Death and Dying Issue

Contributors:
Kathryn Layman, and Jessica Swenson, University of Wisconsin-River Falls

Death and dying is a complicated and multifaceted topic. This Practice Brief will focus on death and dying, the counseling process, and those facing death. Also, the Practice Brief will cover caregivers who work with the dying, cultural and age differences, and the spiritual aspects related to this topic.

An early description of the process of grief was addressed by Kübler-Ross (http://www.ekrfoundation.org/five-stages-of-grief/ in describing possible stages of grief. Ober, Granello and Wheaton (2012) defined grief as, “the emotion generated by and experience of loss and characterized by sorrow and/or distress and the personal and interpersonal experience of loss” (p. 150). Buglass (2010) described a dual process model of moving between grief and coming to terms with the loss. Complicated grief is described as an individual having continual beliefs related to a death and functional impairment that lasts at least 6 months (Lobb, Kristjansen, Auon, Monterosso, Halkett, & Davies, 2010). Noppe (2006) and Daneker and Smith (2007) examined the existential or spiritual aspects of defining, understanding, and finding meaning with death, dying, and the grief process.

Death Education
Ethical therapeutic competence is necessary for any professional working with client issues related to death and dying (Gamino, & Ritter, 2012). Educational experiences can include planned activities and experiences relating to understanding the meaning of death, dying, and other aspects of the grief process (Noppe, 2006). Related factors that influence the grieving style include personality, culture, and gender role socialization (Doka & Martin, 2011).

Harrawood, Doughty and Wilde (2011) posited that death education increased understanding of death, reduced negativity about death and increased openness to studying death constructs. Counseling competence regarding death is a specialized skill requiring tolerance, the ability to manage clients’ problems related to dying, death, and bereavement while maintaining an ethical therapeutic relationship (Gamino & Ritter, 2012). Chan and Tin (2012) described four competence categories (a) self-competence (subcategories: personal resources, existential coping, and emotional coping), (b) practice competence, (c) knowledge competence, and (d) work environment competence. The competencies, as described by Chan and Tin, allow professionals focus on necessary knowledge and skills to cope with death work.

VonDras and White (2006) examined the role that spiritual beliefs and practices played in the pro- cessing of the death experience including comfort for family members and hope for the dying in end-of- life care. The authors suggested that caregivers may go through a cycle of shock and grief and return to composure and function. Potential counseling issues for caregivers include putting loss and suffering into perspective (Rossheim & McAdams, 2010). Rubin and Malkinson (2011) focused on cultural sensitivity, individual religious experiences, and potential barriers to grief and mourning specifically for educators, counselors, caregivers, and the dying.

Identification of Issues
A number of authors have dealt with identification of issues and assessment related to loss, includ- ing ethical/legal concerns, practice considerations, and recommendations from the field. Werth and Crow (2009) focused on all three issues while making a strong case for the use of assessment. Inman, Yeh, Madan-Bahel, and Nath (2007) examined coping strategies in South Asian families. The researchers focused on the role of culture in the grieving process and found that effective strategies included interactions with family members and other victim families, reliving memories of the deceased, displaying emotion (anger, sadness), increasing or decreasing religious behaviors, and/or seeking support (formal and informal).

In a similar study Rubin and Malkinson (2011) examined grief and mourning cultural issues in Israel. The researchers investigated contextual issues related to minority and majority cultural issues including questions appropriate to ask a client of cultural minority groups. Rubin and Malkinson suggested that therapists should ask questions seeking information not only about the story surrounding the death, but also about the story of the life that person lived to understand the continuing bonds held. Questions about the individual’s story, the family’s story and the community’s story were all significant. Rubin and Malkinson (2011) stated that, “it is important to consider the contributions of cultural, social and reli- gious frameworks to help assist in “adequate, emotionally sensitive, and cultural meaningful separation from the deceased” (p. 49).

Cultural issues also were explored by Strohbuecker, Eisenmann, Galushko, Montag, and Voltz (2011) in their study on palliative care in Germany. Strohbuecker et al. described six palliative care needs of nursing home residents within the context of living in Germany: (a) Being recognized as a person, (b) Having a choice and being in control, (c) Being connected with family, (d) Being connected with the out- side world, (e) Being spiritually connected, (f ) Physical comfort, and (g) Dealing with death and dying.

Assessment Tools
Altmaier (2011) provided information on four distinct grief measures. The Texas Revised Inventory of Grief (TRIG, http://149.142.76.35/assessment/IB/List_Scales/Texas%20Revised%20Inventory%20of%20 Grief.htm; Faschingbauer, Zisook, & DeVaul, 1987) includes two subscales (Current Grief and Past Disrup- tion) along with descriptive sentences that gauge participant responses via a five point scale (1 being com- pletely false and 5 being completely true). Scores are used to determine participants grieving progress. The Grief Experience Inventory (GEI; Sanders, Mauger, & Strong, 1985) uses descriptive true or false statements. Three validity scales and nine clinical scales are used to determine scores. The Core Bereavement Items (CBI, http://eprints.qut.edu.au/26824/1/c26824.pdf; Burnett, Middleton, Raphael, & Martinek, 1997) aids in assessing the intensities of bereavement reactions. The scale covers seventeen items in the following three subscales: (a) Images and Thoughts, (b) Acute Separation, and (c) Grief. The Hogan Grief Reaction Check- list (HGRC; Hogan, Greenfield, & Schmidt, 2001) is the most recent of the assessment tools. The HGRC identifies the following six categories of grief: (a) despair, (b) panic behavior, (c) blame/anger, (d) disorgani- zation, (e) detachment, and (f ) personal growth. Altmaier (2011) stated that this tool attempts to, “delineate normal grief and…avoid blurring grief with symptoms like depression or anxiety“(p. 37). Jordan, Baker, Matteis, Rosenthal and Ware (2005) tested the validity of another assessment tool for bereaved adults, The Grief Evaluation Measure (GEM). The researchers concluded that, although lengthy, “the GEM offers the most comprehensive clinical assessment tool for bereaved individuals, “(p. 319).

Intervention Strategies
Best practices, when counseling clients through grief and loss focus on common practice for all clients, empathic presence, conversation, trust building and support (Altmaier, 2011). Equally important issues include developmental capacities of the client and experience with loss (Whiting & Bradley, 2007). Whiting and Bradley also explored intervention techniques that were useful in creating a dialogue around grief and loss. According to the researchers intervention strategies, helpful in the construction and reconstruction processes for creating meaning, included journaling, artistic expressions, letter writing, poetry and scrapbooking.

Breen (2011) interviewed 19 grief counselors exploring their practices, issues and dilemmas. The author described three intervention issues (a) conceptualization, (b) dilemmas, and (c) improving grief counseling. Recommendations for counselors include continuously updating and increased access to grief education. Breen (2011) suggested that this can be done by increasing understanding of grief litera- ture, use of workshops, literature reading groups, and active research.

Theoretical Orientations
Researchers explored the use of specific theoretical constructs when dealing with grief and loss. Parkes (2011) described the relationship between attachment theory, grief and the effect of parental attachment. Boeln and Keijser (2007) compared cognitive-behavior therapy, cognitive restructuring, exposure therapy, and supportive counseling when working with complicated or debilitating grieving. Cognitive-behavior therapy was found to be effective when working with clients suffering from debilitating grief.

A number of researchers explored the effectiveness of bibliotherapy when dealing with grief, death and bereavement. Bowman (2003) described the effectiveness of bibliotherapy in helping clients to understand feelings, memories, and unconscious thoughts. Other benefits of bibliotherapy included prompting discussion, creating solutions, and normalizing the process. Briggs and Pehrsson (2008) studied 487 practitioners and found that 88% utilized bibliotherapy in the treatment of grief and loss. The authors noted that bibliotherapy is utilized primarily with children.

Other specific strategies when working with children included storytelling and bereavement camp. Glazer and Marcum (2003) focused on the power of hearing and telling stories to create meaning for expressing grief. McClatchey and Wimmer (2012) examined bereavement camp experiences and found the experience beneficial for children and adolescents.

Palliative care strategies
Tubbs-Cooley, Santucci, Kang, Feinstein, Hexem, and Feudtner (2011) described specific issues related to end of life, bereavement and palliative care with the goal of facilitating a dignified death. Issues included “lack of communication among physicians, nurses and families, lack of defined treatment plan, discom- fort with death and dying unnecessary prolongation of life, and lack of resources” (Tubbs-Cooley, et. al, 2011, p.31). Currier, Holland and Neimeyer (2008) also examined helping strategies for end of life issues for the dying and grieving. The researchers gathered information from 119 practitioners and found that presence, process, and procedures were vital components when working with these groups.

REFERENCES

Altmaier, E. M. (2011). Best practices in counseling grief and loss: Finding benefit from trauma. Journal of Mental Health Counseling, 33, 33-45.

Boeln, P. A. & Keijser, J. (2007). Treatment of complicated grief: A comparison between cognitive-behavioral therapy and supportive counseling. Journal of Counseling and Clinical Psychology, 75(2), 277-284.

Bowman, T. (2003). Using literary resources in bereavement work: Evoking words for grief. An International Interdisciplinary Organization: Professional Development- Expressive Arts in Bereavement, 29, 8-9. http://www.adec.org/AM/Template.cfm?Section=The_Forum&Template=/CM/ContentDisplay. cfm&ContentID=1529

Breen, L. J. (2011). Professionals’ experiences of grief counseling: Implications for bridging the gap between research and practice. OMEGA, 62(3), 285-303.

Briggs, C. A. & Pehrsson, D. (2008). Use of bibliotherapy in the treatment of grief and loss: A guide to current counseling practices. Adultspan, 7, 32-42.

Buglass, E. (2010). Grief and bereavement theories. Nursing Standard, 24(42), 44-47. http://nursingstandard.rcnpublishing.co.uk/archive/article-grief-and-bereavement-theories

Chan, W. C. H. & Tin, A. F. (2012). Beyond knowledge and skills: Self-competence in working with death, dying, and bereavement. Death Studies, 36, 899-913.

Currier, J. M., Holland, J. M., & Neimeyer, R. A. (2008). Making sense of loss: A content analysis of end-of-life practitioners’ therapeutic approaches. OMEGA, 57(2), 121-141.

Daneker, D. & Smith, C. M. (2007). The spiritual needs of the dying: Best practices for professional counselors. http://counselingoutfitters.com/vistas/vistas07/Daneker.htm

Doka, K. J. & Martin, T. L. (2011). Grieving styles: Grief and gender. Grief Matters: The Australian Journal of Grief and Bereavement, 14, 42-45. http://www.adec.org/AM/Template.cfm?Section=GriefMatters&Template=/CM/ContentDisplay.cfm&ContentID=2761

Gamino, L. A., & Ritter, R.H. Jr (2012). Death competence: An ethical imperative. Death Studies, 36, 23-40.

Glazer, H. R., & Marcum, D. (2003). Expressing grief through storytelling. Journal of Humanistic Counseling, Education and Development, 42, 131-138. http://imet.csus.edu/imet12/portfolio/cunkelman_ david/EDTE286/edte286_story/Files/articles_to_link_to/expressing_grief_through_storytelling.pdf

Harrawood, L. K., Doughty, E. A., & Wilde, B. (2011). Death education and attitudes of counselors-in-training toward death: An exploratory study. Counseling and Values, 56, 83-95.

Inman, A. G., Yeh, C. J., Madan-Bahel, A., & Nath, S. (2007). Bereavement and coping of South Asian families post 9/11. Journal of Multicultural Counseling and Development, 35, 101-115.

Jordan, J. R., Baker, J., Matteis, M., Rosenthal, S., Ware, E. S. (2005). The grief evaluation measure (GEM): an initial validation study. Death Studies, 29, 301-332.

Lobb, E. A., Kristjansen, L. J., Auon, S. M., Monterosso, L., Halkett, G. K. B., Davies, A. (2010). Predictors of complicated grief: A systematic review of empirical studies. Death Studies, 34, 673-698. http://espace.library.curtin.edu.au/R/?func=dbin-jump-full&object_id=147256&local_base=GEN01-ERA02

McClatchey, I. S. & Wimmer, J. S. (2012). Healing components of a bereavement camp: Children and adolescents give voice to their experiences. OMEGA, 65 (1), 11-32. http://web.ebscohost. com/ehost/pdfviewer/pdfviewer?sid=6ff336be-d811-4089-968a-1da166ed5b0e%40session- mgr10&vid=2&hid=10

Noppe, I. C. (2006). Death education and the scholarship of teaching: A meta-educational experience. The Forum by the ADEC: Professional Development- Update on Death Education, 30, 1-4. http:// www.adec.org/AM/Template.cfm?Section=The_Forum&Template=/CM/ContentDisplay.cfm&- ContentID=1532

Ober, A. M, Granello, D. H., & Wheaton, J. E.(2012). Grief counseling: An investigation of Counselors’ training, experience, and competencies. Journal of Counseling and Development, 90, 150-159.

Parkes, C. M. (2011). Recent developments in loss theory and practice: Individual, family, national, and international implications. Grief Matters: The Australian Journal of Grief and Bereavement, 14, 36-40. http://www.adec.org/source/search/index.cfm?q=grief+matters&i_Search=GO

Rossheim, B.N. & McAdams, C.R. (2010). Addressing sorrow of long-term spousal caregivers: A primer for counselors. Journal of Counseling and Development, 88, 477-482.

Rubin, S. S. & Malkinson, R. (2011). Minding the gap in Israel: Working within and between cultures to identify barriers to grief and mourning. Grief Matters: The Australian Journal of Grief and Bereave- ment, 14, 48-51. http://www.adec.org/source/search/index.cfm?q=grief+matters&i_Search=GO

Strohbuecker, B., Eisenmann, Y., Galushko, M., Montag, T., & Voltz, R. (2011). Palliative care needs of chronically ill nursing home residents in Germany: Focusing on living, not dying. International Journal of Palliative Nursing, 17(1), 27-34.

Tubbs-Cooley, H. L, Santucci, G., Kang, T. I., Feinstein, J.A., Hexem, K. R., & Feudtner, C. (2011). Pediatric nurses’ individual and group assessments of palliative, end-of-life, and bereavement care. Journal of Palliative Medicine, 14 (5), 631-637.

VonDras, D. D. & White, J. L. (2006). Spirituality and death: A transformation into new life. The Forum, 32(2), 1-4. http://www.adec.org/AM/Template.cfm?Section=The_Forum&Template=/CM/Con- tentDisplay.cfm&ContentID=1544

Werth, J. L. Jr. & Crow, L. (2009). End-of-life care an overview for professional counselors. Journal of Counseling and Development, 87, 194-203.

Whiting, P. & Bradley, L. J. (2007). Artful witnessing of the story: Loss in aging adults. Adultspan, 6, 119-128.

Published: December 2013
Updated: December 2013

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