun
seling is also critical. Time itself is important. Because grieving does not fol
low a predictable trajectory, counselors will need to be patient.
Last, engaging trust communicates to the client that she has the ability to
recover and grow. Grieving clients may not see a future without the loved one,
may not have confidence that they will ever be free of their feelings, or may
feel overwhelmed by the demands of everyday life. Communicating a trust that
continues to engage the client in the tasks of grief is essential. Using books that
allow clients to have their own journey through grief may be helpful; Wolfelt
(1997) is an example.
Most writers about grief counseling do not propose techniques per se. Rather,
the best technique or treatment may be a different view of the relationship
between counselor and client. Wolfelt ( 1998) argues that certain treatment goals
are misguided, among them treating grief as a syndrome to be eliminated, pro
moting the client disengaging from the deceased and terminating the relation
ship, having the client finish a series of tasks, using a recovery or resolution
model to suggest a return to the pre-loss state, considering grief as a life crisis
where balance can be re-achieved, and failing to attend to the spiritual aspects

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Altmaier I BEST PRACTICES IN GRIEF

41

of grief. Companioning for these goals involves several tenets, Wolfelt says,
including learning from the client, discovering the gift of silence, and listening
with the heart (Wolfelt, 2007).
Using this perspective focuses the counselor on facilitating client grieving
needs (Wolfelt, 1997). These needs form a structure for the relationship, but
meeting them is not a linear or "led" process. Rather, within the relationship
with the counselor, maintaining a companioning model helps the client to meet
the needs of "acknowledging the reality of the death, embracing the pain of the
loss, remembering the person who died, developing a new self-identity, search
ing for meaning, and receiving ongoing support from others" (p. 2). Meeting
these human needs will lead to healing and reconciliation, what Wolfelt
describes as "the new reality of moving forward in life without the physical
presence of the person who died" (p. 135).
CAN GRIEF COUNSELING PROMOTE GROWTH?

In their research on trauma and growth, Tedeschi and Calhoun (1995)

described characteristics that make an event traumatic: being sudden, unex
pected, and uncontrollable; and producing continuing, sometimes lifelong,
effects. A recent interest in psychology has been to examine the positive rather
than the pathological aspects of human functioning. Research suggests that
through times of hardship, stemming from stressful life events or trauma, indi
viduals have experienced "benefits" or have grown. Posttraumatic growth
(Tedeschi & Calhoun, 1995) has been defined as experiencing positive growth
following traumatic life events.
An increasing number of studies have begun to examine positive psycholog
ical outcomes of trauma. Linley and Joseph (2004) found that posttraumatic
growth has been documented in a wide variety of human events: cancer, the
Oklahoma City bombing, sexual assault, plane crash, and combat. Of particu
lar interest is a study by Davis, Nolen-Hoeksema, and Larson (1998) in which
persons who lost a family member to death were interviewed before and after
the loss. The authors considered two ways participants thought about the event:
making sense of the loss (e.g., the participant accepted the death as fate or
God's will) and finding something positive in the experience (e.g., improved
family relationships). Those participants who either found benefit or made
sense of the loss were less distressed six months after the death and experienced
better adjustment.
Coping strategies may influence which individuals adjust better during and
after trauma. Psychosocial coping resources may protect against depressive
symptoms, and social support (perceived or actual) is thought to enhance psy
chological well-being by fulfilling the need for a sense of coherence and
belonging, thus counteracting feelings of loneliness (Bisschop, Kriegsman,

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Beedman, & Deeg 2004). Relationships between coping and posttraumatic

growth have been reported. In Tedeschi and Calhoun's posttraumatic growth
model ( 1995, 2004), coping plays an important role in the ability of individu
als to adjust after a traumatic event and ultimately experience and perceive
growth. In a review of coping and posttraumatic growth among cancer patients,
Stanton, Bower, and Low (2006) identified eight studies that used multiple cop
ing strategies. They found that posttraumatic growth was more commonly asso
ciated with approach-oriented coping strategies (e.g., active acceptance) than
avoidance strategies.
Spirituality and religion also play major roles in how individuals cope with
trauma and adversity. Both have been linked to a range of positive health out
comes, including reduced depression and lower risk of substance abuse (Larson
& Larson, 2003). Pargament, Koenig, and Perez (2000) found that individuals
cope differently depending on their perception of God, other spiritual beings, or
religion. The trend toward understanding spirituality and religiosity as a
resource in traumatic situations has prompted the need for further research on
how religiosity impacts such phenomena as coping and posttraumatic growth.
The spirituality of individuals experiencing traumatic events has been found
to change as a result of the events (Tedeschi & Calhoun, 1995, 1996; Tallman,
Altmaier, & Garcia, 2007). Such spiritual or religious changes are thought to be
a major component in changes in the life perspectives/philosophies growth
domain. In a study of women who survived sexual assault, individuals reported
becoming more spiritual (Kennedy, Davis, & Taylor, 1998), and increased spir
ituality was related to increased well-being after the assault. Tedeschi and
Calhoun (1995) state that "the degree to which religious beliefs can help sur
vivors assimilate traumatic events and grow from their difficulties seems a
promising area for investigation" (p. 117).
Finding benefit is a significant outcome for grieving clients. Whether indi
viduals are assisted in finding benefit through expressive approaches (King &
Miner, 2000; Smyth & Pennebaker, 2008), where participants write about their
trauma or their emotions; "benefit reminding" approaches (Tennen & Affleck,
2002); or enhancement of active coping (Antoni et al., 2001) may not be as
important as simply having the client participate in a process where meaning
found through grieving is articulated and integrated into her overall view of the
loss.
CONCLUSION

This article and others in this section have had as the overall goal the descrip
tion of ways counselors can effectively conceptualize, empathize with, respond
to, and assist a grieving client-much-needed but very difficult work. Indeed,

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Altmaier I BEST PRACTICES IN GRIEF

43

counselors who work regularly with grieving clients can suffer from compas
sion fatigue or even secondary traumatization. However, the promise of coun
seling with grieving clients is the possibility of impacting a person in both the
present andthe future, and perhaps also improving the health and well-being of
the client's children and other family members. It is not a task to be taken
lightly. In her memoir of the year after her husband's death, Joan Didion (2006)
writes of her ambivalence over her recovery from grief:
I did not want to finish the year because I know that as the days pass, as January becomes
February and February becomes summer, certain things will happen. My image of John at the
instant of his death will become less immediate, less raw. It will become something that hap
pened in another year .... I know why we try to keep the dead alive: we try to keep them alive in
order to keep them with us. I also know that if we are to live ourselves there comes a point at
which we must relinquish the dead, let them go, keep them dead. Let them become the photo
graph on the table. (pp. 225-226)
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