Altmaier, E.M. - Best Practices in Counseling Grief and Loss - Finding Benefit From Trauma

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Transcript of Altmaier, E.M. - Best Practices in Counseling Grief and Loss - Finding Benefit From Trauma

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    Best Practices in Counseling Grief and Loss: Finding Benefit from TraumaAltmaier, Elizabeth M

    Journal of Mental Health Counseling; Jan 2011; 33, 1; ProQuest Psychology Journalspg. 33

    Journal of Mental Health Counseling Volume 33/Number 1/January 2011/Pages 33-xxx

    Best Practices in Counseling Grief and Loss: Finding Benefit from Trauma

    Elizabeth M. Altmaier

    Grief may be a primary presenting concern of clients or may form a background to another presenting concern. In either case, use of best practices in assessing and treating grief is essential. In this article I review what best practices are in general and in assessment and treatment. I also evaluate ways lo measure grief and describe domains of the grief experience. The article also discusses controversies within the literature on grief counseling, including the potential for deterioration after treatment. It concludes with a view of counseling grief that promotes finding benefit from trauma.

    This special section describes the devastating impact of loss on the life of a person. However common it may be, loss causes significant individual grieving, which in tum can impair emotional, cognitive, and behavioral functioning. Throughout this special section we have emphasized the difficulties caused by the crisis of loss and the experience of bereavement, such as the potential of complicated grief and the special case of parentally bereaved children. We have also noted the importance of culture-based counseling issues related to grief.

    More important, however, is a larger perspective introduced by Harvey, who defined loss as a "fundamental human experience" (Harvey, 2002, p. 2) from which we can grow and learn to understand others, help others, and develop our own courage to live with pain. It is critical to keep this positive view of grief in mind when considering best practices in counseling those who are grieving because it treats counseling as facilitating growth rather than simply mending loss.

    In this article I focus on the evidence that underlies assessment and treatment, and on practices that should be considered in counseling the grieving client. Thinking of grieving within the context of posttraumatic growth will define alternative counseling approaches.

    Elizabeth M Altmaier is affiliated with The University of Iowa. Correspondence concerning this article should be directed to Elizabeth M Altmaier, Department of Psychological and Quantitative Foundations, The University of Iowa College of Education, 360 Lindquist Center, Iowa City, Iowa 52242-1529. E-mail:





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    What are best practices? Though the term has been adopted widely, its usage is not agreed upon-much like terminology related to grief. Concisely, best practices, a term borrowed from the business world, suggests that there is a particular technique, approach, or method that when used with a particular target is more effective (reaches its goals) and efficient (uses fewer resources) than other techniques, approaches, or methods. It also suggests that there are data available to influence the decision to use this particular technique. Within the mental health field, other terms that denote a similar emphasis on using data to make decisions on assessment and treatment are evidence-based practice and empirically supported treatment.

    One approach to understanding best practices is to focus on outcome data gathered in clinical trials of a particular treatment (empirically supported treatments). Many consider these studies to be the best basis upon which to select a treatment. Advocates of empirically supported treatment argue that although a treatment is only one of several influences on client outcome, it is the influence that a counselor in training can most readily learn and the influence that can be most easily studied scientifically (Norcross, Beutler, & Levant, 2005).

    There are two other sources of data to inform treatment choice. One is clinical lore-the accumulated experience of many practitioners transmitted through personal testimony, continuing education, client reports, news coverage, and so on. Unfortunately, clinical lore has the drawback of promoting treatments later shown to be ineffective or less effective than alternatives. Fad diets might be the health counterpart to selection of counseling approaches predicated on clinical lore.

    Another data source is the counselor's own personal clinical experience. A seasoned counselor can recall similar clients, similar desired outcomes, similar contexts, and so on-memories that can inform a present treatment decision. Unfortunately, clinical experience can fall prey to the biases that influence human memory, such as confirmation bias, which emphasizes previous successes and overlooks previous failures. Another bias is the availability heuristic, where clients who are memorable for any reason are prominent images in the counselor's memory, while less memorable clients fade.

    An alternate view of counseling effectiveness is the primacy of the counselor within the interpersonal relationship. In this view, treatments are essentially equal in their effectiveness, but it is whether the counselor is, for example, warm or rejecting, sensitive or insensitive, astute or ignorant that most influences outcomes. When data are sought to support treatment decisions, the personhood of the counselor is typically overlooked although it accounts for as







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    much of the outcome as treatment. Wampold (Norcross et al., 2005), for example, argues that overlooking the personhood of counselors in research on best practices, particularly research that focuses on the treatment as the sole or primary influence on outcome, causes two types of misattribution: First, it inflates the effects attributed to treatment and thereby creates a false sense of confidence in a treatment when the counselor may be the agent for change. Second, a focus on treatment alone creates an impression that counseling is a package of techniques that can be delivered impersonally-a gross misunderstanding of the deeply human enterprise of counseling.

    Alternatively, the counselor-client relationship may be the primary source of influence. Lambert (Norcross et al., 2005) notes that when clients are asked about their counseling experience in qualitative and retrospective studies, the relationship with the counselor is typically cited as the primary reason for change: clients feel understood, valued, appreciated, supported, and so on. Technique and theoretically based explanations of treatment outcome (e.g., change in dysfunctional cognitions) are almost never mentioned.

    Last, the fact that clients are active agents in their own improvement and change cannot be overlooked. Rather than being a passive recipient of a treatment, the client elaborates on the insights of counseling outside the session, works the information and insights into her life, and through self-healing and self-determination mechanisms creates a medium for effective outcome.

    In summary, the background of best practices is important in selecting counseling approaches for a grieving client, keeping in mind that there is controversy over whether grief counseling is appropriate for everyone, only for persons seeking treatment, or only for persons experiencing complicated grief. Moreover, though in general some counseling approaches may seem to be effective, research should not imply that the personhood of the counselor, the relationship of client and counselor, or the client's own self-healing processes are insignificant aspects of change.


    Although grief is a universal phenomenon, it has not been adequately conceptualized. As the accompanying articles note, the lack of consistency in defining grief has led to inconsistency in the development of grief measures. In what follows I describe the most prominent of these measures. They were chosen because they (a) are the most widely used; (b) focus on grief, rather than broad psychiatric symptoms; ( c) assess normal, not complicated, grief; and ( d) consider grief across all possible losses, rather than a specific loss, such as the loss of a child. (See Stroebe, Hansson, Schut, & Stroebe, 2008, for more complete coverage of conceptual issues in the measurement of grief.)





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    Grief Measures Texas Revised Inventory of Grief (TRIG; Faschingbauer, Zisook, & DeVaul,

    1987). The TRIG, probably the most widely used measure of grief, is a brief measure with two subscales: Current Grief and Past Disruption. Items, created based on a review of the literature and the clinical experience of the authors, contain sentences of personal description to which the participant responds on a five-point scale (I =completely false to 5 =completely true). Because of the contrasting temporal nature of the two sections, the developers assert that the two scores can be used to assess progress in grieving.

    Niemeyer and Hogan (2001) summarized the psychometric qualities o