Grief Counseling and Grief Therapy

329 Pages·2008·1.81 MB·English

by  J. William Worden

PRAISE FOR GRIEF COUNSELING AND GRIEF THERAPY

“The fourth edition of this book retains all the theoretical strengths and clinical
wisdom of past editions, while incorporating emerging theories and cutting-
edge research. It is required reading for any counselor, educator, or researcher
who wishes to understand grief.”

—Kenneth J. Doka, PhD, Professor, The Graduate School, The College of
New Rochelle; Senior Consultant, The Hospice Foundation of America

“[If] you knew Worden’s work and his writings previously, you’ll fi nd an en-
hanced book with a much broader and challenging perspective than his previ-
ous editions. If you are not familiar with Bill Worden, then it is time to begin.”

—Ben Wolfe, MEd, LICSW, Fellow in Thanatology, Program Manager/Grief
Counselor, St. Mary’s Medical Center’s Grief Support Center, Duluth, MN;
Past President, Association for Death Education and Counseling

“This book challenges how we conceptualize the experience of grief and the
process of mourning, it informs how we assess those experiencing problems in
adjusting to loss, and it guides our treatment approaches. I can’t think of a thing
Worden has missed.”

—Stephen Fleming, PhD, Department of Psychology, Faculty
of Health, York University, Toronto, Ontario, Canada

“Simply stated, you will not fi nd a better book to guide you in assisting people
struggling with the myriad of issues following a death.”

—Donna L. Schuurman, EdD, CT, Executive Director,
The Dougy Center for Grieving Children & Families

Praise for Earlier Editions

“This book is the ‘Bible’ for those involved in the fi eld of bereavement work. . . . It
is a straightforward, tightly focused, practical, soundly reasoned, compact work-
ing text.”

—William M. Lamers, Jr., MD, The Lamers Medical Group

“[Worden] has again provided mental health professionals with a superb guide
describing specifi c . . . procedures that may be helpful in working with bereaved
clients undergoing normal or abnormal grief reactions . . . [An] extremely prac-
tical book and an invaluable resource.”

—Contemporary Psychology, now known as PsyCritiques

J. William Worden, PhD, ABPP, is a fellow of the American Psycholog-
ical Association and holds academic appointments at the Harvard
Medical School and at the Rosemead Graduate School of Psychol-
ogy in California. He is also co-principal investigator of the Harvard
Child Bereavement Study, based at Massachusetts General Hospital.
Recipient of fi ve major NIH grants, his research and clinical work
over 40 years have centered on issues of life-threatening illness and
life-threatening behavior.
His professional interests led him to become a founding member
of the Association of Death Education and Counseling and the Inter-
national Work Group on Death, Dying, and Bereavement. A pioneer
in the hospice movement in the United States, Dr. Worden was on the
advisory board for the fi rst hospice in the United States in Branford,
Connecticut, as well as the Hospice of Pasadena, California. He has
been a consultant to various research projects across the United States,
including “Women and HIV” for Columbia University, “Assisted
Suicide and End-of-Life Decisions” for the American Psychological
Association, and “Fathers’ Experience With Pediatric End of Life
Care” for the University of California, San Francisco. He served for
7 years on the national board of the American Cancer Society and is
active in the society at the state and local levels.
Dr. Worden has lectured and written on topics related to terminal
illness, cancer care, and bereavement. He is the author of Personal
Death Awareness and Children & Grief: When a Parent Dies, and is
coauthor of Helping Cancer Patients Cope. Grief Counseling & Grief
Therapy: A Handbook for the Mental Health Practitioner has been
translated into 11 foreign languages and is widely used around the
world as the standard reference on the subject. Dr. Worden’s clinical
practice is in Laguna Niguel, California.

Grief Counseling and
Grief Therapy
A Handbook for the Mental
Health Practitioner

FOURTH EDITION

J. William Worden, PhD, ABPP

New York

Copyright © 2009 Springer Publishing Company, LLC

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or trans-
mitted in any form or by any means, electronic, mechanical, photocopying, recording,
or otherwise, without the prior permission of Springer Publishing Company, LLC.

Springer Publishing Company, LLC
11 West 42nd Street
New York, NY 10036
www.springerpub.com

Acquisitions Editor: Sheri W. Sussman
Production Editor: Julia Rosen
Cover design: Mimi Flow
Composition: Apex CoVantage
Book cover photo: Celestino Garcia

08 09 10 11 12/ 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Worden, J. William (James William)
Grief counseling and grief therapy : a handbook for the mental health practitioner /
J. William Worden. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8261-0120-4 (alk. paper)
ISBN 978-0-8261-2456-2 (int’1 ed.)
1. Grief therapy. 2. Mental health counseling. I. Title.
[DNLM: 1. Counseling—methods. 2. Grief. 3. Psychotherapy—methods.
WM 55 W924g 2008]
RC455.4.L67W67 2008
616.89'14—dc22 2008016551

Printed in the United States of America by Bang Printing.

To my children, Michael and Karin
And my grandchildren, Abigail Ann and Andrew William
May these thoughts be helpful to you one day.

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Grieving allows us to heal, to remember with love rather than pain.
It is a sorting process.
One by one you let go of things that are gone
and you mourn for them.
One by one you take hold of the things that have become a part of
who you are and build again.
—Rachael Naomi Remen

Happiness has gone out of our lives;
Grief has taken the place of our dances.
—Lamentations 5

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ix

Preface xiii

Introduction 1
What Is the Nature of Complicated Bereavement? 1
Disenfranchised Grief 2
Continuing Bonds 3
Meaning Making 4
Resilience 5
Trauma and Grief 6

1
Attachment, Loss, and the Experience of Grief 13
Attachment Theory 13
Is Grief a Disease? 16
Normal Grief 17
Grief and Depression 31

2
Understanding the Mourning Process 37
Tasks of Mourning 39
Dual-Process Model of Grieving 53

3
The Mourning Process: Mediators of Mourning 57
Mediator 1: Who the Person Who Died Was 57
Mediator 2: The Nature of the Attachment 58
Mediator 3: How the Person Died 59
Mediator 4: Historical Antecedents 63
Mediator 5: Personality Variables 64
Mediator 6: Social Variables 73
Mediator 7: Concurrent Stresses 75
Caution 75
When Is Mourning Finished? 76

Contents

4
Grief Counseling: Facilitating Uncomplicated Grief 83
Goals of Grief Counseling 84
Identifying the At-Risk Bereaved 87
Counseling Principles and Procedures 89
Useful Techniques 105
The Use of Medication 108
Grief Counseling in Groups 109
Facilitating Grief Through Funeral Ritual 118
Does Grief Counseling Work? 120

5
Abnormal Grief Reactions: Complicated Mourning 127
Why People Fail to Grieve 127
How Grief Goes Wrong 134
An Emerging Diagnosis of Complicated Grief 135
An Existing Model of Complicated Mourning 137
Diagnosing Complicated Mourning 146

6
Grief Therapy: Resolving Complicated Mourning 153
Goals and Setting of Grief Therapy 155
Procedures for Grief Therapy 156
Special Considerations for Grief Therapy 167
Techniques and Timing 169
Dreams in Grief Counseling and Therapy 171
Some Considerations 172
Evaluating Results 174

7
Grieving Special Types of Losses 179
Suicide 179
Counseling Survivors of Suicide Victims 183
Sudden Death 187
Sudden Infant Death Syndrome (SIDS) 192
Miscarriages 195
Stillbirths 197
Abortion 199
Anticipatory Grief 201
AIDS 206

x
Contents

8
Grief and Family Systems 217
Death of a Child 222
Children Whose Parents Die 230
Family Intervention Approaches 236
Grief and the Elderly 239
Family Versus Individual Needs 244

9
The Counselor’s Own Grief 251
Loss History 254
Stress and Burnout 255

10 Training for Grief Counseling
261
Grief Sketches 1–18 264

Appendix 283
Bibliography 285
Index 305

Contents
xi

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xiii

Twenty-fi ve years have passed since the fi rst edition of Grief Counsel-
ing & Grief Therapy was published. In these 25 years there have been
a number of challenges and changes to the fi eld. Some have challenged
the effectiveness of grief counseling, while others have suggested that
it can have a negative effect on some mourners. Is grief counseling
unnecessary, ineffective, and harmful? I want to address these issues
in this edition of the book.
Still others have wanted to challenge the tasks of mourning by
suggesting that they are nothing other than stages of mourning, and
that this stage theory of mourning is passé. This belief is based on a
limited understanding of the task model and a failure to keep abreast
of its development through the earlier editions of the book.
Others support the task of mourning idea but put their own spin
on how and when these tasks should be accomplished. For example,
the dual process of mourning approach of Schut and Stroebe covers
the tasks but does so in an oscillating fashion. Doka, Corr, and Rando
have each increased the number of tasks and come up with an alterna-
tive model.
I still believe that the task model is a useful way to think about the
process of mourning, but I have modifi ed it and made some changes
in this edition of the book. Readers will notice that the mediators of
mourning now has its own chapter. These mediators affect how the
tasks are adapted to or not. While bereavement is a universal phe-
nomenon, the experience of grief is not. These mediators account for
much of this individual difference.
Task III has been reformulated as “adjusting to a world without
the deceased” and has been divided into three subtasks: external, in-
ternal, and spiritual tasks. These subtasks were included in the third

Preface

edition, but some apparently missed this, so I have tried to make this
emphasis clearer and link it with current research fi ndings, including
those having to do with meaning making.
Readers of earlier editions will understand how task IV has evolved
from its original conceptualization of “emotionally withdrawing from
the deceased so that emotional energy can be reinvested in other re-
lationships.” This early Freudian notion gave way to object relations
thinking, where the task involved “keeping the deceased in one’s life
but emotionally relocating the deceased so that one can move forward
with one’s life.” Currently, a good defi nition of this fourth task, which
is supported by research on continuing bonds, would be: “To fi nd an
enduring connection with the deceased in the midst of embarking
on a new life.” Select a defi nition that makes the most sense to you in
understanding your personal loss experience as well as in understand-
ing what is going on with your clients. I do think that a fourth task is
needed to round out one’s overall adaptation to the loss. Incidentally,
I prefer to use the word “adaptation” rather than words like “recov-
ery” or “resolution.”
Special acknowledgments are due a number of people who
assisted me with this project. I would like to thank Robert Cochran
for his help in tracking down the vast amount of recent literature.
My appreciation is also extended to Karin Worden, Jim Monahan,
Carlos Canales, Sharon Hsu, and Jason Smith for their assistance, and
Sheri W. Sussman, vice president, Editorial, at Springer Publishing
Company, who has added her wisdom and encouragement for all four
editions of this book.
The professionals in the Worden group, which meets monthly for
support and supervision, have inspired me and clarifi ed my thinking.
These include Dennis Bull, Ann Goldman, Linda Grant, Bill Hoy,
Annette Iverson, Michael Meador, Ron Ritter, Barbara Smith, and
Stephanie Thal. And, as always, my family and friends provided im-
portant emotional support.

xiv
Preface