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Support Therapies

Different approaches to bereavement support and counselling

So your GP or friend says they think you should have counselling- but how do you know where to go, and which approach is best for you?

Many bereavement support organisations have a team of volunteers, usually co-ordinated by a paid staff member or nominated volunteer. Usually volunteers are trained ‘in house’ and provided with internal supervision. They will possibly have personal experience of bereavement, and /or will be interested in supported others through this process. Often these volunteers will be carefully trained to listen with empathy and unconditional positive regard, providing a space for people to talk, share and reflect. Counselling can feel like a formal approach to what may be a natural life event, and often, it is bereavement support, rather than counselling that is required. It is all about creating a space where you can feel safe enough to talk through and process what has happened with someone who is not emotionally involved, so that you do not internalise your thoughts and feelings.

Sometimes bereavement volunteers will be counsellors or counsellors in training. Your counsellor will have been trained at college or university in how to work with people in particular ways based on a variety of theoretical models and approaches. Qualified counsellors or therapists should be registered with the British Association of Counselling and Psychotherapy or the UKCP, United Kingdom Council of Psychotherapists. The BACP has a useful website with information on different types of therapy and a directory where you can find independent, BACP registered counsellors close to you.

Often people come to counselling because they feel stuck or overwhelmed, are experiencing physical symptoms or have relationship difficulties, memories or worries. Sometimes just one session can be all you need, alternatively these issues may take some time to work through, and then regular reviews within your sessions are a good idea to check that you are both on track and making the progress you had hoped for, and if not looking at why.

Monitoring or outcome tools can be useful measures so that you can see for yourself how you are doing in comparison, for example, to six sessions previously.

Support and counselling is not for everyone, lots of people utilise workplaces, friends, family, community groups, websites or other resources for support- but if you are thinking of accessing it- it can be helpful to understand more about the different types. Here we look into some of the different approaches to help demystify the process.

Person-Centred Therapy:

The Person Centred approach often forms the basis of bereavement support training. Founded by Carl Rogers, a basic premise is that we are all "becoming;" we are all moving towards self-actualisation. Rogers believed that each of us has the innate ability to reach our own unique full potential. As infants we are born with this ability, but because of early experiences, we may lose our connection to it. The self-concept that we develop in response to our early experiences may tend to alienate us from our true self. In this theory there is no such thing as mental illness. It is just a matter of being disconnected from our self-potential. This therapy is often considered the most optimistic approach to human potential.


This often lengthy therapy is based on developing the client-therapist relationship. The therapist is to provide the conditions necessary for the client's growth: genuineness, unconditional positive regard, and empathic understanding. To be genuine the therapist must strive to be transparent and open. There is no hiding behind expertise or degrees. Therapists must be constantly doing their own inventory. Unconditional positive regard is synonymous with acceptance and appreciation of the client for who the client is in the present. Empathic understanding is based on the therapist's ability to see the world through the client's eyes, to move into the client's world at the deepest levels and experience what the client feels. If the process works, the client moves back toward self-actualisation.

Person centred therapy works on the assumption that people are capable of working out their own solutions once they have gained recognition of their own potential to do so. That no matter how defeated a person seems to be, there is a human instinct to survive, and have the potential for success.   

In both his therapeutic and his research work Rogers used a phenomenological approach in his attempts to understand human behaviour.  He tried to unravel the difficulties or perceiving reality through another person’s eyes.  His early work was known as non-directive psychotherapy.  This was based on the idea that the counsellor cannot decide the directions in which people should change and develop, or impose their own frame of reference or belief system onto their client, but should instead help clients explore their needs from their own point of view, and help them to discover their own directions. 

Rogers was holistic in his thinking, believing that humans are innately good and that they are growth orientated.  A person who is functioning effectively and well is an adaptive organism, changing to meet new situations in the most satisfying ways and moving towards higher and higher levels of actualisation and becoming a ‘fully functioning person’.

  In bereavement support, the person centred approach often works well because it enables the client to find their own, authentic way through their grief and re-establish their core sense of self from which they can continue to self-actualise and grow without judgement or anothers agenda. It provides a unique opportunity to be heard, valued and validated in such a healing environment, that strong therapeutic bonds are often made and then worked with carefully when the time comes to end.

The presence of the core conditions is fundamental to the person centred approach. There are 6 core conditions, and 3 better known ones.

Congruence or genuineness as it is sometimes referred to means that the counsellor must be real; that is, they are genuine, integrated and authentic during therapy.  What the counsellor is feeling on the inside is conveyed on the outside, i.e. the body language matches what the counsellor is saying and thinking. They can openly express feelings and attitudes that are present in the relationship with the client.  This facilitates honest communication with the client. This does not mean that the counsellor should share all feelings with the client or self-disclose. Self disclosure from the counsellor is not often encouraged as it takes the focus of the work from the client.



Unconditional positive regard or acceptance is the communication to the client a deep and genuine caring for him or her as a person regardless of their individual circumstances or belief system.  This caring is unconditional, in that it is not contaminated by evaluation or judgement of the clients feelings, thoughts or behaviour, be it good or bad.  The message the counsellor conveys to the client is I accept you as you are.  This can be challenging for the counsellor, if the client has very alternative views to themselves, however UPR can be achieved through application of true empathy.


Empathy is one of the main tasks of the counsellor.  It is more than reflecting back to the client, it is a genuine connection, a sense of personal identification with the client’s experiences.  Counsellors are able to share the client’s subjective world by tuning in to their own feelings that are like the client’s feelings.  It is important however that the counsellor does not get lost in their client’s world.  He must keep his own separateness and identity for change to occur, with one foot in the client’s world, and another foot firmly in their own.

All of the core conditions interlink and enable each other, over time it becomes for the counsellor a way of being, and you can often sense counsellors that are predominantly person centred in their approach.

Integrative

Increasingly, counsellors are being trained to work integratively. That is that they have been trained to use a variety of models and approaches that they can use autonomously with clients as is felt to fit best with the presenting issue at the time, in consultation with the client and their supervisor. Often the main approaches taught to counsellors working integratively are the Person Centred approach, Cognitive Behavioural Therapy and Psychodynamic.

Cognitive Behavioural Therapy or CBT

The use of CBT is bereavement support has only just started to be researched in more recent years. CBT in the use of complicated grief disorder (now included in the Diagnostics and Statistics Manual V as a medical disorder) is said to be an effective treatment.

CBT is often a short term, usually between 8 and 20 session, approach to working with a client’s presenting issues. In its purist form, a robust assessment of the client will be undertaken, followed by an agreed formula of goal setting and a treatment plan. CBT work is focused and reviewed in every session. The client is seen as the expert in their lives, and the therapist as an expert in their approach.

Currently, the National Institute for Care and Excellence (NICE) recommend CBT in various forms (self-help, computerised, 1-1, Intensive Applied Psychological Therapy or IAPT, Mindfulness Based Cognitive Therapy or MBCT) as an effective tool for adults with depression and relapse prevention (NICE, 2013). Commissioners of health care services are understandably favouring therapeutic models with evidence based research that reports effective outcomes through randomised controlled trials in a shorter term framework, which traditionally have been based on the application of CBT as recommended by NICE. More recently, and of particular interest to the author, is the introduction of newer interventions being commissioned, such as the Counselling for Depression (CfD) programme currently being delivered by local Any Qualified Providers (AQP), an eight week counselling programme conceptually based on person centred approach whilst working within a short term framework (BACP, 2015)

This interesting development has seen CBT, which for some time has been considered a short term fix for longer term issues that can enable someone to live an active and fulfilling life without going into psychoanalytical or relational counselling for years, being teamed up with a person centred approach- perhaps because some of the key concepts in both are more similar than widely acknowledged within the counselling field, or perhaps, due to financial implications of the cost of providing counselling to an increasing population of people with mental health issues accessing support.

There are as many similarities in the key concepts between CBT and Person Centred approaches as there are differences. And if the intent of the practitioner is to be working in the best interests of the clients as per the BACP ethical framework, the more tools a practitioner has in their tool box, the more likely they will be to find the right one for their client in any moment of time. There is perhaps no right or wrong, no one approach ‘better’ than another, simply different ways of working with different people in any given moment.

Mindfulness

Mindfulness is a buzzword in counselling and helping professions at present. Encouraging people to live in the here and now, rather than worry about the past or future, can help us to stop catastrophizing, ruminating, or looking outside our selves for answers. Training ourselves to have the ability to live in the moment is said to increase appreciation, or at least acceptance, for life as it is. There is some research to indicate that mindfulness in bereavement can be an incredibly useful and empowering tool.Sameet Kumar’s book Grieving Mindfully (2012), is a gentle exploration of the use of mindfulness during the grieving process.

New ‘3rd wave’ CBT approaches such as Mindfulness Based Cognitive Therapy (MBCT) are also becoming increasingly popular, with Mark Williams’s book and accompanying CD ‘Mindfulness- Finding Peace in a Frantic World’ still sitting on the bestseller Amazon list after a considerable amount of time. Jon Kabbat Zinn, in his book with Mark Williams, ‘Mindfulness Based Cognitive Therapy for Depression’ reports how publications of books on mindfulness have gone from 0 in 1980, to nearly 400 in 2011. (Kabbat Zinn, 2012).

MBCT links undisputedly to Carl Rogers’s concept of the locus of evaluation, whereby the therapist facilitates an environment within which a client may find their frame of reference or locus of evaluation for the very first time, and can be incredibly powerful. Combining simple CBT concepts, such as identifying ‘hot thoughts’ and encouraging the thinking around these, or confronting difficult situations with meditation and mindfulness techniques offers both CBT and opportunity for person centred growth in a very phenomenological and often life changing way. These concepts of CBT and meditation / mindfulness are not new, but they are being presented perhaps in a different combination, with a new energy and with a positive intent that is certainly gaining interest and can be of use to individuals

Solution Focused Therapy

Most psychotherapy begins in a way that seems to make intuitive sense. Clients describe their problems and therapists question them for a better understanding, client and therapist then discuss the predicament, and the therapist tries to help the patient develop alternatives. Yet many psychotherapists find that concentrating on failures and inadequacies in this way can make clients feel worse rather than better, at least in the short run. If the focus on shortcomings and mistakes continues, the client’s self-esteem may decline and the situation may deteriorate.

Clinicians in growing numbers are now trying to avoid this problem by using different approaches such as solution-focused therapy, which do not fit perfectly into any of the classical psychotherapeutic categories. Solution Focused Therapy is neither exclusively supportive nor exclusively exploratory and insight-oriented. Originally developed by the Family Therapy Centre in Milwaukee, it uses methods largely adapted from the work of Milton Erickson using systemic theory and tools such as socratic questioning.

Solution-focused therapists make a special point of asking clients to describe as fully as possible what they believe their lives would be like without the problem for which they have sought therapy. It can be that many clients are so preoccupied with their presenting issues that they have not given much thought to this question. A related question, designed to encourage clients by helping them evaluate their progress, is, "What is the smallest sign that would prove to you conclusively that you were getting better?"

Questions are asked, such as, "What do you want different as a result of coming here?" The idea is to help the client generate a description of what will be different when the problem is solved. Sometimes, client goals include statements about what they want others to do differently. In order to help clients return focus to themselves and their own role in creating the solution, therapists ask questions about what others will notice the client doing differently when the things are better, or what the client can do differently to help the other person do or not do whatever the problem is. The miracle question is often asked in order to help develop such thinking and goals, the full miracle question is:

"Suppose a miracle happened tonight while you were sleeping and the problem ... was solved by tomorrow morning. Assume, too, that you did not know that the miracle had happened because you were asleep. What is the first thing you would notice that would tell you that things were better? What would others notice about you that was different that would tell them you were doing better?"

One reason for the increasing popularity of this approach is its simplicity. No complex theory is involved, and the method is easy to understand and learn. Manuals and case studies are readily available. Some critics regard the approach as simplistic, but proponents believe it shows the value of making few theoretical assumptions in psychotherapy. Furthermore, the short-term emphasis characteristic of solution-focused therapy is becoming more acceptable in psychotherapy than it used to be. Another reason for the popularity of this technique is the growing conviction that psychological problems can often be solved without investigating their origins.

This approach could be useful in working with bereavement by helping clients to explore outside of their current world, and perhaps without the physical supporting presence and dialogue of the person that has died. It may not be useful in the early days of bereavement when it can be difficult to feel what is beyond the death of the person they love and miss- and the very miracle or solution they wish for may be the person returning to them, which of course cannot be the case. However every person, bereavement, and circumstance is different, and this may well be an approach that works for your particular client in a particular moment.

Psychodynamic

The Psychodynamic approach to therapy was pioneered by Freud almost 100 years ago. Today, a psychodynamic counsellor facilitates a client’s insight and understanding by linking the past and present, In particular they will focus on child development and stories as well as the current and personal history of the adult client. 

The moving to a clearer understanding of what led a client to have a particular problem in the first place is a central goal because a painful situation in the present may have its roots in the past, however the individual may not be aware of the connection. Psychodynamic counselling assists a person to uncover these hidden links, which in turn it is hoped allows a client greater freedom of thought, choices and action.

It is believed in psychodynamic counselling that human beings have a tendency to repeat patterns of behaviour, and even when they would like to change they find themselves unable to do so as it can be embedded within the unconscious processes of the mind. These patterns may repeat themselves in the counselling room, this is seen as being helpful, as it is felt that this will enable a client to look at their behaviour and relationship patterns without fear of rejection in the safety of the therapeutic relationship. 

Psychodynamic counselling can be a useful approach in bereavement helping clients to make sense of their patterns of behaviour, responses to loss, and making informed choices for the future. Psychodynamic counselling can often take time to work through, and because of this, is not very often funded by commissioners.

Transactional analysis

Transactional Analysis or TA is influenced greatly by psychoanalytic theory, it sees personality as comprising three ego states - parent, child and ego.  This corresponds with the id, ego and superego from Freud’s psychodynamic theory.  It is literally an analysis of our transactions with each other. 

TA offers the idea that each person writes the script of his or her own life story, the process starts at birth and the question -who am I?.  This approach places a high priority upon understanding the process whereby we make early decisions, which continue to influence our thinking, feeling and behaviour into adulthood- and how certain conditions can trigger us into different ego states.

A structural analysis of an individuals ego states enables the person to understand their behaviour and change it in a way which will give them greater control or choices in their life.

In bereavement counselling, understanding the ego states, and the transactions that we make with each other in life, can enable a client to understand their relationships and how we place ourselves within our world.

Gestalt

Gestalt Therapy: This term was first used as the title of a book in 1951, written by Fritz Perls,et.al. The therapy did not become well known until the late 1960's. "Gestalt," a German word meaning "whole," operates as a therapy by keeping the person in what is known as the here and now. Therapists help clients to be attentive to all parts of themselves: posture, breathing, methods of movement, etc. Unresolved conflicts are worked out in the therapy session as if they are happening in that moment. An emphasis is placed on personal responsibility for one's own well-being through being as aware as possible at all times of one's interactions with the environment. This usually lengthy therapy is accomplished by the therapist asking questions and suggesting experiments which will increase the awareness and sensitivity to the many parts of the client's total self.

The aim of this therapy is to raise awareness of how the client functions in their environment.  Essential to the gestalt view of the self, is the observation that people define, develop and learn about their ever-changing selves in relationship to others.  The person-to-person relationship is now widely recognised as a principle component of healing across the field of counselling and psychotherapy.

The focus of therapy is the here and now, the past is gone and the future has not happened.  Past events are looked at in the now, i.e. when recalling something from the past it is felt in the present and explored in the now, e.g. when I think about my childhood I think of it as an adult, I do not regress back to my childhood.

Perls  suggests that we tend to cling to our past in order to justify our willingness to assume responsibility for the present.  By remaining in the past, we can play endless games of blame for the way we are therefore never really facing our own capacity to move in new directions.   

Unfinished business or unexpressed feelings are often those such as rage, resentment, anger, grief, pain, anxiety, guilt or abandonment, particularly in bereavement.  These are all powerful feelings, but are not always fully experienced in conscious awareness.  This often leads to unsatisfactory contact with the people around us.  Each time the person attempts to meet the related original need they mail fail over and over again, since it is based, unknowingly perhaps on the original experience of failure.

One window into seeing if people are accepting responsibility for themselves is in their use of language.  Perls emphasised that carelessness in speaking results in limitations or orientation and of action, and encouraged appreciation for the power of the word.  Our choice of words and sentence construction if reporting and representing our inner world.  The way we speak is often an accurate reflection of our inner process.  Even apparent mistakes as Freud pointed out, often bring to consciousness aspects to which we may not have paid attention.  In our use of language we can deny or assume responsibility and reinforce a position of powerlessness or self-direction from moment to moment, e.g. ‘you make me so angry’ could become ‘I feel angry when you do that’.   

Having explained what some of the aims of Gestalt Therapy are, you might still be wondering how therapists achieve all this.   The therapist will use a lot of different techniques to bring awareness to the forefront for their client.

One popular method is the two-chair technique.  The client is required to play all the roles of a scenario alone, either by acting each part in turn or in the form of dialogues between the various parts (including physical props).  Other methods are imagery, body works and awareness, immediacy, use of props such as stones or drawing, bat and cushion and the list goes on.  It is suggested that the main limit to Gestalt counselling is the counsellor himself and his or her lack of imagination.  The overall aim is, by bringing elements into the open, people are able to identify and integrate the various diverse parts of themselves and thereby achieve an individual gestalt. 

Aspects of gestalt therapy should be used with caution when working with bereavement, as inviting a client to take on the role of a deceased person can be incredibly powerful and emotive.

Adlerian:

Named after its founder, Alfred Adler, it is also called individual psychology. Considered the first "common sense" therapy, the basic premise is that human beings are always "becoming," that we're always moving toward the future, and our concerns are geared toward our subjective goals rather than an objective past. We are constantly aiming towards what Adler calls superiority. When we have unrealistic or unattainable goals, this can lead to self-defeating behaviours and discouragement which may foster neurosis, psychosis, substance abuse, criminal behaviour, or suicide. The role of the therapist is to help the client identify mistaken goals, and to help the client do away with self-centeredness, egotism, and isolation, and to develop positive, meaningful interpersonal relationships. Generally, a long term therapy, sessions involve the therapist listening and questioning towards the goal of knowing the client as fully as possible, so that the therapist can feedback the faulty objectives and behaviours of the client, enabling further more informed choices.Adlerian therapy can be useful in bereavement as part of the search for or reconnection with a self of self.

You can begin to see that there are many similarities between just the few models we have looked at here. One of the themes that threads through them all is the relationship between the counsellor or therapist and the client, and the facilitation of a space for the client to connect with their core self. Sometimes the approach that you receive as a client will be determined by the service provider you are receiving support under, and sometimes, you might be in a position to choose what work you would like to undertake in persuit of wellbeing.

Always feel that you can ask your bereavement volunteer or counsellor about the way they work or the training they have had and how they can help you. Sometimes, it can take a little while to find the right person for you, or you might feel you connect immediately, every support person and counsellor has their own unique background, just as you will. Relationships can take time to establish, so it can be worth giving something a try even if you are not sure how it will work for you.

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