This approach to intervention addresses the varied levels of need in bereavement and the way in which the Range of Response to Loss model can be used to determine a support or therapeutic focus.
Three theoretical starting points for all levels of working with bereaved people:
1. A person-centred approach as a way of being respectful / non-judgemental, genuine and empathic with help seekers (Rogers 1980)
2. A narrative approach in which the story of loss is attended to by addressing the events and circumstances of the loss, its impact on the bereaved person, and how they can engage with these facts to find meaning in their experience (Angus and Hardke 1994).
3. A systems approach in which the wider relationships and social networks are explored to understand the roles and responsibilities of the bereaved and the (potential) support they provide ( Shapiro 2001).
Figure 1. Four levels of intervention (based on the NICE guidance 2004)
Level 1. General bereavement support and sign-posting to information and useful practical services where the grief reactions are normal.
i) Provide information about the nature of grief.
ii) Check the emotional mood of the bereaved person and how they are coping with the loss and its consequences. Reassure about the normality of grief or if necessary refer on.
iii) Discuss resources which might be helpful e.g. self-help groups, faith groups, community/ social groups, Citizens Advice Bureau etc.
Level 2. One -to-one or group engagement with grief needs where grief reactions or circumstances require some additional support. This may be determined by assessment.
i) Explore the story of loss; what happened -when and how, the impact on the bereaved person, how they are coping practically and emotionally and making sense of their loss.
ii) Explore how the grief of the bereaved person is understood and supported by the people around them, family, friends. colleagues etc. What support are they having to provide for other people?
iii) Explore the ways in which emotional and social adjustment have to be made to the death of someone of close.
iv) Encourage the bereaved person to recognise the ways in which they are coping well e.g. managing new tasks, gaining confidence etc
Level 3. Focused therapeutic work where the bereaved person demonstrates vulnerability and requires more intense support in coping with the consequences of their loss. A pluralistic approach is one which can effectively engage with the individual needs of bereaved clients by using appropriately different therapeutic concepts and methods ( Cooper and McLeod 2011; chapter 7 – Machin 2014). (See Table 1. Summary of the therapeutic journey)
i) Set Goals with the bereaved person i.e. engage with their aspirations. Goals may be revised or adjusted as therapeutic work progresses. (See Figure 2. An overview of the tasks needed to embrace the diversity of grief responses and nurture resilience.)
Fig. 2. An overview of the tasks needed to embrace the diversity of grief responses and nurture resilience.
ii) Prioritise the tasks which are appropriate for each individual, based on what still needs to be achieved in acknowledging the loss, processing the pain, adjusting to life without the deceased or finding a new life direction.
iii) Use methods which will bring feelings and functioning into balance and promote resilience. (See Fig. 3. The RRL as a guide to intervention)
Table 1. Summary of the therapeutic journey (Machin 2014)
Fig. 3. (below) provides a therapeutic strategy which first attends to the external factors which may produce vulnerability or resilience, and then focuses on facilitating a balance between feeling and functioning grief reaction and aligning them with the tasks of coping with the practical, emotional, social and meaning-making consequences of loss.
Fig. 3. The RRL as a guide to intervention (Machin 2014)
Level 4. Complex grief reactions and needs requiring skilled psychological intervention from experienced practitioners.
i) A focus on particular psychological symptoms e.g. anxiety, depression, suicidal tendencies etc.
ii) Approaches set out for level 3, above, may also be used to address deep seated grief issues and longer term support needs.
Angus, L. and Hardke, K. (1994) Narrative Processes in Psychotherapy, Canadian Psychology, 35: 190-203
Cooper, M. and McLeod, J. (2011) Pluralistic Counselling and Psychotherapy. London: Sage.
Machin, L. (2014) Working with Loss and Grief. London: Sage (2nd edition)
National Institute of Clinical Excellence (NICE) (2004). Improving Supportive and Palliative Care for Adults with Cancer. London.
Rogers, C. (1980) A Way of Being. Boston, MA: Houghton Mifflin.
Shapiro, E.R. (2001) ‘Grief in Interpersonal Perspective: Theories and their Implications’, in M.S. Stroebe, R.O. Hansson, W. Stroebe and H. Schut (eds) Handbook of Bereavement Research. Washington, DC: American Psychological Association. pp.301-27.