- Email: [email protected]
Workshops to support the bereavement process
Patient Education and Counseling 34 (1998) 53–62
Workshops to support the bereavement process a, b b Ellen E. Beem *, Elisabeth H.M. Eurelings-Bontekoe , Marc P.H.D. Cleiren , Bert Garssen a a
b
Helen Dowling Institute, Postbox 25309, 3001 HH Rotterdam, The Netherlands Section of Clinical and Health Psychology, University of Leiden, Leiden, The Netherlands
Received 28 March 1997; received in revised form 4 September 1997; accepted 11 September 1997
Abstract When a bereaved person is in need of extra support during the bereavement process, at present four types of support can be distinguished: professional individual- and group counseling and non-professional individual- and group counseling. In this article another support facility is proposed: the workshop. It is indicated that the workshop can be considered as a valuable addition to the current counseling alternatives for bereavement and can possibly prevent more serious bereavement problems. After an explanation of bereavement counseling, the set-up of the workshop is described. Special attention is payed to the group dynamic aspects of the workshop. 1998 Elsevier Science Ireland Ltd. Keywords: Bereavement; Counseling; Workshops; Support
1. Introduction Although the death of a close relative or friend is considered to be one of the most drastic events in a person’s life, not every bereaved person needs (non)professional help to get through this period of bereavement. The majority of the bereaved are persons over 65 years of age [1]. People from this age group are particularly vulnerable to and at risk for the development of depression and suicidal behaviour after a major life event, such as the loss of a beloved one [2]. When it becomes evident that the bereaved person does need extra support, one has to make a distinction between psychotherapy and coun*Corresponding author. E-mail address: [email protected]
seling. Psychotherapy is indicated when there is a severe disturbance in daily functioning, that is out of control for the bereaved person and often associated with pre-existing problems. This extensive form of support is provided by professionals. However, when the disturbance in daily functioning is mild, counseling can be offered both by professionals as well as by non-professionals. In this article the focus will be on grief counseling. The bereaved person can make a choice out of four support facilities: professional individual counseling, professional group counseling, non-professional individual counseling and nonprofessional group counseling. Professional counseling is given by psychotherapists, social workers, psychiatrists, and nurses with additional training. Non-professional counseling consists of support from
0738-3991 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0738-3991( 98 )00044-5
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volunteers in health care and support from people who have suffered a loss themselves. Depending on the need for support of the bereaved person, each of these types of support plays an important part in bereavement counseling. Although professional support facilities are considered to be inappropriate by the majority of counselors within the period of half to one and a half years after the loss [3], our clinical experiences with bereaved persons over the past 5 years have shown that, by all means, it is a mistake to consider counseling to be inappropriate during the first 6 months after bereavement. The provision of attention and support immediately after the loss may prevent much unnecessary grief. Especially, if the attention and support given by the own social environment of the bereaved person has not the quality and / or quantity needed, counseling can be valuable. How accessible is support for bereaved persons? Difficulties in accessibility may be due to the following three factors: (a) theories about mourning; (b) problems of communication between potential, bereaved clients and counselors; (c) financial aspects.
probably not doing it right, because I should be able to do it myself, but I can’t.’
1.2. Problems in communication between potential, bereaved clients and counselors Many especially elderly bereaved persons consider it to be a weakness when they need support in bereavement, and this makes it difficult for them to ask for help with problems. Although it is important that (non)professional help in bereavement is offered with a low threshold, a downright question for help from the bereaved person in a mildly disturbed grieving process is the only rationale for offering (non)professional help. An additional problem is that the communication between counselors and bereaved sometimes is not optimal. The bereaved person often has no idea where and which support facilities are available. When a health care institute organizes bereavement counseling, it is possible that a telephone operator has not been informed about the name of the person who could give the bereaved information about bereavement counseling.
1.1. Theories about mourning 1.3. Financial aspects It is difficult for the bereaved to receive counseling for a non-urgent request within the period of 6 months after the loss. Often, only non-professional support is available. Professional counselors tend to advise to take time to grieve. This advice is based on the theoretical stage and / or phase models, which assume that the process of mourning is characterized by several stages or phases to go through. It is expected that ‘the pain’ becomes less with the passage of time. If this is not the case after a year and a half, then there is the possibility of a stagnated bereavement process and only then professional support or help would be indicated. However, nowadays there are strong doubts about the validity of such theoretical stage models [4]. Indeed, time is an important factor in the bereavement process, but when the bereaved person does not have the capacity to work it through by himself, counseling must be available. When people with a recent loss are not given the help they subjectively need, they are not only strengthened in their idea that ‘you have to do it yourself’, but they can also get the feeling that ‘I am
Professional counseling for bereavement is quite expensive and is not always reimbursed by health insurance. These costs contrast sharply with the costs of services from non-professional counseling which is often very cheap or free of charge. The accessibility of support facilities is therefore partly determined by the financial resources of the bereaved. So, due to several factors, the current health care system always provides optimal support to those who suffered a recent loss, which might be considered an undesirable situation given the fact that various studies show that a large percentage (5–24%) of the bereaved still have above average to severe problems 1–2 years after the loss [5–8]. This all led us to develop a 2-day workshop, especially suited for those who are most vulnerable, the elderly. Our experiences with this alternative type of support in bereavement are positive. However, such a design for bereavement support has a few group dynamic aspects that differ somewhat from a bereavement counseling group. The format of the workshop is
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described in this article, followed by a discussion of several related group dynamic aspects.
2. Theoretical background of the workshop The format of the workshop has been based on 7 years of research on bereavement and an extensive research of the therapy literature [9]. Gask and Eurelings mentioned seven important non-specific contextual factors which foster successful outcome in therapy: (a) interventions need to be flexible both in nature and in frequency; (b) providing information and knowledge is not enough, it is important to increase self-efficacy and self-control by providing the opportunity to practice new skills; (c) it is important to aim at cognitive restructuring; (d) interventions should be provided within a warm emotional relationship; (e) it is important to cope with compliance problems by working on the participation principle; (f) home-practice is important to maintain changes; (g) attention should be paid to the involvement of significant others. As will be outlined later on, many of these contextual factors are incorporated in the workshops. The interventions provided are flexibly attuned to the needs of the participants, cognitive interventions are provided to aim at self-control and self-efficacy. Finally, in addition to the provision of information, much effort is directed at fostering emotional expression within a holding environment.
3. Description of the workshop
3.1. Aim of the workshop The principal aim of the workshop is to give information and insight to the bereaved person about what one can expect in bereavement and which support facilities are available. In addition, the participant has the opportunity to meet people who find themselves in similar situations, whereby elements of recognition, sharing and modelling are important. Furthermore, there is ample space for emotional release.
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3.2. Characteristics of the counselors The counselors must be familiar with individual and group processes, have experience with discussion and intervention techniques and be up to date on current theories on bereavement. Furthermore, one must be capable of organizing a structured program. According to our experiences, a workshop can be given by professional and non-professional counselors, as long as they satisfy the aforementioned description. It is desirable to have two counselors for every 12 participants.
3.3. Characteristics of the participants Because of the importance of sharing of experiences and the possibility of recognition, it is recommendable to opt for a homogeneous group f.i. with regard to the relationship to the deceased: the participants of our workshops were homogeneous in the sense that they all had suffered the loss of a partner. Furthermore, the workshop has no restrictions concerning time after the loss: participants with a recent loss are as welcome as are people who have suffered a loss several years ago. For a few participants the workshop in itself will provide enough support during a difficult period and might as such have a secondary preventive quality. Other participants might need additional support and help: especially for this group of people it is important to provide information about support facilities available in their neighbourhood. The maximum number of participants is 35 with a minimum of 20. When the group counts more than 35 persons, group cohesion may be severed: the participant will feel ‘lost’. Furthermore, such a large group will form a large number of sub-groups. Within the setting of the workshop (two sessions), it is not possible for the counselors to recognize and control the interactions taking place in all the different sub-groups and these interactions will influence the goals of the workshop in a negative way. A group with less than 20 participants will give rise to too strong cohesion and personal involvement which may give the group a more therapeutic character, which goes beyond the aim of the workshop.
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3.4. Recruitment of the participants Prior to the workshop, referring institutes have received a letter with information about the aims and the target group of that particular workshop. This letter clearly states that this workshop is not a therapy group, and that it is not intended for people who want individual attention or who have always been anxious and / or tense. Furthermore, the same information about the workshop is given by regional newspapers and radio stations. By presenting the workshop as a setting in which people are invited to learn something, the workshop is especially inviting for bereaved persons who do not want help and who do not want to be ‘weak’, which is, according to our experiences, in particular characteristic of elderly people. Because the workshop is not meant to be a therapeutic group, there is no intake procedure.
3.5. General strategy for intervention The workshop’s intention is based on the idea of ‘safety’. The program is highly structured in order to provide a basis for a safe environment for the participants. For instance, there should be no deviation from the starting time and the finishing time. In addition, there is respect for the participants defences. Besides the concept of ‘safety’ two other elements can be identified that play an important role in the workshop: (a) the alternation between providing information and time for one’s own experiences and feelings, referring to the earlier mentioned importance of the factor of intervening within an emotional context and (b) the alternation between working in the large group or in a sub-group, which refers to the earlier mentioned concept of flexibility. The counselors are restricted in the possibilities of giving individual counseling because the workshop has a limited duration. This is the reason for choosing an intervention strategy in which only those interventions are applied that can be conducive to a safe environment (supportive interventions) and which basically take place at the group level. Occasionally, interventions on an individual level cannot be avoided; for example, in case of severe distress of one of the participants, one may first identify the participant’s intense emotions, but subsequently one
has to address these on the group level. Group members can be invited to share their own — possibly similar — experiences (recognition).
3.6. General organization of the workshop The workshop consists of 2 days which are not successive, because for many people who are going through the bereavement process it is difficult to absorb information and to actively confront the grieving. Instead, the first and the second workshop days are separated by a week. For most participants this provides the opportunity to integrate their emotions and to be open for information and experiences which are presented on the second day. Every workshop day begins and ends with a block of information, and in between, exercises are done which provide cognitive insights. At the change of a block, a half hour break is given: this gives participants the chance to adjust and to meet other participants. The information is presented to the whole group of participants in a spacious room with chairs which are placed in rows. Audiovisual aids, such as slides or videos, can be used to supplement the information block. There is a maximum of 18 participants for the insight-providing exercises which implies that the maximum amount of participants is split up, after the information block, into two subgroups which work in separate rooms with their own counselor. The setting is different: chairs are now arranged in circles in order to facilitate the communication. Depending on the available time, a choice is made to do either one or two insight-providing exercises. These exercises take place in small groups of about three participants, after which the exercises are discussed in the subgroup. The counselors see to it that the participants take turns in doing the exercises.
3.7. The first workshop day The first workshop day starts with a word of welcome and an introduction. Information about bereavement is given by several experts (medical doctor, psychologist, therapist) who explain in plain language, from their own area of expertise, what bereavement can bring about. This information is presented in short lectures at the beginning of the
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workshop. After the break the group of participants is split up into two smaller groups and an exercise is done to introduce participants to each other. In groups of three, participants answer questions, provided by the counselors, which aim to encourage getting to know each other: for example, who are you, what happened and when, and why did you come here. The counselors make sure that every participant feels comfortable and gets the space that he needs. The reactions of the participants are discussed in the session with the sub-group. The counselors encourage the participants to speak from their own feelings and experiences (not the story ‘as told by the neighbour’). The questions which are discussed in the subgroups must be decided beforehand and must have a logical sequence (an example of the exercises is given in Fig. 1). The next exercise consists of two questions which are focused on how you ‘see’ yourself. The second and last block of information of this first workshop day follows after this exercise, and three aspects are covered. First, the participant’s experiences are recounted (summary of the day) and are placed within a theoretical framework. It is emphasized that there is no particular fixed duration of the mourning process, and that there are no particular rules about
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‘how to mourn’. This also implies that bereavement does not necessarily take place in strict phases. Secondly, information is given about services which can be consulted in case of emergency (the general practitioner is mentioned as one of the options). Thirdly, the day is closed at a meta-level (for example: ‘Today a lot of things were covered, and soon everyone will go his own way. Some people could feel tired. Don’t be surprised if you feel tired because it is only natural to feel tired when a lot has happened. It could also be that you won’t feel tired at all when you get home. This is also possible. Not everyone experiences this day in the same way.’)
3.8. The second workshop day The structure of the second workshop day is comparable to the first one: once again the day starts and ends with a block of information, and the middle section consists of insight providing exercises, hence of cognitive restructuring. The second workshop day starts with an introduction of a short film in which various people express their loss in their own way. After showing the film, the content of the film is placed within a theoretical framework as discussed on the first workshop day. Once again it is empha-
Fig. 1. Questions for insight-providing exercises in sub-(sub-)groups.
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sized that everyone tries to find his own way to cope with the loss. After the break participants have the opportunity to discuss several questions in small groups within the subgroups. The questions, which are raised in this insight-providing block, are directed at the coping capacity of the participants: did you find different ways to cope with the new situation, what do you need, and what are you going to do to get it. The closing block of information includes a review of the experiences of the second day as well as those of the first day. Attention is paid to the importance of mourning: ‘it is something personal, it belongs to you and the deceased’. How to ask for support in your circle of friends and relatives is also a topic, as is the fact that everyone needs a ‘shoulder to lean on’ at some time or another. Asking for help is allowed, and it is not a sign of weakness. Attention is paid to what to do if you cannot find enough support in your own surroundings. After a closing, which once again takes place at a meta-level, the participants are told where to find the available information on bereavement counseling in the area and are given the list of addresses of the participants (only listings based on prior, written permission from the relevant participants). After the entire workshop has come to an end, participants have a chance to chat over a drink with fellow participants.
3.9. Crisis intervention Depressed feelings are inextricably linked to mourning. Everyone who mourns has moments of ‘not seeing a way out’. Many bereaved have caught themselves with a feeling of ‘it’s not worth it any more’. Therefore, it is difficult to clearly draw the line between the normal feelings of depression and latent suicidal expressions. When someone remarks on the meaninglessness of life, it cannot be assumed that this is an ordinary expression of depression. It is important to have more information about the feelings of the participant. Although the chance that a crisis situation develops is kept minimal by means of the structured approach of the workshop, it is possible that a participant decompensates. If the capacity of the participant has been overtaxed, an individual session outside the context of the group is necessary. Sometimes, it helps the participant when the counselor makes an appointment to call within a
few days to ask the participants how he feels (offering some structure out of the workshop setting). All efforts should be made to help the participant, whereby extra attention must be paid to latent or manifest suicidal expressions. Depending on the situation, one can respond immediately or later on in the workshop (individual level). Diekstra’s indications [10] for suicidal behaviour can serve as guidelines. In case, there might be an indication for suicidal behavior it is important to get help from a G.P. and / or psychiatrist. In addition, it is important that participants are aware of the support possibilities when they encounter a crisis. It is advisable to pay attention in the workshop to those care facilities which are available in their network and how one can obtain and utilize this type of care (family, friends, general practitioner, minister / priest). The S.O.S. telephone service could be mentioned which can be reached 24-h a day.
4. Group dynamic aspects in the workshop Within a group dynamic context, the following four aspects will be highlighted: (a) handling the unresolved focal conflict; (b) handling countertransference feelings; (c) finding the optimal balance between individual and groupwise interventions; (d) handling participants feelings of anger and (e) handling the ‘silent’ participant.
4.1. Handling the unresolved focal conflict The workshop consists of a group of participants and a few counselors. It is obvious that all kinds of group dynamic processes will take place. Everyone will encounter a loss through death at some point in life. Many counselors will have their own experiences with bereavement, which may give rise to unrecognized countertransference feelings. For example, the counselor could disclose to the group his own experiences with bereavement without questioning its significance for the group. When the sharing of the counselors’ own feelings and / or experiences arises from feelings of uneasiness and own grief, his role becomes unclear for group members. This ambiguity intensifies the regression which leads to an unsafe climate to work in. An
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important process, which may occur as a reaction of the group to intense feelings or desires of one or more of the group members and / or counselors, is the focal conflict. One type of focal conflict that may arise in a group is that between grieving and the desire to be attended to on the one hand and the fear of losing one’s autonomy on the other [11]. When the counselors do not have sufficient insight into their own feelings about death and loss, this can cause them to look for a restrictive solution in which only one side of the conflict is exposed. In this case we speak of an unresolved focal conflict. For example, the counselors’ own (sometimes unrecognized) defense mechanisms could cause the counselor to satisfy his own desire to help by giving advice. This restrictive solution of the focal conflict can lead to strong reactive feelings in the group. A reactive response could be anger. A group member might respond, without apparent, immediate reason, with ‘all this soft business: I came here for factual information, because mourning I can do on my own’ with which he expresses the other side of the conflict, the fear of losing one’s autonomy. This, in turn, can lead to anger on the side of the counselor. If the counselor expresses these countertransference feelings, it can greatly disturb the interaction between counselors and the group. The disturbance of the group process by an unresolved focal conflict due to the counselor’s intra-psychic processes, can be avoided by applying the following guidelines. First, it is important that ground rules are agreed upon between the counselors: who has which responsibility, and how does one, within the program of the workshop, apply this responsibility. This agreement must also include how and when feedback should be given. Because the workshop does not specifically make use of group dynamics (after all, it is not a therapy group), it is recommended not to give feedback to a co-counselor in the group. If a counselor cannot handle the emotions of a particular participant, then it is important that he leaves the intervening to this person to a colleague. In a good team of counselors this handing over can often be done with a non-verbal sign. Secondly, it is very important to create the possibility of intervision focusing on how the counselor deals with his own experiences with bereavement. Not only does a good counselor realize what bereavement means to him personally, it is also important that he trains his
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introspective abilities, for example, ‘why I am intervening now?’ and ‘what triggers my irritation?’ It is indeed true that also experienced counselors can be confronted by situations which trigger their own defenses. By having mandatory intervision, at least one before the workshop takes place, counselors can discuss their feelings and experiences with sickness, dying, death and solitude.
4.2. Handling countertransference feelings Especially during the first few hours of the workshop it is possible that a participant (or several) has trouble dealing with his anxiety. This participant, for example, could be anxious to get in touch with his feelings, feelings such as grief, ‘pain’, or relief. In order to control these anxieties, the participant could become very critical: he takes on the role of aggressor. A counselor should not take the participants’ critical comments personally, but may consider whether or not such a reaction is part of the group process. For example, after the introduction during which the counselors are introduced, the participants get the opportunity to ask questions about the program, and a participants reacts: ‘You do not know what it is like to lose your husband! You might have an education, but I don’t know if you can help me . . . ’ An inappropriate response of a counselor would be: ‘Counselor X has also lost her husband, so we do know what you are going through. But you could always leave.’ Aggression is answered with aggression and a ‘yes I do, no you don’t’ atmosphere develops. The climate becomes unsafe. In this example, the counselor not only did not recognize the participant’s underlying motives, but also acted-out upon his unrecognized feelings of anger by abusing his role as counselor in order to regain control: ‘you can always leave’. As said before, a smooth interaction with the co-counselor(s) and intervision may help in handling the countertransference feelings.
4.3. Finding the optimal balance between individual and groupwise interventions People who are mourning need their defenses more than usual: the psychological and physical pain is sometimes unbearable, and, therefore, it could be helpful if one does not feel anything. Many counselors believe it is important for the bereaved to
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express their emotions. Interventions are often aimed at facilitating this, but one forgets to respect the personal limitations that the bereaved has. In general, it does not take long to let someone ‘get in touch with his feelings’, but it takes a long time to teach someone to cope with these difficult feelings, which cannot be accomplished within the short time of the workshop. Hence, all interventions aimed at breaking down the defenses are strongly discouraged and avoided. This is done by approaching the feelings of a group member indirectly and in general terms. For example, when it turns out during a sub-group exercise that a participant has a lot of trouble dealing with his emotions, then this can be dealt with in general terms, directed at the group: ‘People handle their emotions very differently. One person might be able to cry a lot and realize that this gives him comfort. Someone else might ‘swallow’ his tears and have the idea that this comforts him. Of course it can also give you an unpleasant feeling, if you think that you cannot cry. It could be that you are crying in your mind, but that your body is not up to crying yet. Allow your body some time. Sometimes it is helpful to tell the people around you that you would like to cry, but you cannot. After all, every one has his own way of dealing with his feelings and this is good . . . ’. This intervention at group level acts as an indirect, individually directed interpretation. Not only the person in question, but also the other group members can identify themselves with this example. A type of group cohesion develops which stimulates the group’s ego-strength: the counselor’s influence on the group processes diminishes — temporarily — and the group members experience that they do not ‘stand alone’. Such an intervention has the advantage that each group member’s responsibility for his contribution to the group is appealed to. Although, it is preferable to intervene as much as possible on a group level, there are however situations in which it is important to work on an individual level for a short while, before one intervenes at a group level. When a participant has an intense emotional breakdown, it is important, as is mentioned earlier, to identify and explain these emotions on an individual level. When one does not do this, the group will identify with this person and regression occurs: the group becomes unsafe.
A direct intervention on a group level is called for when the group becomes tense: ‘During the period after the loss of your wife some people are overwhelmed by their feelings, which can sometimes lead to the idea that they are losing their grip. At this time mister X has the feeling that he does not want to continue any more. Maybe someone recognizes this feeling and wants to share with us how he coped with that feeling.’
4.4. Handling the participants feelings of anger In the setting of the workshop with bereaved, two important causes can be pointed out as possible underlying mechanisms of aggression: fear of losing control (‘if only I can hold back my tears’) and the mechanism of projection (‘my husband died in the hospital, so the whole health care system fails’). A good intervention towards an aggressor is recognizing the aggression and labelling it as positive (‘I think it is admirable that you have said this, and you are right: no one can feel exactly what you are going through.’) The counselor does not start defending himself in this case. After the individually directed intervention, he continues on a group level. A general comment can be made, based on the basic assumption of the fear of losing control and the mechanism of projection (fear of losing control: ‘Something about being here: it is possible that you feel at ease here. However, for many people it could also be a tense situation. Everyone responds in his own way. If you feel ill at ease, give yourself time to adjust . . . ’).
4.5. Handling the ‘ silent’ participant Chances are that there are more ‘silent’ participants in a workshop than in a bereavement counseling group: the workshop’s format allows the participants to keep up their defenses. It was pointed out earlier that defenses serve a useful purpose, and that these should be respected in the setting of the workshop. However, it would be a misconception if the counselor thinks that the ‘silent participant’ can manage. One should check regularly with the ‘silent participant’ if the mental burden does not exceed the limits of his tolerance, and whether he feels comfortable with his role as ‘silent group member’.
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5. Conclusion The current support facilities for problems with the bereavement process are not always easily accessible. In particular, this concerns those people who need ‘a helping hand’ shortly after the loss from people outside of their social circle. The workshop for bereaved has been developed to provide for this hiatus. In the first place, the workshop offers bereaved information about bereavement and support facilities for bereavement problems. Secondly, the workshop gives people the opportunity to meet fellowbereaved. The workshop is not intended as a therapy and therefore, is not suitable for people who seek therapy or for whom individual counseling would be better (for example, in case of a panic disorder). The short-term support program, as the workshop can be described, pays much attention to creating a safe climate. A structured program, alternating between group, sub-groups, and small groups within subgroups and intervening mostly on a group level are mentioned as important factors which discourage regression. Moreover, the interventions which are applied are mostly intended to support, and group psychotherapy is deliberately avoided. The reasoning behind this is that the workshops are intended for anyone with bereavement problems and not specifically for people who are going through a pathological bereavement process. Even though it is expected that the workshop will be a contribution to the prevention of pathological bereavement, it is possible that for a small group of bereaved, psychotherapeutic bereavement counseling will eventually be indicated. As it is clearly pointed out that this workshop is not a therapy group, several of these people will go directly on to psychotherapeutic counseling. For another group the workshop could be a step towards more intense counseling. However, the workshop’s target group consists of people for whom the bereavement process has no complications, but who need a little extra support. The workshops are based on the assumption that bereavement is a normal reaction to an abnormal situation, and that it is not a pathological reaction. To provide psychotherapy for this group would mean that normal bereavement becomes pathological too early in the process.
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As has become clear, the workshop for counseling bereaved persons has not become a regular part of the mental health care so far. Based on our experiences with workshops for bereaved persons, we believe that this type of support can be an addition to the existing support options for bereavement. Especially for those bereaved who need support shortly after the loss, as well as for people who do not obtain the desired support right away, or for those who cannot afford the available support facilities, can the workshop be a — temporary — solution. This is assuming that the workshop can be included structurally in the health care services. We therefore hope that counselors are motivated to offer the bereaved persons, who are in need of this, a ‘shoulder to lean on’ through this workshop.
Acknowledgements In developing the program for the workshop many people helped us, and we would hereby like to thank all these people for their commitment: we especially wish to thank Prof. Marco de Vries and Dr. Henk Schut.
References [1] Zisook S, Shuchter SR, Sledge P. Diagnostic and treatment considerations in depression associated with late-life bereavement. In: Schneider LS, Reynolds CF, Lebowitz BD, et al., editors. Diagnosis and treatment of depression in late life. Washington: American Psychiatric Press, 1994. [2] McIntosh JL. Older adults: the next suicide epidemic?. Suicide Life-Threat Behav 1992;22:322–32. [3] Schut HAW, Stroebe MS. Does help help? Paper presented at the Fifth International Conference on Grief and Bereavement, Washington, 25–29 June, 1995. [4] Cleiren MPHD, Diekstra RFW. After the loss. Bereavement after suicide and other types of death. In: Mishara BL, editor. The impact of suicide. New York: Springer, 1995:7–39. [5] Stevens NL. Widowhood, well-being, and the quality of primary relationships. In: Knipscheer KCPM, Antonoucci TC, editors. Social network research: substantive issues and methodological questions. Amsterdam: Swets and Zeitlinger, 1990:83–90. [6] Lund DA, Caserta MS, Dimond DF. Gender differences through two years of bereavement among elderly. The Gerontologist 1986;26:314–320.
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[7] Cleiren MPHD. Adaptation after bereavement. Leiden: DSWO Press, 1991. [8] Schut HAW. Omgaan met de dood van de partner (Coping with conjugal bereavement). Amsterdam: Thesis Publishers, 1992. [9] Gask L, Eurelings-Bontekoe EHM. Disseminating mental
health skills: parallels between treatment and training. Eur J Psychiatry 1995;9:242–50. ¨ [10] Diekstra RFW. Over suıcide (About suicide). Alphen a.d. Rijn: Samson, 1981. [11] Whitaker DS, Liebermann MA. Psychotherapy through the group process. New York: Atherton Press, 1964.
Workshops to support the bereavement process a, b b Ellen E. Beem *, Elisabeth H.M. Eurelings-Bontekoe , Marc P.H.D. Cleiren , Bert Garssen a a
b
Helen Dowling Institute, Postbox 25309, 3001 HH Rotterdam, The Netherlands Section of Clinical and Health Psychology, University of Leiden, Leiden, The Netherlands
Received 28 March 1997; received in revised form 4 September 1997; accepted 11 September 1997
Abstract When a bereaved person is in need of extra support during the bereavement process, at present four types of support can be distinguished: professional individual- and group counseling and non-professional individual- and group counseling. In this article another support facility is proposed: the workshop. It is indicated that the workshop can be considered as a valuable addition to the current counseling alternatives for bereavement and can possibly prevent more serious bereavement problems. After an explanation of bereavement counseling, the set-up of the workshop is described. Special attention is payed to the group dynamic aspects of the workshop. 1998 Elsevier Science Ireland Ltd. Keywords: Bereavement; Counseling; Workshops; Support
1. Introduction Although the death of a close relative or friend is considered to be one of the most drastic events in a person’s life, not every bereaved person needs (non)professional help to get through this period of bereavement. The majority of the bereaved are persons over 65 years of age [1]. People from this age group are particularly vulnerable to and at risk for the development of depression and suicidal behaviour after a major life event, such as the loss of a beloved one [2]. When it becomes evident that the bereaved person does need extra support, one has to make a distinction between psychotherapy and coun*Corresponding author. E-mail address: [email protected]
seling. Psychotherapy is indicated when there is a severe disturbance in daily functioning, that is out of control for the bereaved person and often associated with pre-existing problems. This extensive form of support is provided by professionals. However, when the disturbance in daily functioning is mild, counseling can be offered both by professionals as well as by non-professionals. In this article the focus will be on grief counseling. The bereaved person can make a choice out of four support facilities: professional individual counseling, professional group counseling, non-professional individual counseling and nonprofessional group counseling. Professional counseling is given by psychotherapists, social workers, psychiatrists, and nurses with additional training. Non-professional counseling consists of support from
0738-3991 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0738-3991( 98 )00044-5
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volunteers in health care and support from people who have suffered a loss themselves. Depending on the need for support of the bereaved person, each of these types of support plays an important part in bereavement counseling. Although professional support facilities are considered to be inappropriate by the majority of counselors within the period of half to one and a half years after the loss [3], our clinical experiences with bereaved persons over the past 5 years have shown that, by all means, it is a mistake to consider counseling to be inappropriate during the first 6 months after bereavement. The provision of attention and support immediately after the loss may prevent much unnecessary grief. Especially, if the attention and support given by the own social environment of the bereaved person has not the quality and / or quantity needed, counseling can be valuable. How accessible is support for bereaved persons? Difficulties in accessibility may be due to the following three factors: (a) theories about mourning; (b) problems of communication between potential, bereaved clients and counselors; (c) financial aspects.
probably not doing it right, because I should be able to do it myself, but I can’t.’
1.2. Problems in communication between potential, bereaved clients and counselors Many especially elderly bereaved persons consider it to be a weakness when they need support in bereavement, and this makes it difficult for them to ask for help with problems. Although it is important that (non)professional help in bereavement is offered with a low threshold, a downright question for help from the bereaved person in a mildly disturbed grieving process is the only rationale for offering (non)professional help. An additional problem is that the communication between counselors and bereaved sometimes is not optimal. The bereaved person often has no idea where and which support facilities are available. When a health care institute organizes bereavement counseling, it is possible that a telephone operator has not been informed about the name of the person who could give the bereaved information about bereavement counseling.
1.1. Theories about mourning 1.3. Financial aspects It is difficult for the bereaved to receive counseling for a non-urgent request within the period of 6 months after the loss. Often, only non-professional support is available. Professional counselors tend to advise to take time to grieve. This advice is based on the theoretical stage and / or phase models, which assume that the process of mourning is characterized by several stages or phases to go through. It is expected that ‘the pain’ becomes less with the passage of time. If this is not the case after a year and a half, then there is the possibility of a stagnated bereavement process and only then professional support or help would be indicated. However, nowadays there are strong doubts about the validity of such theoretical stage models [4]. Indeed, time is an important factor in the bereavement process, but when the bereaved person does not have the capacity to work it through by himself, counseling must be available. When people with a recent loss are not given the help they subjectively need, they are not only strengthened in their idea that ‘you have to do it yourself’, but they can also get the feeling that ‘I am
Professional counseling for bereavement is quite expensive and is not always reimbursed by health insurance. These costs contrast sharply with the costs of services from non-professional counseling which is often very cheap or free of charge. The accessibility of support facilities is therefore partly determined by the financial resources of the bereaved. So, due to several factors, the current health care system always provides optimal support to those who suffered a recent loss, which might be considered an undesirable situation given the fact that various studies show that a large percentage (5–24%) of the bereaved still have above average to severe problems 1–2 years after the loss [5–8]. This all led us to develop a 2-day workshop, especially suited for those who are most vulnerable, the elderly. Our experiences with this alternative type of support in bereavement are positive. However, such a design for bereavement support has a few group dynamic aspects that differ somewhat from a bereavement counseling group. The format of the workshop is
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described in this article, followed by a discussion of several related group dynamic aspects.
2. Theoretical background of the workshop The format of the workshop has been based on 7 years of research on bereavement and an extensive research of the therapy literature [9]. Gask and Eurelings mentioned seven important non-specific contextual factors which foster successful outcome in therapy: (a) interventions need to be flexible both in nature and in frequency; (b) providing information and knowledge is not enough, it is important to increase self-efficacy and self-control by providing the opportunity to practice new skills; (c) it is important to aim at cognitive restructuring; (d) interventions should be provided within a warm emotional relationship; (e) it is important to cope with compliance problems by working on the participation principle; (f) home-practice is important to maintain changes; (g) attention should be paid to the involvement of significant others. As will be outlined later on, many of these contextual factors are incorporated in the workshops. The interventions provided are flexibly attuned to the needs of the participants, cognitive interventions are provided to aim at self-control and self-efficacy. Finally, in addition to the provision of information, much effort is directed at fostering emotional expression within a holding environment.
3. Description of the workshop
3.1. Aim of the workshop The principal aim of the workshop is to give information and insight to the bereaved person about what one can expect in bereavement and which support facilities are available. In addition, the participant has the opportunity to meet people who find themselves in similar situations, whereby elements of recognition, sharing and modelling are important. Furthermore, there is ample space for emotional release.
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3.2. Characteristics of the counselors The counselors must be familiar with individual and group processes, have experience with discussion and intervention techniques and be up to date on current theories on bereavement. Furthermore, one must be capable of organizing a structured program. According to our experiences, a workshop can be given by professional and non-professional counselors, as long as they satisfy the aforementioned description. It is desirable to have two counselors for every 12 participants.
3.3. Characteristics of the participants Because of the importance of sharing of experiences and the possibility of recognition, it is recommendable to opt for a homogeneous group f.i. with regard to the relationship to the deceased: the participants of our workshops were homogeneous in the sense that they all had suffered the loss of a partner. Furthermore, the workshop has no restrictions concerning time after the loss: participants with a recent loss are as welcome as are people who have suffered a loss several years ago. For a few participants the workshop in itself will provide enough support during a difficult period and might as such have a secondary preventive quality. Other participants might need additional support and help: especially for this group of people it is important to provide information about support facilities available in their neighbourhood. The maximum number of participants is 35 with a minimum of 20. When the group counts more than 35 persons, group cohesion may be severed: the participant will feel ‘lost’. Furthermore, such a large group will form a large number of sub-groups. Within the setting of the workshop (two sessions), it is not possible for the counselors to recognize and control the interactions taking place in all the different sub-groups and these interactions will influence the goals of the workshop in a negative way. A group with less than 20 participants will give rise to too strong cohesion and personal involvement which may give the group a more therapeutic character, which goes beyond the aim of the workshop.
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3.4. Recruitment of the participants Prior to the workshop, referring institutes have received a letter with information about the aims and the target group of that particular workshop. This letter clearly states that this workshop is not a therapy group, and that it is not intended for people who want individual attention or who have always been anxious and / or tense. Furthermore, the same information about the workshop is given by regional newspapers and radio stations. By presenting the workshop as a setting in which people are invited to learn something, the workshop is especially inviting for bereaved persons who do not want help and who do not want to be ‘weak’, which is, according to our experiences, in particular characteristic of elderly people. Because the workshop is not meant to be a therapeutic group, there is no intake procedure.
3.5. General strategy for intervention The workshop’s intention is based on the idea of ‘safety’. The program is highly structured in order to provide a basis for a safe environment for the participants. For instance, there should be no deviation from the starting time and the finishing time. In addition, there is respect for the participants defences. Besides the concept of ‘safety’ two other elements can be identified that play an important role in the workshop: (a) the alternation between providing information and time for one’s own experiences and feelings, referring to the earlier mentioned importance of the factor of intervening within an emotional context and (b) the alternation between working in the large group or in a sub-group, which refers to the earlier mentioned concept of flexibility. The counselors are restricted in the possibilities of giving individual counseling because the workshop has a limited duration. This is the reason for choosing an intervention strategy in which only those interventions are applied that can be conducive to a safe environment (supportive interventions) and which basically take place at the group level. Occasionally, interventions on an individual level cannot be avoided; for example, in case of severe distress of one of the participants, one may first identify the participant’s intense emotions, but subsequently one
has to address these on the group level. Group members can be invited to share their own — possibly similar — experiences (recognition).
3.6. General organization of the workshop The workshop consists of 2 days which are not successive, because for many people who are going through the bereavement process it is difficult to absorb information and to actively confront the grieving. Instead, the first and the second workshop days are separated by a week. For most participants this provides the opportunity to integrate their emotions and to be open for information and experiences which are presented on the second day. Every workshop day begins and ends with a block of information, and in between, exercises are done which provide cognitive insights. At the change of a block, a half hour break is given: this gives participants the chance to adjust and to meet other participants. The information is presented to the whole group of participants in a spacious room with chairs which are placed in rows. Audiovisual aids, such as slides or videos, can be used to supplement the information block. There is a maximum of 18 participants for the insight-providing exercises which implies that the maximum amount of participants is split up, after the information block, into two subgroups which work in separate rooms with their own counselor. The setting is different: chairs are now arranged in circles in order to facilitate the communication. Depending on the available time, a choice is made to do either one or two insight-providing exercises. These exercises take place in small groups of about three participants, after which the exercises are discussed in the subgroup. The counselors see to it that the participants take turns in doing the exercises.
3.7. The first workshop day The first workshop day starts with a word of welcome and an introduction. Information about bereavement is given by several experts (medical doctor, psychologist, therapist) who explain in plain language, from their own area of expertise, what bereavement can bring about. This information is presented in short lectures at the beginning of the
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workshop. After the break the group of participants is split up into two smaller groups and an exercise is done to introduce participants to each other. In groups of three, participants answer questions, provided by the counselors, which aim to encourage getting to know each other: for example, who are you, what happened and when, and why did you come here. The counselors make sure that every participant feels comfortable and gets the space that he needs. The reactions of the participants are discussed in the session with the sub-group. The counselors encourage the participants to speak from their own feelings and experiences (not the story ‘as told by the neighbour’). The questions which are discussed in the subgroups must be decided beforehand and must have a logical sequence (an example of the exercises is given in Fig. 1). The next exercise consists of two questions which are focused on how you ‘see’ yourself. The second and last block of information of this first workshop day follows after this exercise, and three aspects are covered. First, the participant’s experiences are recounted (summary of the day) and are placed within a theoretical framework. It is emphasized that there is no particular fixed duration of the mourning process, and that there are no particular rules about
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‘how to mourn’. This also implies that bereavement does not necessarily take place in strict phases. Secondly, information is given about services which can be consulted in case of emergency (the general practitioner is mentioned as one of the options). Thirdly, the day is closed at a meta-level (for example: ‘Today a lot of things were covered, and soon everyone will go his own way. Some people could feel tired. Don’t be surprised if you feel tired because it is only natural to feel tired when a lot has happened. It could also be that you won’t feel tired at all when you get home. This is also possible. Not everyone experiences this day in the same way.’)
3.8. The second workshop day The structure of the second workshop day is comparable to the first one: once again the day starts and ends with a block of information, and the middle section consists of insight providing exercises, hence of cognitive restructuring. The second workshop day starts with an introduction of a short film in which various people express their loss in their own way. After showing the film, the content of the film is placed within a theoretical framework as discussed on the first workshop day. Once again it is empha-
Fig. 1. Questions for insight-providing exercises in sub-(sub-)groups.
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sized that everyone tries to find his own way to cope with the loss. After the break participants have the opportunity to discuss several questions in small groups within the subgroups. The questions, which are raised in this insight-providing block, are directed at the coping capacity of the participants: did you find different ways to cope with the new situation, what do you need, and what are you going to do to get it. The closing block of information includes a review of the experiences of the second day as well as those of the first day. Attention is paid to the importance of mourning: ‘it is something personal, it belongs to you and the deceased’. How to ask for support in your circle of friends and relatives is also a topic, as is the fact that everyone needs a ‘shoulder to lean on’ at some time or another. Asking for help is allowed, and it is not a sign of weakness. Attention is paid to what to do if you cannot find enough support in your own surroundings. After a closing, which once again takes place at a meta-level, the participants are told where to find the available information on bereavement counseling in the area and are given the list of addresses of the participants (only listings based on prior, written permission from the relevant participants). After the entire workshop has come to an end, participants have a chance to chat over a drink with fellow participants.
3.9. Crisis intervention Depressed feelings are inextricably linked to mourning. Everyone who mourns has moments of ‘not seeing a way out’. Many bereaved have caught themselves with a feeling of ‘it’s not worth it any more’. Therefore, it is difficult to clearly draw the line between the normal feelings of depression and latent suicidal expressions. When someone remarks on the meaninglessness of life, it cannot be assumed that this is an ordinary expression of depression. It is important to have more information about the feelings of the participant. Although the chance that a crisis situation develops is kept minimal by means of the structured approach of the workshop, it is possible that a participant decompensates. If the capacity of the participant has been overtaxed, an individual session outside the context of the group is necessary. Sometimes, it helps the participant when the counselor makes an appointment to call within a
few days to ask the participants how he feels (offering some structure out of the workshop setting). All efforts should be made to help the participant, whereby extra attention must be paid to latent or manifest suicidal expressions. Depending on the situation, one can respond immediately or later on in the workshop (individual level). Diekstra’s indications [10] for suicidal behaviour can serve as guidelines. In case, there might be an indication for suicidal behavior it is important to get help from a G.P. and / or psychiatrist. In addition, it is important that participants are aware of the support possibilities when they encounter a crisis. It is advisable to pay attention in the workshop to those care facilities which are available in their network and how one can obtain and utilize this type of care (family, friends, general practitioner, minister / priest). The S.O.S. telephone service could be mentioned which can be reached 24-h a day.
4. Group dynamic aspects in the workshop Within a group dynamic context, the following four aspects will be highlighted: (a) handling the unresolved focal conflict; (b) handling countertransference feelings; (c) finding the optimal balance between individual and groupwise interventions; (d) handling participants feelings of anger and (e) handling the ‘silent’ participant.
4.1. Handling the unresolved focal conflict The workshop consists of a group of participants and a few counselors. It is obvious that all kinds of group dynamic processes will take place. Everyone will encounter a loss through death at some point in life. Many counselors will have their own experiences with bereavement, which may give rise to unrecognized countertransference feelings. For example, the counselor could disclose to the group his own experiences with bereavement without questioning its significance for the group. When the sharing of the counselors’ own feelings and / or experiences arises from feelings of uneasiness and own grief, his role becomes unclear for group members. This ambiguity intensifies the regression which leads to an unsafe climate to work in. An
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important process, which may occur as a reaction of the group to intense feelings or desires of one or more of the group members and / or counselors, is the focal conflict. One type of focal conflict that may arise in a group is that between grieving and the desire to be attended to on the one hand and the fear of losing one’s autonomy on the other [11]. When the counselors do not have sufficient insight into their own feelings about death and loss, this can cause them to look for a restrictive solution in which only one side of the conflict is exposed. In this case we speak of an unresolved focal conflict. For example, the counselors’ own (sometimes unrecognized) defense mechanisms could cause the counselor to satisfy his own desire to help by giving advice. This restrictive solution of the focal conflict can lead to strong reactive feelings in the group. A reactive response could be anger. A group member might respond, without apparent, immediate reason, with ‘all this soft business: I came here for factual information, because mourning I can do on my own’ with which he expresses the other side of the conflict, the fear of losing one’s autonomy. This, in turn, can lead to anger on the side of the counselor. If the counselor expresses these countertransference feelings, it can greatly disturb the interaction between counselors and the group. The disturbance of the group process by an unresolved focal conflict due to the counselor’s intra-psychic processes, can be avoided by applying the following guidelines. First, it is important that ground rules are agreed upon between the counselors: who has which responsibility, and how does one, within the program of the workshop, apply this responsibility. This agreement must also include how and when feedback should be given. Because the workshop does not specifically make use of group dynamics (after all, it is not a therapy group), it is recommended not to give feedback to a co-counselor in the group. If a counselor cannot handle the emotions of a particular participant, then it is important that he leaves the intervening to this person to a colleague. In a good team of counselors this handing over can often be done with a non-verbal sign. Secondly, it is very important to create the possibility of intervision focusing on how the counselor deals with his own experiences with bereavement. Not only does a good counselor realize what bereavement means to him personally, it is also important that he trains his
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introspective abilities, for example, ‘why I am intervening now?’ and ‘what triggers my irritation?’ It is indeed true that also experienced counselors can be confronted by situations which trigger their own defenses. By having mandatory intervision, at least one before the workshop takes place, counselors can discuss their feelings and experiences with sickness, dying, death and solitude.
4.2. Handling countertransference feelings Especially during the first few hours of the workshop it is possible that a participant (or several) has trouble dealing with his anxiety. This participant, for example, could be anxious to get in touch with his feelings, feelings such as grief, ‘pain’, or relief. In order to control these anxieties, the participant could become very critical: he takes on the role of aggressor. A counselor should not take the participants’ critical comments personally, but may consider whether or not such a reaction is part of the group process. For example, after the introduction during which the counselors are introduced, the participants get the opportunity to ask questions about the program, and a participants reacts: ‘You do not know what it is like to lose your husband! You might have an education, but I don’t know if you can help me . . . ’ An inappropriate response of a counselor would be: ‘Counselor X has also lost her husband, so we do know what you are going through. But you could always leave.’ Aggression is answered with aggression and a ‘yes I do, no you don’t’ atmosphere develops. The climate becomes unsafe. In this example, the counselor not only did not recognize the participant’s underlying motives, but also acted-out upon his unrecognized feelings of anger by abusing his role as counselor in order to regain control: ‘you can always leave’. As said before, a smooth interaction with the co-counselor(s) and intervision may help in handling the countertransference feelings.
4.3. Finding the optimal balance between individual and groupwise interventions People who are mourning need their defenses more than usual: the psychological and physical pain is sometimes unbearable, and, therefore, it could be helpful if one does not feel anything. Many counselors believe it is important for the bereaved to
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express their emotions. Interventions are often aimed at facilitating this, but one forgets to respect the personal limitations that the bereaved has. In general, it does not take long to let someone ‘get in touch with his feelings’, but it takes a long time to teach someone to cope with these difficult feelings, which cannot be accomplished within the short time of the workshop. Hence, all interventions aimed at breaking down the defenses are strongly discouraged and avoided. This is done by approaching the feelings of a group member indirectly and in general terms. For example, when it turns out during a sub-group exercise that a participant has a lot of trouble dealing with his emotions, then this can be dealt with in general terms, directed at the group: ‘People handle their emotions very differently. One person might be able to cry a lot and realize that this gives him comfort. Someone else might ‘swallow’ his tears and have the idea that this comforts him. Of course it can also give you an unpleasant feeling, if you think that you cannot cry. It could be that you are crying in your mind, but that your body is not up to crying yet. Allow your body some time. Sometimes it is helpful to tell the people around you that you would like to cry, but you cannot. After all, every one has his own way of dealing with his feelings and this is good . . . ’. This intervention at group level acts as an indirect, individually directed interpretation. Not only the person in question, but also the other group members can identify themselves with this example. A type of group cohesion develops which stimulates the group’s ego-strength: the counselor’s influence on the group processes diminishes — temporarily — and the group members experience that they do not ‘stand alone’. Such an intervention has the advantage that each group member’s responsibility for his contribution to the group is appealed to. Although, it is preferable to intervene as much as possible on a group level, there are however situations in which it is important to work on an individual level for a short while, before one intervenes at a group level. When a participant has an intense emotional breakdown, it is important, as is mentioned earlier, to identify and explain these emotions on an individual level. When one does not do this, the group will identify with this person and regression occurs: the group becomes unsafe.
A direct intervention on a group level is called for when the group becomes tense: ‘During the period after the loss of your wife some people are overwhelmed by their feelings, which can sometimes lead to the idea that they are losing their grip. At this time mister X has the feeling that he does not want to continue any more. Maybe someone recognizes this feeling and wants to share with us how he coped with that feeling.’
4.4. Handling the participants feelings of anger In the setting of the workshop with bereaved, two important causes can be pointed out as possible underlying mechanisms of aggression: fear of losing control (‘if only I can hold back my tears’) and the mechanism of projection (‘my husband died in the hospital, so the whole health care system fails’). A good intervention towards an aggressor is recognizing the aggression and labelling it as positive (‘I think it is admirable that you have said this, and you are right: no one can feel exactly what you are going through.’) The counselor does not start defending himself in this case. After the individually directed intervention, he continues on a group level. A general comment can be made, based on the basic assumption of the fear of losing control and the mechanism of projection (fear of losing control: ‘Something about being here: it is possible that you feel at ease here. However, for many people it could also be a tense situation. Everyone responds in his own way. If you feel ill at ease, give yourself time to adjust . . . ’).
4.5. Handling the ‘ silent’ participant Chances are that there are more ‘silent’ participants in a workshop than in a bereavement counseling group: the workshop’s format allows the participants to keep up their defenses. It was pointed out earlier that defenses serve a useful purpose, and that these should be respected in the setting of the workshop. However, it would be a misconception if the counselor thinks that the ‘silent participant’ can manage. One should check regularly with the ‘silent participant’ if the mental burden does not exceed the limits of his tolerance, and whether he feels comfortable with his role as ‘silent group member’.
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5. Conclusion The current support facilities for problems with the bereavement process are not always easily accessible. In particular, this concerns those people who need ‘a helping hand’ shortly after the loss from people outside of their social circle. The workshop for bereaved has been developed to provide for this hiatus. In the first place, the workshop offers bereaved information about bereavement and support facilities for bereavement problems. Secondly, the workshop gives people the opportunity to meet fellowbereaved. The workshop is not intended as a therapy and therefore, is not suitable for people who seek therapy or for whom individual counseling would be better (for example, in case of a panic disorder). The short-term support program, as the workshop can be described, pays much attention to creating a safe climate. A structured program, alternating between group, sub-groups, and small groups within subgroups and intervening mostly on a group level are mentioned as important factors which discourage regression. Moreover, the interventions which are applied are mostly intended to support, and group psychotherapy is deliberately avoided. The reasoning behind this is that the workshops are intended for anyone with bereavement problems and not specifically for people who are going through a pathological bereavement process. Even though it is expected that the workshop will be a contribution to the prevention of pathological bereavement, it is possible that for a small group of bereaved, psychotherapeutic bereavement counseling will eventually be indicated. As it is clearly pointed out that this workshop is not a therapy group, several of these people will go directly on to psychotherapeutic counseling. For another group the workshop could be a step towards more intense counseling. However, the workshop’s target group consists of people for whom the bereavement process has no complications, but who need a little extra support. The workshops are based on the assumption that bereavement is a normal reaction to an abnormal situation, and that it is not a pathological reaction. To provide psychotherapy for this group would mean that normal bereavement becomes pathological too early in the process.
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As has become clear, the workshop for counseling bereaved persons has not become a regular part of the mental health care so far. Based on our experiences with workshops for bereaved persons, we believe that this type of support can be an addition to the existing support options for bereavement. Especially for those bereaved who need support shortly after the loss, as well as for people who do not obtain the desired support right away, or for those who cannot afford the available support facilities, can the workshop be a — temporary — solution. This is assuming that the workshop can be included structurally in the health care services. We therefore hope that counselors are motivated to offer the bereaved persons, who are in need of this, a ‘shoulder to lean on’ through this workshop.
Acknowledgements In developing the program for the workshop many people helped us, and we would hereby like to thank all these people for their commitment: we especially wish to thank Prof. Marco de Vries and Dr. Henk Schut.
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