Introduction
Bereavement and grief can theoretically affect any person who may experience the loss of a partner, friend, or family member. The latter term is defined as a range of emotions that people experience as a result or in anticipation of the death of a person to whom they are attached (Tucker, 2019). Before the 1990s, it was believed that individuals undergo five stages of grievance: “denial, anger, bargaining, depression, and acceptance,” which were similar to phases that dying people went through (Tucker, 2019, p. 18). Later, researchers and health practitioners realized that this process is not always linear because human beings experience a more comprehensive range of emotions. Therefore, the four tasks of mourning were introduced: accepting loss, refining physical and mental pain, learning to cope new world without the lost person, and moving on with life (Tucker, 2019). The case study that will be analyzed in this paper presents a lady, 40-year-old Nara, who is in grieving after her husband lost the battle with cancer. Since she is depressed and cannot foresee her future life without her soulmate, Nara needs professional counseling to accept and overcome this situation.
Factors That Could Be Impacting the Grieving Person: External Factors
It has been long known that an individual’s quality of life has a significant impact on one physical and mental well-being. According to Breen et al. (2020), chronic loneliness can be considered equivalent to smoking fifteen cigarettes daily in terms of its damage to cardiovascular health. On the other hand, connectedness to others and social help is known to lower the risk of early death by half (Breen et al., 2020). Similarly, people’s response to grief and their ability to handle it depends on the environment that they live in, especially the level of perceived community support (Lavorgna & Hutton, 2019). If a country’s legislation gives workers a short break for bereavement, it will be easier for a person to later return to everyday life. For instance, the United Kingdom and Canada provide grieving parents 2-week paid leave after the loss of a child (Breen et al., 2020). In Australia, active movements have been started to convince the government to pass similar laws (Breen et al., 2020). Still, although external factors are critical in one’s mourning process, internal values and inner strength are essential.
Internal Factors
The strength of bonding with the deceased, individual acquired attachment styles, and personal goals play a crucial role in the severity of grief. Counselors often use Bowlby’s attachment models to understand clients’ mourning (Van Wielink et al., 2019). This theory was initially focused on children’s ability to form strong bonding with their caregivers, but it is believed that the attachment style developed during infancy frequently dominates in adulthood (Garcia & Pomeroy, 2021). An individual with an ambivalent model is more likely to mourn in an excessively emotional way (Garcia & Pomeroy, 2021). A person with an avoidant attachment type will be reserved to express their feelings of grief (Garcia & Pomeroy, 2021). Bowlby hypothesized that mourning occurs in four phases: numbness and denial, searching and yearning, disorganization and desolation, and movement toward reorganization (Garcia & Pomeroy, 2021). Moreover, it is essential to consider such aspects of a person’s life as professional history, family and partner, and occupation influence on values and beliefs (Van Wielink et al., 2019). The knowledge about one’s morals and objectives are essential for classifying stages of mourning and necessary for helping a person overcome this challenge.
Nara’s External and Internal Factors
In the case of Nara, various factors contributed to the woman’s response to the death of her husband. Since she was originally born in Spain, where she obtained an education and had her own social circle, moving to Australia was a difficult transition, even if it was to marry her boyfriend. Since Nara’s husband was supportive, she could adapt, build her career anew, bring her sister and mother to Australia, and she did not have any financial difficulties.
She did not seem to be alone after her husband’s passing because she moved in with her mother and sister. Despite the support and encouragement from her friends and colleagues, Nara cannot picture her life improving. One of the possible reasons of chronic grief was that her husband asked to cremate his body and not to conduct funerals or memorial. Since Nara was raised as a strict Catholic, she suffered emotionally because of inability to help her husband transition to the next life according to her religious beliefs. Therefore, she feels guilty and has a painful sense of longing for her husband, whom she loved even if he was abusive at times and engaged in adultery.
The Impact of These Factors on the Grieving Process
Since people respond differently to challenges, various factors do not have an identical influence on individuals’ grief process. Although definitions of grief exist, it is only what an individual describes it to be because some move on with their lives after the death of a loved one while others are paralyzed (Stebnicki, 2018). Some people are able to find meaning and purpose to overcome grief and conduct a healthy and happy life. At the same time, many individuals continue to agonize and may even develop a substance dependence in the strive to eliminate traumatic memories and guilt (Furr & Hunsucker, 2022). However, since exogenous substances that impact neurochemistry have a temporary relieving effect, these individuals become addicted to alcohol or drug use. The outcome of grief is mainly dependent on protective and risk internal and external factors. Many bereaved individuals desire social and emotional support after a traumatic loss (Cacciatore et al., 2021). Such internal factors as work, education, hobby, volunteering, and spiritual beliefs are considered powerful motivators for people to continue living without being substantially depressed after the death of a loved one.
Nara’s protective factors are her career achievements, but the main risk factors are the lack of family support and her guilt about not conducting proper Christian funerals. Indeed, the case states that she is a professional who seems to be highly recognized by her colleagues. However, her mother and sister, whom she brought to Australia from Spain, are cold towards her grief. Moreover, her strong religious beliefs make her feel ashamed about fulfilling her husband’s will and cremating his body.
Application of a Bereavement and Grief Theoretical Model to Analysis
The concept of grief has long been investigated by philosophers, physicians, and researchers; thus, various theoretical models about this issue are known. Sigmund Freud suggested that pathologic grief develops when a person obsessively concentrates on remembering the deceased loved one (Garcia & Pomeroy, 2021). Lindemann described six characteristics of acute mourning: physical distress, thinking about the deceased, guilt about surviving, anger, functioning decline, and internalization of the traits of the person who died (Garcia & Pomeroy, 2021). Elisabeth Kubler-Ross divided grief into five stages, highlighting that the last phase, acceptance, is essential for people to return to normal lives after losing a family member or a spouse (Garcia & Pomeroy, 2021). David Kessler added the sixth stage, finding meaning, to sustain one’s “love for the person after their death while moving forward” with the life (Garcia & Pomeroy, 2021, p. 5). Worden and Rando viewed grief not as a stagewise process but as a challenge that needs to be resolved through specific tasks that allow to recognize and re-experience the problem, readjusting to life (Hedtke, 2020). Bowlby’s attachment and grief models have been described earlier in this paper.
If some of these models are applied to Nara’s case, Bowlby’s, Kubler-Ross’s, Kesler’s, Worden’s, and Rando’s theories can be implemented in her situation. Since Nara’s grievance had likely started when her husband received a terminal diagnosis and left her work for six months to care for him, this client seems to be in the fourth stage, depression. Nara is still functional and is able to perform routine tasks and job duties; however, she is evidently traumatized by this loss because she cannot even spend a night in their old apartment. Therefore, the goal of therapy would be to help Nara transition to acceptance and find meaning using task-based technique. Although the case did not mention the quality of her relationships with her parents during childhood, Nara describes her mother as abusive and unsupportive, which may suggest that the client has an insecure attachment style. Furthermore, according to the scenario, it appears that she suffers alone, not revealing her emotional challenges to her circle and small family, but she still ruminates about the deceased excessively.
Bereaved people often need counseling to help them understand and accept their situation. Since grief is a multidimensional phenomenon, it is essential for counselors to accurately identify the form of its expression in a client (Beaunoyer et al., 2020). For example, Nara seems to be reserved in showing her emotions, but at the same time, she is devastated and depressed. Some individuals are able to outgrow the trauma of loss and become even more resilient, and this scenario is known as posttraumatic growth (Rogalla, 2020). However, Nara could not cope with this problem alone, even if end-of-life care was provided to their family. Indeed, Nara had appropriate physical and emotional support while caring for her terminally ill husband. The goal of palliative care is to improve the patient’s quality of life and provide psychological aid to the family (Breen et al., 2019). Still, an individual plan to help Nara find another meaning and purpose after her husband’s passing is needed.
The Client’s Grief Response
Before starting an intervention, it is essential to determine how the client responds to grief. The pathognomonic characteristics of acute grief include somatic distress, preoccupation with the image of the deceased, hostile reaction, guilt, and loss of function (Worden, 2018). The response of the bereaved can be classified into four groups: feelings, sensations, behaviors, and cognitions (Worden, 2018). Physical symptoms include muscle weakness, stomach pain and hollowness, tightness of the chest and throat, dry mouth, fatigue, and lack of energy (Worden, 2018). In this case, Nara feels guilt for not organizing a proper burial. Furthermore, she has developed such somatization symptoms as constant stomach pain and weight loss. At the same time, she is traumatized to the point that she cannot stay in their old apartment for a long time because her husband spent the last six months of his life there.
Although the client is aware that her grief has become pathologic, she claims that her life will not be better anymore. It indicates that Nara understands her situation, but the client is unable to accept it yet because she is still emotionally connected to her husband, who died four years ago. In fact, according to Harris and Winokuer (2019), grief itself is an adaptation response to someone’s death. Even if it may be painful and paralyzing for the bereaved, it is critical to reassure clients that their feelings and thoughts are normal (Harris & Winokuer, 2019). The only thing they need to do is learn how to live without the deceased with the help of counseling, therapy, and social support.
Plan for Therapy
Since this client’s mourning became chronic, it is essential to offer both counseling and therapy. The loss of a significant other is considered one of the most stressful events, possessing “a higher risk for developing a complicated grief” (Zuniga-Villanueva et al., 2021, p. 13). The death of a spouse may designate the loss of self-worth for those who associated the deceased with their own identities (Zuniga-Villanueva et al., 2021). Since determining the client’s attachment model will help find a proper approach to Nara, the four types need to be defined. Firstly, people with a secure attachment style can create meaningful relationships and are “able to navigate through grief with support and normal coping mechanisms” (Harris & Winokuer, 2019, p. 33). Secondly, avoidant personalities try to use distraction and business to cope with grief (Harris & Winokuer, 2019). Thirdly, individuals with an ambivalent attachment model think about the deceased excessively, and loss usually occupies all aspects of their lives (Harris & Winokuer, 2019). Fourthly, disorganized types may drift between asking for support and complete isolation (Harris & Winokuer, 2019). From the case’s description of Nara’s behavior, she has an ambivalent attachment style.
Goals for Counseling
The primary goal of counseling when working with clients undergoing grief, the primary goal of counseling is to help these individuals understand their feelings, accept the situation, and find a new purpose to continue living. It is also crucial to assist Nara in the detachment process from her deceased husband, which may be painful, considering her ambivalent attachment style. Although the five stages of grief became a classic representation of mourning, these phases “were more like descriptors rather than a prescription to follow” (Harris & Winokuer, 2019, p. 36). Thus, the task-based model will be utilized to help Nara overcome this challenge.
Suitable Counseling Techniques
The task-based technique developed by Worden involves four essential tasks that the client needs to be guided through during counseling sessions. Firstly, it is vital to assist the mourner in acknowledging the reality of the loss (Harris & Winokuer, 2019). The second task is to assess the pain of grief, and the client needs to be reassured that feeling anger, fatigue, sadness, and distress after the death of a loved one is normal (Harris & Winokuer, 2019). Thirdly, a counselor should help the bereaved adjust to living in the world without the deceased by refocusing one’s attention on other people or activities (Harris & Winokuer, 2019). The fourth task is to find an appropriate spiritual place for the deceased to occupy in the mind of the bereaved while the latter continues one’s journey in life.
Although Nara continues to work, she does not socialize and claims that she cannot imagine herself in a new relationship. It is critical to recognize and respect her feelings and wishes by offering the options of adopting a pet or engaging in community work. Since Nara is a strict Catholic, she may be convinced to conduct the funeral and memorial, burring the ashes of the deceased. The proper ceremony may relieve her guilt and give the client a sense that her husband finally attained peace.
Additional Support
Apart from the client’s friends and colleagues, the additional aid for Nara can be provided through group therapy, peer support, and digital resources. For example, in Australia, the grassroots movement known as Sorry Business offers befriended models of emotional help to mourning individuals (Breen et al., 2020). Furthermore, Nara can be referred to grievance support on social media or particular websites. Mental health professionals usually monitor these online groups; hence, they may give additional advice to the bereaved (Worden, 2018). Lastly, by engaging in group therapy, Nara will be able to find people with issues similar to hers, resulting in creating a new network that may contribute to her emotional healing.
Monitoring Progress and Evaluation
Even though grief is often described in the literature as a five-phase process, it is critical to understand that it is not a linear event that terminates suddenly. Instead, it is a gradual condition that may cycle; thus, the bereaved requires continuous monitoring and support. Nara will be recommended to create a digital journal that can be accessed by the counselor, too, so that her progress can be evaluated. One’s resilience and ability to withstand or outgrow trauma are mainly dependent upon individual well-being, social connectedness, life satisfaction, and external empowerment (Garcia & Pomeroy, 2021). Monitoring the client’s progress should involve continuous reassurance that Nara belongs to a specific niche in this society and that her work is meaningful for her company and colleagues.
Conclusion
In summary, grief counseling is a complex process due to the multifaceted nature of the problem. Various theories were developed to understand and describe mourning by such thinkers and clinical psychologists as Freud, Bowlby, Lindemann, Kubler-Ross, Kesler, and Worden. The case of Nara can be considered chronic grief because her husband passed away four years ago, but she continues feeling guilt and having somatic symptoms. The goal of counseling for this client will be to help her accept the death of a significant other and find strength to start a new life without him. This objective can be attained through a task-based technique, group-based therapy, and online support. Conducting a proper burial ceremony for the remnants of her husband’s cremated body should be proposed to the client to relive her spiritual suffering. Lastly, Nara’s progress should be monitored, and she needs to receive additional empowerment about her place in the community.
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