The client, a remodeling contractor, described a breakthrough in my grief counseling with him. It came to me this morning, while drinking my morning coffee. I’m in the midst of the biggest remodeling project of
my life! Big parts of the life I built together with my wife no longer fit. I’ve got to figure out what I can retain as is, what I need to let go, and what I need to remodel. I’m going to have to tear down some walls, rip up some carpet, and throw away some outdated, now useless
furniture. But I’ve got to do it in such a way that I do not tear down anything that holds my life together. Then I’ve got to remodel my life to suit new purposes and goals. His most important insight came last, when he said, “I know now that God led me into this business two years ago, not just to fix up old homes, but to give me the tools to
remodel my life after the death of my wife.” Using the remodeling metaphor, we began to make progress in our sessions together.
Counseling with older adults involves working with grief, the behaviors and emotions surrounding a loss, as well as bereavement, the process of readjustment to loss. The therapeutic goal is to help the person acknowledge a loss and readjust his or her life to that loss. My focus
will center on bereavement care for aging populations—the challenge of doing bereavement care for the elderly (65+), the dynamics of grief
and bereavement in older adults, and bereavement intervention strategies for counselors.
The Challenge of Bereavement Care for the Elderly
Although people over 65 years of age represent only 13% of the population in the United States, “in 1994 this group experienced an estimated total of nearly 1.7 million deaths or approximately 73% of the nearly 2.3 million deaths in the country that year.”1 Multiply those numbers by the number of bereaved persons affected by these deaths and the need for bereavement care and counseling is significant.
Overall life expectancy in America has also risen from an average of 47
years in 1900 to 76 years in 1990. At that time there were 7.8 million widowed women aged 65 or older in the U.S. and 1.5 million male survivors in the same age range.2 The implication of this data is that surviving spouses, especially women, will live considerably longer as singles, requiring adjustments in many areas of their lives. A darker statistic, barely acknowledged by society, is the fact that the elderly lead the nation in suicides. “The national average is 12.0 suicides
per 100,000 while there is an estimated 24.0 per 100,000 in the 75-
84 year old age group and 27.0 per 100,000 in the group that is 85 years
old or older.”3 “Caucasian males, age 65 have rates of 32 per 100,000,
which climbs to 67.5 per 100,000 by age 85…much of this attributed to
untreated depression and institutionalization.”
A unique feature in counseling older adults is that many have experienced a lot of “little deaths” over their life spans. The young old (65–74) and middle old (75–84) begin to experience gradual decline in physical energy and mobility. The very old(85+) frequently experience decline in mental functioning. Many have lost friends and have few contemporaries to comfort them. The middle and very old usually have lost important roles in life which gave them meaning. Add to this a major grief event, like the death of a spouse or child, and they may go into bereavement overload. The loneliness, role adjustments, and anxiety of going it alone are significant challenges for the elderly. Elderly populations are underserved by counseling professionals. Our delivery systems focus on officeoriented visits rather than home care outreach models, ignoring difficulties in transportation and mobility for the elderly. There is also a need for a paradigm shift from a curative to
a preventive model of bereavement care. Mourning is viewed much like
a cold virus—if you wait a few days, you will get over it—rather than an
infection that needs to be treated aggressively. Because of this myopic
view, many cases of uncomplicated mourning turn into complicated or
pathological mourning.
Dynamics of Grief and Bereavement in Older Adults
Anyone who has loved someone and then suffered a loss knows the
high price for loving…grief! Some of these losses have been recognized
and supported by society, like deaths of grandparents, parents, children, or close friends. Other losses, forms of disenfranchised grief, have not been recognized or supported by the community, yet are part of one’s and duration of grief as primary determiners of whether grief is normal or abnormal. He identifies four indicators to help counselors identify complicated grief reactions: “Chronic grief—never finishing with grief; delayed grief—inhibited/postponed; exaggerated grief—overwhelmed long after a death; masked grief—the symptoms not seen as related to the loss.”6 Using the remodeling metaphor, some people have more resources than others to rebuild their lives after a loss. Others have complicated grief histories, filled with psycho-social,
physical, or spiritual challenges that require the rebuilding to be done with certain limitations in mind. Physical, mental, financial, and social limitations, especially for elderly clients, can inhibit adjustment to a loss. In such cases, goals need to be modified to more modest expectations.
Bereavement Intervention Strategies for Counselors
Taking a good psychosocial-spiritual assessment is critical in treatment
planning: It identifies high risk factors in grief and assesses the quality of resources clients possess. From the assessment, the counselor obtains a good sense of the bereavement issues facing a client.
The treatment plan should be designed to help the client successfully
complete the four tasks of mourning: “Accepting the reality of the loss, working through the pain of grief, adjusting to the environment in
which the deceased is missing, and emotionally relocate the deceased
and move on with life.”7 The goal is to help the client work through grief to a state of completed grief, where a person is able to think about his or her loss without pain. Therapeutic techniques should be
designed to help clients affectively and cognitively process a loss and
adjust to a new life. Gestalt empty chair techniques, group therapy, life review, cognitive restructuring and reframing are some of the tools used to help in the mourning process. Family systems approaches lend
themselves well to working with a bereaved family.
Spiritual considerations should be given a primary place in grief counseling and bereavement. Issues of meaning and purpose are central in
death and dying and in bereavement. Many clients’ spiritual assumptive
worlds have collapsed with the death of a loved one. They are deeply disappointed in a God who lets bad things happen to good people. Inclusion of a trained pastoral counselor in the counseling process who
integrates theology and psychology could be helpful in assisting clients
to reframe their faith following a significant loss. Mobilizing psychosocial-spiritual support for grieving clients is essential. Older clients have multiple needs, requiring a broad array of peer support (grief support groups/ congregational care programs) and professional services (social workers, parish nurses, doctors, clergy, and financial planners). The counselor needs to facilitate these interventions.
Conclusion James tells us that “religion that is pure and undefiled before God and the Father is this: to visit orphans and widows in their affliction, and to keep oneself unstained from the world” (James 1:27, rsv). For Christians who take their faith seriously, bereavement care is an essential part of our life and work. Let’s comfort those who mourn!
David A. Thompson, M.Div., M.S.E., is a Grief Counselor, working in the Hospice Department of Methodist Hospital in suburban Minneapolis, Minnesota. He also has a private practice, New Directions Counseling & Consulting, specializing in Grief Counseling and Gerontological Counseling. David is a retired U.S. Navy Chaplain and ordained minister in the Free Methodist Church.
