1. Module 5: Grief Counseling
Lindsey Parrish, L.M.S.W.
Licensed Master Social Worker
Palliative Care Team-Saint Joseph’s Hospital, Atlanta, GA
Unit 9: End of Life Care

2. Objectives: Provide overview of theories of grief counseling
Review Worden’s 7 Mediators of Mourning and 10 General Grief Counseling Principles
Describe “complicated grief”
Identify, by developmental age, ways in which children both understand death and grieve
Unit 9: End of Life Care

3. Introduction to Grief Counseling
“Grief,” derived from Latin gravis
Multidimensional response to loss
Emotional (“Feelings”)
Physical
Cognitive
Behavioral
Unit 9: End of Life Care

4. Theories of Grief Counseling
Stages model: Kubler-Ross (1968)
Phases: Bowlby (1980), Parkes (1972), Rando (1988)
Tasks: Worden (1982)
Dual-Process Model : Stroebe and Schut (1999)
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5. The Mediators of Mourning
Grief Counseling
The Mediators of Mourning
(Worden, 2002)
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6. Mediator 1: Who the Person Was
Grief Counseling
Mediator 1: Who the Person Was
Mediator 2: The Nature of the Attachment
Strength of the attachment
Security of the attachment
Ambivalence in the relationship
Conflicts with the deceased
Level of dependence
Mediator 3: Mode of Death
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7. Mediator 4: Historical Antecedents
Grief Counseling
Mediator 4: Historical Antecedents
Grief baggage from previous losses?
Mental health hx?
Mediator 5: Personality Variables
Age and gender
Coping style
Attachment style
Cognitive style
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8. Mediator 7: Concurrent Stresses
Grief Counseling
Mediator 6: Social, Cultural, Religious Factors
Social network
Cultural expectations?
Religious rituals
Mediator 7: Concurrent Stresses
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9. 10 Grief Counseling Principles and Procedures for Acute Grief
(Worden, 2002)
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10. Help the Survivor Actualize the Loss
Grief Counseling
Help the Survivor Actualize the Loss
Help the Survivor to Identify and Experience Feelings
Assist Living Without the Deceased
Help Find Meaning in the Loss
Facilitate Emotional Relocation of the Deceased
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11. Interpret “Normal” Behavior Allow for Individual Differences
Grief Counseling
Provide Time to Grieve
Interpret “Normal” Behavior
Allow for Individual Differences
Examine Defenses and Coping Styles
Identify Pathology and Refer
Unit 9: End of Life Care

12. When is grief “finished? “
Grief Counseling
When is grief “finished? “
Stages
Phases
Tasks
Dual-Process Model
Importance of education of pts / families during grief counseling re: expectations (i.e. return to pre- grief state?)
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13. Grief Counseling
“Complicated grief”
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14. Worden’s classifications (2002)
Grief Counseling
Overview
3 categories of distinguishing symptoms (Hooyman & Kramer, 2006)
Worden’s classifications (2002)
Chronic grief reactions
Delayed grief reactions
Exaggerated grief reactions
Masked grief reactions
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15. Prolonged Grief Disorder (aka Complicated Grief, Complicated Bereavement)
Criterion A: Yearning, pining, longing for the deceased. Yearning must be experienced at least daily over the past month or to a distressing or disruptive degree.
Criteria B: In the past month, the person must experience four of these eight symptoms as marked, overwhelming, or extreme.
1. Trouble accepting the death
2. Inability trusting others since the death
3. Excessive bitterness or anger about the death
4. Feeling uneasy about moving on with one’s life (e.g., difficulty forming new relationships)
5. Feeling emotionally numb or detached from others since the death
6. Feeling life is empty or meaningless without the deceased
7. Feeling the future holds no meaning or prospect for fulfillment without the deceased
8. Feeling agitated, jumpy or on edge since the death
Criterion C: The above symptom disturbance causes marked dysfunction in social, occupational, or other important domains.
Criterion D: The above symptom disturbance must last at least 6 months.
J Pall Med 2006;9:
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16. Newly Recognized Disorder: Detect, Refer and Stay Up to Date!
Prolonged Grief Disorder (aka Complicated Grief, Complicated Bereavement)
Newly Recognized Disorder:
Detect, Refer and Stay Up to Date!
Unit 9: End of Life Care

17. Special Considerations: Grief and Children
“How adults respond when someone loved dies has a major effect on the way children react to the death. Sometimes, adults don’t want to talk about the death, assuming that by doing so children will be spared some of the pain and sadness.
However, the reality is very simple: children will grieve, anyway.”
--Dr. Alan D. Wolfelt
Director, Center for Loss and Life Transition
Fort Collins, Colorado
Unit 9: End of Life Care

18. Special Considerations: Children & Grief
How Children Understand Death:
Newborn to 10 months (Infant): Security linked to touch, warmth, scent, and manner; will have to adjust to new faces & voices in environment; cannot comprehend meaning but will perceive changes and negative stimuli as routines changed and interrupted
10 months to 2 years (Babies): Can recognize adults; major growths in memory, language, socialization; cannot conceptualize or understand death, but will experience loss of attachment to primary caregiver
2 to 5 years: (Children): Egocentric, curious, very literal interpretation of their world; use facts and reality, not vague or indirect language, death perceived as temporary state (“sleeping”) and deceased will awaken at some point. Use words: totally, not, very, very….,
6 to 9 years: (Children): Significant cognitive and developmental progress, socially involved, aware of roles, can conceptualize the fact of death, can distinguish fantasy vs. reality, can experience guilt, being able to understand factually does not mean can cope well
10 to 12 years (Preadolescent):Know that death is permanent, grasp significance of rituals, understand how the death occurred, grasp impact of death on them and the family, strong sense of own mortality, may deny the death will change their lives or “don’t care, don’t feel anything”
12 years +: (Adolescent): Sense of themselves and their place in society, death is the complete opposite of everything currently impt. to them , understanding comparable to adult but emotional state full of turmoil and change, reactions vary widely and change abruptly
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19. Special Considerations: Children & Grief
How Children Grieve:
Newborn to 10 months (Infant): Difficult to assess how much infants grieve; do know infants react with distress to loss of primary caregiver; can also sense the distress of those around them; may become cranky, cry often for no apparent reason, and alter eating / sleeping patterns
10 months to 2 years (Babies): May respond to loss and changes with temper tantrums and anger outbursts to express despair / frustration; may search rooms and familiar spots for the lost loved one; decreased interest in toys and food; may revert to infantile thumb-sucking, fetal position
2 to 5 years: (Children): Grief expressed through bewilderment, regressive behavior, ambivalence (“I can’t find my doll”), may be expressed through play in which loss and death themes occur, separation anxiety, forming attachments to other adults who resemble the deceased
6 to 9 years: (Children):Denial the death happened; idealization of the deceased; guilt they caused the death; fearing for survival of remaining caregivers / parents; caretaking of younger siblings
10 to 12 years (Preadolescent): May hold off on any outward signs of grief so as not to be perceived as “different” by their peers; may assume caretaking; uncharacteristic displays of anger; fear may be expressed as physical complaints, moodiness, disinterest in school; may try to collect memories / bond of the deceased (photos, mannerisms, wearing clothing, perfume of deceased)
12 years +: (Adolescent): May band together with friends; might shut down emotions; magnified feelings of cynicism or depression; self-destructive coping mechanisms (poor grades, alcohol); caretaking and increased responsibility, previous teen-parent conflicts with deceased cause guilt
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20. Conclusion and Resources
“Just as there is no one way to mourn, there is not one kind of help that makes grief come to an end. Help is not a matter of providing the bereaved with a clear formula for what to do. The goals of help will vary depending on what mourners feel they need at a particular time and where they are in their grieving process.”
-Phyllis Silverman in Living With Dying (2004)
Remember to meet your patients and families “where they are” in their grief journey.
Stay away from cliches: Your patients and families deserve unbiased assessment and skilled grief intervention, not the cliches they are hearing from everyone else in their lives.
Remember professional self-care: set boundaries, resolve your own grief tasks (possibly therapy), & nurture yourself. Be able to identify professional Compassion Fatigue and seek support.
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21. Resources Unit 9: End of Life Care
The Compassionate Friends:
The Good Grief Program, Boston Medical Center: (
Hospice Foundation of America (
CancerCare, Inc.: (
Family Caregiver Alliance: (
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22. References Unit 9: End of Life Care
Baohui, Z, El-Jawahri, A., & Prigerson, H. Update on bereavement research: evidence-based guidelines for the diagnosis and treatment of complicated bereavement. Journal of Palliative Medicine. October 2006, 9(5):
Berzoff, J. & Silverman, P. (2004). Living With Dying: A Handbook for End-of-Life Healthcare Practitioners. New York: Columbia University Press.
EndLink: An Internet-based End of Life Care Education Program: Social and Psychological Considerations. (
Hooyman, N. & Kramer, B. (Eds.) (2006). Living Through Loss: Interventions Across the Life Span. New York: Columbia University Press.
Kroen, W. (1996). Helping Children Cope with the Loss of a Loved One. Minneapolis: Free Spirit Publishing, Inc.
Wolfelt, A. (1995). Helping Children Cope with Grief. [Brochure].
Wolfelt, A. (1995). Helping Teenagers Cope with Grief. [Brochure].
Worden, J. William. (2002). Grief Counseling and Grief Therapy. New York: Springer.
Unit 9: End of Life Care