Atlas›Domain VI · Brief, integrative, trauma, hypnosis & coaching›Guide 128
Guide VI-128

Grief counselling (tasks, dual process, continuing bonds)

J. William Worden, Margaret Stroebe, Henk Schut, Dennis Klass1996
A 31 · L 41 · M 2827 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Worden's tasks of mourning and ten counselling principles as given in Grief Counseling and Grief Therapy (4th ed. 2009; 5th ed. 2018, which "refines" the tasks). The task wording comes from published summaries. The Dual Process Model (DPM) follows Stroebe & Schut (1999) as restated by the authors in 2016 and in Stroebe's conference handout (the 2016 version adds "overload"). Continuing bonds follows Klass, Silverman & Nickman (1996) as summarised in secondary sources. Prolonged grief disorder (PGD) follows the ICD-11 and DSM-5-TR criteria. [source: Our House summary; Springer 5th ed. page; Stroebe & Schut 2016; Stroebe handout; Wikipedia "Continuing bonds"; Kaplow et al. 2024]

This is not a single manualised therapy. It is three practitioner models that are usually combined in bereavement counselling:

  • Worden's tasks of mourning: mourning is active work on four tasks, which are not a fixed sequence and can be revisited.
  • The DPM: adaptive coping means oscillating between loss-oriented and restoration-oriented coping, with some time off from both.
  • Continuing bonds: an evolving inner relationship with the deceased is a normal part of grief. It sits alongside acceptance that the death is permanent, and it is not a failure to "let go".

Taken together, change happens when the bereaved person:

  • takes in the reality of the death;
  • lets themselves feel the pain in tolerable doses;
  • rebuilds roles and daily life;
  • finds a place for the deceased that allows living on.

The counsellor works within normal grief and screens for prolonged grief, depression, PTSD and suicide risk, which need specialised treatment. [source: Our House summary; Ministry review 2011; Stroebe & Schut 2016; Wikipedia "Continuing bonds"]

Worden himself did not want grief counselling to become a new profession. He wanted existing helpers (clergy, nurses, social workers, physicians, family therapists, funeral staff) to work with more skill, and he rejected a "one-size-fits-all" approach. [source: Ministry review 2011]

2. Framework

Worden's four tasks (4th/5th ed. wording, paraphrased) [source: Our House summary; Ministry review]:

  1. Accept the reality of the loss. This means taking in the death fully, emotionally as well as intellectually. Funeral tasks or milestones often bring it home.
  2. Process the pain of grief. The pain can be emotional, cognitive, physical and spiritual. "Be strong, move on" messages work against this task.
  3. Adjust to a world without the deceased. This has three parts:
    • external: new responsibilities and skills;
    • internal: a changed sense of self;
    • spiritual: challenged beliefs and sense of meaning.
  4. Find an enduring connection with the deceased while embarking on a new life. The aim is a balance between the bond and full living.

The tasks overlap, have no fixed order and are revisited over time. Worden explicitly rejects stage models. [source: Our House summary; Ministry review]

Factors that affect mourning (Worden's book, ch. 3 "Mediators of mourning"; the 5th ed. adds social variables) [source: Springer page]. Student study notes on the book group the factors that hinder grieving as follows [source: Brainscape study notes on Worden; uncertain]:

  • Relational: for example a highly ambivalent relationship with unexpressed hostility.
  • Circumstantial: for example an uncertain loss or multiple losses.
  • Historical.
  • Personality: for example being unable to tolerate strong distress, or the "strong one" role in the family.
  • Social: losses that are unspeakable or socially negated, or no support network (Lazare). This includes disenfranchised grief.

[uncertain: the full list of Worden's mediators]

DPM structure [source: Stroebe handout; Stroebe & Schut 2016]:

  • Loss-oriented (LO) coping:
    • grief work and rumination;
    • intrusion of grief;
    • letting go, continuing or relocating bonds;
    • denial or avoidance of restoration changes.
  • Restoration-oriented (RO) coping:
    • attending to life changes;
    • doing new things;
    • distraction from grief;
    • denial or avoidance of grief;
    • new roles, identities and relationships.
  • Everyday life experience sits underneath both orientations.
  • Oscillation between LO and RO, including time off, is how grief is regulated.
  • Disturbed patterns:
    • chronic grief: persistent LO focus;
    • absent, delayed or inhibited grief: persistent RO focus and avoidance;
    • traumatic bereavement: disturbed oscillation.
  • Overload (2016): having more to deal with than one feels able to manage. It can be loss overload, restoration overload or dual overload.

Format and timing:

  • Delivery is individual, family or group. Grief support groups aim to give a safe space for all grief reactions. [source: Our House summary]
  • Approaches to offering help. Study notes on Worden list three [source: Brainscape notes; uncertain]:
    • offer counselling to everyone bereaved;
    • wait until the person asks or difficulties appear;
    • intervene early when risk predicts difficulty.
  • When to start: the same notes put the earliest start at about a week after the funeral [source: Brainscape notes; uncertain].
  • Session count: no fixed number is given in the sources cited [uncertain]. Grief counselling is typically brief and open-ended.
  • Specialised PGD treatment for contrast: Shear's Complicated Grief Treatment (CGT) has 16 sessions in four phases (see §4, Referral). [source: CGT Manual preview 2015]

Suggested working structure for counselling [synthesis]:

  • Phase A, Engagement and assessment (sessions 1-2). Cover:
    • the story of the death and of the relationship;
    • which tasks look active or blocked;
    • a DPM stressor inventory, with overload check;
    • the forms the continuing bond takes;
    • supports, culture and faith;
    • risk screening (suicide, PGD, depression, PTSD, substance use).
    Move on when the client has told the story and agreed a focus, and no acute risk needs another pathway.
  • Phase B, Task and oscillation work (about 4-10 sessions). Choose interventions according to which task is blocked and which orientation is over- or under-used. Review at every session whether grief is tolerable and life is resuming.
  • Phase C, Consolidation and ending (1-2 sessions). Plan for anniversaries and difficult dates, agree how the bond will be carried, and review ending as a further loss. Move to Phase C when:
    • grief comes in waves rather than constantly;
    • the client can talk about the deceased without being overwhelmed;
    • restoration tasks are under way;
    • a bond is held that does not stop the client from living.
    Refer instead when PGD criteria or another disorder emerge.

3. Guiding principles

Worden's ten counselling principles (as listed in study notes and AIPC; one-line practical meaning, paraphrased) [source: AIPC "Ten Commandments"; Brainscape notes]:

  1. Help the survivor actualise the loss. Invite concrete talk about the death, such as how they heard and what the funeral was like.
  2. Help them identify and experience feelings. Name anger, guilt, anxiety, helplessness and sadness. Give permission for "unacceptable" feelings such as relief.
  3. Assist living without the deceased. Problem-solve practical tasks and decisions the deceased used to handle, at the client's pace.
  4. Help find meaning in the loss. Explore what the life meant and what the client wants to carry forward.
  5. Facilitate emotional relocation of the deceased (in the study notes). AIPC words this as the transition to new relationships. Help the client find a place for the deceased that does not block new attachments. [uncertain: the wording differs between sources and probably between editions]
  6. Provide time to grieve. Anticipate anniversaries, birthdays and holidays, and plan for them in advance.
  7. Interpret "normal" behaviour. Reassure the client that intense grief is not "going crazy", while watching for signs that it goes beyond normal grief.
  8. Allow for individual differences. There is no single expected pattern or timeline.
  9. Examine defences and coping styles. Reinforce helpful coping. Name blocking coping such as substance use, compulsive activity, withdrawal or rushed relationships.
  10. Identify pathology and refer. In AIPC's words, "The goal here is to know when to refer."

DPM principles [source: Stroebe & Schut 2016; Stroebe handout]:

  • Both orientations are legitimate. Restoration work and distraction are coping, not avoidance to be broken down.
  • Oscillation is healthy. "One cannot cope the whole time", so plan time off from grief.
  • Match the work to the pattern. If loss focus dominates, build in restoration. If avoidance dominates, gently build in loss focus [synthesis for the matching step].
  • Watch for overload. When demands exceed capacity, oscillation alone is not enough. Help the client take active control of stressors and mobilise support.
  • Do not impose stages. Expecting a sequence can harm people who do not follow it.
  • Be cautious about forcing disclosure. The "dose" of grief work, and when it helps, are open questions.

Continuing bonds principles [source: Wikipedia "Continuing bonds", summarising Klass et al. 1996, Stroebe & Schut 2005, Field 2006]:

  • Do not push detachment. A continuing relationship with the deceased is normal.
  • Bonds coexist with acceptance and change over time. Ask how the bond is evolving rather than whether it should exist.
  • Bonds are not uniformly helpful. Assess how, when and for whom a bond comforts or hinders.
  • Internalised bonds are generally adaptive. These include comforting memories and the deceased as a secure base. Externalised forms that go with disbelief may signal non-integration.
  • Culture shapes what is adaptive. Ask about the family's and faith's ways of relating to the dead.

Cross-cutting stance [synthesis]:

  • Treat the client's account of the death and the relationship as their experience, not as facts to be investigated.
  • Never use imagery or suggestion to "recover" memories.
  • Follow the client's pace.
  • Address safety first in traumatic or violent deaths.

4. Intervention inventory

The inventory has four parts:

  • A. Worden's counselling principles used as interventions, and the techniques he lists.
  • B. DPM-based procedures.
  • C. Continuing-bonds work.
  • D. Screening and referral.

Worden's technique list, as recorded in study notes on the book, is: evocative language, symbols, writing, drawing, role-play, cognitive restructuring, memory book, directed imagery and metaphor [source: Brainscape notes; AIPC "Techniques"]. Where the sources cited give only a technique's name, the steps below are marked [synthesis].

A1. Telling the story of the death (actualising the loss)

  • Purpose: Task 1. Make the loss real by giving it concrete detail. Use early on, and whenever the client speaks as if the death has not happened. [source: AIPC "Ten Commandments"; Our House summary]
  • Steps:
    1. Ask open, concrete questions: where they were, how they heard, who told them, what they saw.
    2. Ask about the funeral or ritual, the last time they saw the person, and the grave or ashes.
    3. Listen without hurrying, and reflect specifics back.
    4. Return to the story across sessions; repeated telling is expected.
    5. With violent or traumatic deaths, keep to the client's chosen level of detail and check arousal (see §5). [synthesis for steps 3-5]
  • Example language (illustrative):
    • "Can you tell me how you found out that he had died?"
    • "What was the funeral like for you?"
  • Watch for: Over time the client uses past tense and makes fewer "it isn't real" statements. Flooding or numbing means you should slow down. Persistent disbelief well beyond the expected time is a screening cue for PGD. [synthesis]

A2. Evocative language

  • Purpose: Task 1 and Task 2. Plain words about the death bring home its reality and the feelings attached. [source: AIPC "Techniques"]
  • Steps:
    1. Use it only once rapport and trust are established; too early, it can feel insensitive. [source: AIPC]
    2. Use direct words ("died", "dead") instead of euphemisms ("lost", "passed").
    3. Speak about the deceased in the past tense.
    4. Pause and allow the feeling that follows. [synthesis for step 4]
  • Example language (illustrative): "When your son died..." rather than "When you lost your son..."
  • Watch for: A rupture if the client hears bluntness as coldness. Repair openly (§5). An emotional response followed by settling means it is working.

A3. Identifying and experiencing feelings

  • Purpose: Task 2. Name and tolerate anger, guilt, anxiety, helplessness and sadness, and give permission for feelings the client judges unacceptable, such as relief after a long illness. [source: AIPC "Ten Commandments"; Brainscape notes]
  • Steps:
    1. Notice and name feelings as they show (tone, tears, clenching).
    2. Ask about each common feeling directly; clients often will not raise anger or relief themselves.
    3. Anger: explore who or what it is directed at (doctors, God, the deceased, oneself). Look for anger turned inward.
    4. Guilt: list specific regrets and reality-test each one. What was known and possible at the time? Separate realistic guilt, which may need amends or ritual, from irrational guilt, which needs cognitive work (A8).
    5. Anxiety: link it to helplessness and to heightened awareness of one's own mortality.
    6. Validate each feeling without hurrying to resolve it.
    [synthesis for steps 3-5 beyond naming the feelings]
  • Example language (illustrative):
    • "Some people feel a kind of relief when a long illness ends, and then feel bad about that. Has anything like that been there for you?"
    • "What do you find yourself blaming yourself for?"
  • Watch for: Feelings that move and soften over sessions. Fixed self-blame, intense anger or hopelessness may point to depression or PGD (D1).

A4. Use of symbols

  • Purpose: Make the deceased present in the session so the client can talk about and to them. Supports Tasks 1, 2 and 4. [source: named in Brainscape notes; steps are synthesis]
  • Steps:
    1. Invite the client to bring photographs, letters, recordings or a belonging.
    2. Ask them to describe the object and the memories it holds.
    3. Use the object as a focus for feelings and for talking about the relationship. [synthesis]
  • Example language (illustrative): "Next time, would you like to bring a photo of her? I'd like to know who she was."
  • Watch for: Distress building too fast; agree beforehand that the client can put the object away. Also watch whether an object comforts or is used to avoid accepting the death (C2).

A5. Writing (letters to the deceased)

  • Purpose: Express thoughts and feelings, and address "unfinished business", meaning what was left unsaid. [source: AIPC "Techniques"]
  • Steps:
    1. Suggest a letter to the deceased saying what the client wishes they had said, or still wants to say.
    2. Encourage honesty and length where appropriate. [source: AIPC]
    3. Write in session or as homework.
    4. In the next session, ask whether the client wants to read the letter aloud or talk about writing it, and process the feelings that come up. [synthesis]
    5. Options [synthesis]:
      • a series of letters;
      • a journal;
      • an imagined reply from the deceased, only if the client finds this comforting.
  • Example language (illustrative): "If you could write to him now, what would you most want him to know?"
  • Watch for: Relief and completion versus rumination. If the letters turn into repetitive self-blame, switch to cognitive work.

A6. Drawing

  • Purpose: According to study notes, drawing can express feelings, show conflicts the mourner has not noticed, increase awareness of what was lost, and show where the person is in mourning. It is especially useful with children and with clients who find words hard. [source: Brainscape notes on Worden; uncertain]
  • Steps (synthesis):
    1. Offer simple materials and a broad prompt, for example the family before and after the death, or the client and the deceased.
    2. Ask the client to describe the drawing; do not interpret it for them.
    3. Explore any surprises.
    4. Repeat later to see change.
  • Example language (illustrative): "Could you draw what your family looks like now? Then tell me about it."
  • Watch for: Whether the images change across repeats. Avoid imposing your own interpretations.

A7. Role-play

  • Purpose: Task 3. Rehearse new roles, skills and feared situations, and build confidence in coping without the deceased. [source: AIPC "Techniques"]
  • Steps:
    1. Identify a situation the deceased used to handle, or a feared one, such as telling a colleague, a first social event alone, or dealing with a bank.
    2. Set the scene.
    3. Either you model the behaviour or the client practises it while you play the other person. [source: AIPC]
    4. Debrief and agree a real-world try. [synthesis for step 4]
  • Example language (illustrative): "Let's try it. I'll be the neighbour who asks how you're doing. What would you like to say?"
  • Watch for: Rising confidence and real-world attempts.

A8. Cognitive restructuring

  • Purpose: Thoughts shape grief feelings. Address irrational thoughts, "secret self scripts" and false guilt. [source: AIPC "Techniques"]
  • Steps:
    1. Identify the thought, for example "I'm all alone" or "I should have known".
    2. Test it against the evidence.
    3. Build a more realistic, functional alternative. [source: AIPC]
    4. Practise the alternative between sessions. [synthesis]
  • Example language (illustrative): "You've said you should have seen it coming. What did you actually know that week?"
  • Watch for: Do not argue the client out of grief itself; target only distorted appraisals. Less self-blame means it is working.

A9. Memory book

  • Purpose: Reminiscing and shared mourning for families. It builds mutual support and a fuller, more balanced picture of the deceased. [source: AIPC "Techniques"]
  • Steps:
    1. Invite family members to gather stories of significant events and memorabilia such as photos, poems and drawings. [source: AIPC]
    2. Assemble the book together over time.
    3. Use it in sessions to share memories, including mixed or difficult ones, at the family's pace. [synthesis]
  • Example language (illustrative): "What would each of you want in a book about Dad, the funny things as well as the hard ones?"
  • Watch for: Idealisation. Gently allow ambivalent memories. Watch for family members being excluded or overruled.

A10. Directed imagery

  • Purpose: Named in Worden's list. Typically the client imagines the deceased and speaks to them, to say goodbye or express what was unsaid. [source: named in Brainscape notes; procedure not given; uncertain]
  • Steps (synthesis):
    1. Get consent, and screen out clients with acute trauma intrusions, severe dissociation or psychosis.
    2. Do a brief grounding exercise with eyes open or closed, as the client chooses.
    3. Invite the client to picture the person in a safe, familiar setting.
    4. Invite them to say what they need to say. Keep it short, about 5-10 minutes.
    5. Bring them back to the room and orient them.
    6. Debrief.
  • Example language (illustrative): "If you'd like, picture her somewhere you used to sit together. What would you want to tell her?"
  • Watch for: This is not hypnosis and must never be used to retrieve or "check" memories of how a death happened. Stop if the client becomes flooded or dissociates (§5).

A11. Metaphor

  • Purpose: Named in Worden's list. Metaphors and images help clients express what they cannot say directly. [source: named in Brainscape notes; steps synthesis]
  • Steps (synthesis):
    1. Listen for the client's own images, for example "a hole in me" or "waves".
    2. Explore and extend the client's image rather than imposing your own.
    3. Track how the image changes over time.
  • Example language (illustrative): "You said it's like a wave. How big are the waves this week?"
  • Watch for: Shifts in the image that mirror progress, for example waves coming further apart.

A12. Problem-solving for living without the deceased

  • Purpose: Task 3 (external adjustment), principle 3. [source: AIPC "Ten Commandments"; Our House summary]
  • Steps:
    1. List practical tasks the deceased used to do, such as bills, estate, cooking, car, or parenting duties.
    2. Prioritise them.
    3. Break them into steps.
    4. Identify help available.
    5. Advise against major irreversible decisions while the client is in acute distress. [synthesis]
    6. Build independence gradually. [source: AIPC]
  • Example language (illustrative): "Which of the things she used to take care of is weighing on you most this week?"
  • Watch for: New skills and growing competence. Also watch for overload (B4).

A13. Meaning-making and legacy action

  • Purpose: Task 3 (spiritual adjustment) and principle 4. The aim is the reassurance that the death "was not in vain". [source: AIPC "Ten Commandments"]
  • Steps:
    1. Explore what the person's life meant and how the loss has changed the client's beliefs.
    2. Where it fits, consider honouring actions such as memorial work, fundraising or prevention advocacy. [source: AIPC]
    3. Respect the client's faith framework, and refer to chaplaincy if wanted. [synthesis]
  • Example language (illustrative): "What did he stand for that you'd want to keep going?"
  • Watch for: Meaning sought too early; it cannot be hurried. Also watch for advocacy that becomes all-consuming at the cost of grieving.

A14. Planning for anniversaries and difficult dates

  • Purpose: Principle 6, giving time to grieve. Birthdays, holidays and the anniversary reactivate grief. [source: AIPC "Ten Commandments"]
  • Steps:
    1. List the dates coming up in the next months.
    2. For each, plan with the client: how to mark it, who to be with, and what to do if it is hard.
    3. Review afterwards. [synthesis for detail]
    4. CGT uses a written "difficult times plan" for the same purpose. [source: CGT Manual preview]
  • Example language (illustrative): "Her birthday is next month. How would you like that day to go?"
  • Watch for: A spike in grief around these dates is expected. Normalise it beforehand.

A15. Normalising and psychoeducation

  • Purpose: Principle 7. Clients often fear they are "going crazy". Explain the range of normal reactions, including intense reactions after suicide. [source: AIPC "Ten Commandments"]
  • Steps:
    1. Describe common emotional, cognitive, physical and spiritual reactions, such as sensing the person's presence, searching, poor concentration and sleep change.
    2. Explain that the tasks are not a sequence and that grief oscillates (B1).
    3. Correct stage myths. [source: Stroebe handout; Our House summary; synthesis for the list]
  • Example language (illustrative): "Many people briefly hear or sense the person who died. On its own it isn't a sign something's wrong."
  • Watch for: Do not normalise away red flags such as suicidal intent, psychotic features or severe impairment (D1).

A16. Reviewing defences and coping styles

  • Purpose: Principle 9. Reinforce coping that helps and replace coping that blocks grief. [source: AIPC "Ten Commandments"]
  • Steps:
    1. Map the client's current coping together.
    2. Mark which helps (self-care, memorial activities, support) and which blocks (alcohol or drugs, overwork, total withdrawal, rushing into relationships).
    3. Plan replacements. [source: AIPC]
  • Example language (illustrative): "When the evenings get bad, what do you do? What does that give you, and what does it cost?"
  • Watch for: Substance misuse may need its own treatment.

B1. DPM psychoeducation and mapping

  • Purpose: Give the client a non-stage map of grief, and identify their current balance between loss-oriented and restoration-oriented coping. [source: Stroebe handout; Stroebe & Schut 2016]
  • Steps:
    1. Draw two columns with the client. Loss-oriented: grief work, intrusions, the bond, avoiding the changes. Restoration-oriented: life changes, new things, distraction, new roles.
    2. Ask the client to list last week's activities and moments in each column.
    3. Explain that moving back and forth, with time off, is healthy.
    4. Agree which side needs more time.
    [synthesis for the worksheet format]
  • Example language (illustrative): "Grieving tends to go back and forth: time facing the loss, time getting on with life, and time off from both. Where has your week gone?"
  • Watch for: Relief that "getting on with things" is not denial. Note any one-sided pattern (B3).

B2. Planned oscillation and time off

  • Purpose: Regulate the "dose" of grief. The authors stress that "one cannot cope the whole time" and that rest and "life goes on" activities are part of coping. [source: Stroebe & Schut 2016]
  • Steps (synthesis):
    1. Agree limited periods of deliberate loss-focus, such as looking at photos, writing or visiting the grave.
    2. Agree deliberate restoration and time-off periods, such as seeing friends, exercise or hobbies.
    3. Have the client record how each felt.
    4. Adjust the balance at the next session.
  • Example language (illustrative): "What if you set aside some time on Sunday for the letters, and planned something that takes you out of the house afterwards?"
  • Watch for: Guilt about enjoying time off; normalise it. Distress that does not ease after loss-focused time suggests pacing down.

B3. Rebalancing for one-sided patterns

  • Purpose: The DPM links chronic grief to persistent loss-focus, and absent or inhibited grief to persistent restoration-focus and avoidance. Traumatic bereavement disrupts oscillation. [source: Stroebe & Schut 2016; Stroebe handout]
  • Steps (synthesis):
    1. Loss-dominated: add graded restoration steps, such as one new activity, one practical task or one social contact, and agreed limits on rumination time.
    2. Avoidance-dominated: add small, consented loss-oriented steps, such as one memory, one photograph or one brief visit. Use A1, A4 and A5 at low intensity.
    3. Traumatic deaths: stabilise first (grounding, sleep, safety); work with intrusions before memorial work (§5).
  • Example language (illustrative): "You've been keeping very busy. Would you be willing to spend ten minutes here with one memory of him?"
  • Watch for: Avoidance that is also protecting someone else (B5). Loss-dominated patterns that persist past the PGD time thresholds (D1).

B4. Overload assessment and stressor control

  • Purpose: The DPM 2016 extension. Overload means more demands than the person feels able to manage. Sources include:
    • multiple losses;
    • conflict;
    • combined loss and restoration demands such as money worries;
    • non-bereavement demands such as caregiving.
    It may lead to burnout. Oscillation alone may not suffice; the person needs active control. [source: Stroebe & Schut 2016]
  • Steps:
    1. List all current stressors and rate how able the client feels to cope with each.
    2. Ask what tipped them over the edge, if anything. [source: Stroebe & Schut 2016]
    3. Ask what has helped most so far. [source: Stroebe & Schut 2016]
    4. Build control:
      • Openness: state needs and teach others how to help (Dyregrov & Dyregrov).
      • Say no to some demands.
      • Become directive about stressors.
      • Mobilise formal and informal support.
      • Reappraise burdens. [source: Stroebe & Schut 2016]
    5. Signpost practical help with money, benefits, housing and childcare. [synthesis]
  • Example language (illustrative): "Let's write down everything on your plate. Which of these could someone else take, and who could you ask?"
  • Watch for: Exhaustion, cynicism and helplessness, which suggest burnout. Physical health problems need medical review. [source: Stroebe & Schut 2016; synthesis for referral]

B5. Family and couple grief communication

  • Purpose: Stroebe's handout reports that bereaved partners who avoided talking about the loss to protect each other later showed more grief, in themselves and in the partner. [source: Stroebe handout]
  • Steps (synthesis):
    1. Ask each person what they hold back and why.
    2. Name protective silence and its cost.
    3. Set up a brief, structured sharing time, with each person speaking uninterrupted.
    4. Respect different styles: one may grieve through talking, another through doing.
    5. Use the memory book (A9) as a shared task.
  • Example language (illustrative): "It sounds like you've each been keeping your sadness away from the other to spare them. What happens to it then?"
  • Watch for: Blame between family members. Children's needs; see the youth-specific treatments in D2.

C1. Exploring the continuing bond

  • Purpose: Task 4. Understand how the client stays connected and whether each form comforts or hinders. [source: Wikipedia "Continuing bonds"; Our House summary]
  • Steps:
    1. Ask about each form of bond:
      • a sense of presence;
      • talking to the deceased;
      • dreams;
      • linking objects and places;
      • belief in the deceased's influence;
      • legacy, meaning traits or values the client has taken on;
      • rituals such as grave visits and candles. [source: Wikipedia "Continuing bonds"]
    2. For each form, ask whether it comforts or distresses, and whether it goes with acceptance that the person has died.
    3. Internalised forms, such as memories and the deceased as an inner guide, are generally adaptive. Externalised forms that go with disbelief may signal non-integration (Field 2006). [source: Wikipedia]
    4. Ask about cultural and religious norms; whether a bond is adaptive varies across cultures (Lalande & Bonanno 2006). [source: Wikipedia]
  • Example language (illustrative):
    • "In what ways is she still part of your life?"
    • "When you talk to him, how do you feel afterwards?"
  • Watch for:
    • A bond that brings comfort and lets the client live on.
    • A bond that requires keeping everything unchanged, or that comes with persistent disbelief.
    • A wish to join the deceased (suicide screen, D1).

C2. Linking objects, places and rituals

  • Purpose: Objects and places act as tangible anchors to the deceased, and rituals give the bond a form. [source: Wikipedia "Continuing bonds"]
  • Steps (synthesis):
    1. Identify the key objects and rituals.
    2. Explore their meaning.
    3. Help the client choose which to keep, display, pass on or let go, at their own pace.
    4. Plan rituals for significant dates (A14).
  • Example language (illustrative): "Which of his things matter most to you? Where do you want them to be?"
  • Watch for: Rooms kept untouched over long periods together with impairment. Objects used to avoid accepting the death. Neither is a problem in itself; assess whether the client is distressed or impaired. [synthesis]

C3. Legacy and identity integration

  • Purpose: Consciously carry the deceased's values or qualities forward as part of one's own identity. This supports Task 4's balance between the bond and a new life. [source: Wikipedia "Continuing bonds"; Our House summary]
  • Steps (synthesis):
    1. Ask what the client learned from or admired in the person.
    2. Identify one way of living that out.
    3. Link this to meaning-making (A13).
  • Example language (illustrative): "What of her do you see in yourself now?"
  • Watch for: Legacy that becomes an obligation to live the deceased's life instead of one's own.

C4. Continuing conversation: dialogue, letters and dreams

  • Purpose: Imagined dialogue and dreams are recognised forms of the bond. Structured conversations can address unfinished business. [source: Wikipedia "Continuing bonds"; AIPC "Techniques"]
  • Steps:
    1. Use letter writing (A5) or directed imagery (A10).
    2. Invite the client to tell you their dreams of the deceased and what they mean to them.
    3. Respect spontaneous private talk with the deceased as a bond, without pathologising it.
    [synthesis for steps 2-3]
  • Example language (illustrative): "You mentioned dreaming of him. What was that like?"
  • Watch for: Distressing recurrent dreams of the death itself are trauma-related; see §5.

D1. Screening for PGD, depression, PTSD and suicide risk

  • Purpose: Principle 10, identify pathology and refer. [source: AIPC "Ten Commandments"; Kaplow et al. 2024]
  • PGD criteria (DSM-5-TR):
    • Timing: at least 12 months since the death in adults (6 months in children and adolescents).
    • Core symptom: intense yearning for or preoccupation with the deceased.
    • Accessory symptoms: at least 3 of 8, nearly every day for at least the last month. They are identity disruption, disbelief, avoidance, intense emotional pain, difficulty moving on, numbness, meaninglessness and intense loneliness.
    • Other requirements: the reaction causes distress or impairment, exceeds cultural and contextual norms, and is not better explained by another disorder.
  • PGD criteria (ICD-11): persistent, pervasive longing or preoccupation with intense emotional pain, for at least 6 months after the loss, clearly exceeding social, cultural or religious norms.

[source: Kaplow et al. 2024]

  • Steps:
    1. Ask at intake and periodically about yearning, preoccupation, disbelief, avoidance, functioning and meaninglessness.
    2. Screen for depression and PTSD; these overlap with PGD but are distinct.
    3. Ask directly about suicidal thoughts, including a wish to be with the deceased. Severe separation distress can include such ideation. [source: Kaplow et al. 2024]
    4. Follow your service's standard risk-assessment protocol.
    5. Use a validated measure where available. For youth, the source names the PGD Checklist (ages 7-18). Do not reproduce items. [source: Kaplow et al. 2024]
    6. Study notes on Worden name four abnormal grief patterns: chronic, delayed, exaggerated (e.g., depression, phobia, substance misuse, PTSD) and masked (physical symptoms or behaviour not linked by the client to the death). [source: Brainscape notes; uncertain]
  • Example language (illustrative): "Sometimes when people miss someone this much they think about not wanting to be here, or wanting to be with them. Has that crossed your mind?"
  • Watch for:
    • Time thresholds plus impairment.
    • Grief worsening rather than coming in waves.
    • Comorbid depression or PTSD.
    • Substance misuse.
    • Suicidal intent: act on this the same day.

D2. Referral to specialised treatment

  • Purpose: PGD, and grief with major depression or PTSD, go beyond grief counselling. [source: AIPC "Ten Commandments"; Kaplow et al. 2024]
  • What specialised treatment looks like:
    • Adults: Complicated Grief Treatment (CGT; Shear, Columbia Center for Complicated Grief). The 2015 manual has 16 sessions in four phases:
      1. Getting started (sessions 1-3): history, psychoeducation, and involving a significant other.
      2. Core revisiting sequence (sessions 4-9): imaginal revisiting, situational revisiting and memories work.
      3. Midcourse review (session 10).
      4. Closing sequence (sessions 11-16): goals, a difficult-times plan and ending. [source: CGT Manual preview]
    • Children and adolescents: Multidimensional Grief Therapy, the Family Bereavement Program, and Trauma and Grief Component Therapy. TF-CBT and Grief and Trauma Intervention are used for traumatic bereavement. Peer support alone may be insufficient for PGD. [source: Kaplow et al. 2024]
  • Steps:
    1. Explain the reason for referral in non-blaming terms.
    2. Give named options.
    3. Offer bridging contact until the client is seen.
    4. Refer to medical care for comorbid depression where medication may be considered.
    [synthesis for steps 1-3]
  • Example language (illustrative): "What you're describing has a name, prolonged grief, and there's a specific treatment for it. I'd like to help you get to it."
  • Watch for:
    • A client who hears referral as abandonment.
    • Specialised methods practised without training. Imaginal revisiting is an exposure procedure; use it only after CGT training. [synthesis]

5. Handling problems

The sources cited say little about handling problems. Most of this section is [synthesis], with sourced points tagged.

  • Stuck in loss-orientation (constant yearning and rumination, no restoration activity):
    • Use B1 mapping.
    • Agree small restoration steps and time-limited grief periods (B2, B3).
    • Use cognitive work on beliefs such as "moving on betrays him" (A8), and frame the continuing bond as compatible with living (C1, C3).
    • If this persists beyond the PGD time thresholds with impairment, refer (D2).
    [source: Stroebe & Schut 2016 for the pattern; synthesis for the responses]
  • Avoidance, "I'm fine", or masked grief:
    • Do not force disclosure; the DPM authors treat the dose and benefit of grief work as open questions. [source: Stroebe handout]
    • Offer graded, consented loss-oriented steps (B3).
    • Watch for physical symptoms or behaviours the client does not link to the death. Study notes on Worden call this "masked" grief. [source: Brainscape notes; uncertain]
    • Respect the possibility that this person grieves mainly through action.
  • Overwhelm during a session (flooding, panic, dissociation):
    • Stop the content.
    • Orient the client to the present: name the room and the date, and do feet-on-floor grounding and paced breathing.
    • Shift to restoration or neutral topics.
    • Close with a containment step, such as putting the letter or photo away, and a plan for the evening.
    • Next session, lower the dose: shorter loss-focus with more time off (B2).
    • Repeated dissociation, nightmares or intrusions about the death mean trauma assessment, and stabilisation before any memorial or imagery work.
  • Traumatic or violent deaths (suicide, homicide, accident, disaster):
    • Safety and stabilisation come first.
    • Normalise the intensity of reactions after suicide. [source: AIPC "Ten Commandments"]
    • Do not use imagery to reconstruct the death.
    • Treat the client's account as their experience.
    • Refer for trauma-focused treatment if PTSD is present. [source: Kaplow et al. 2024 for traumatic-bereavement treatments; synthesis otherwise]
  • Suicidal ideation, including a wish to reunite with the deceased:
    • Ask directly and use your standard risk assessment. [source: Kaplow et al. 2024]
    • Make a safety plan.
    • Do lethal-means counselling, meaning safe storage or removal, including medicines left by the deceased.
    • Involve supports.
    • Escalate the same day if intent or a plan is present.
  • Overload, multiple losses or burnout:
    • Use B4: inventory the stressors, build openness and control, and mobilise support.
    • Check physical health.
    • Kastenbaum's "bereavement overload" from multiple losses is a recognised special case. [source: Stroebe & Schut 2016]
  • Non-adherence to homework (letters not written, grief time skipped):
    • Ask what got in the way. Often the dose was too big; halve it.
    • Offer an alternative format: speaking instead of writing, or drawing.
    • Check whether skipping is healthy time off or avoidance.
  • Ruptures:
    • Evocative language felt harsh: acknowledge it, explain your intent and agree preferred words. The source warns that early use can seem insensitive. [source: AIPC "Techniques"]
    • Client angry at the counsellor: this can be displaced grief-anger. Validate it, then explore.
    • Client feels rushed to "move on": return to the client's pace and re-explain oscillation and continuing bonds.
  • Ambivalent or abusive relationship with the deceased:
    • Study notes on Worden name highly ambivalent relationships with unexpressed hostility as the factor that most often hinders grieving. [source: Brainscape notes; uncertain]
    • Allow mixed feelings, and do not insist on a warm bond.
    • The continuing bond may be minimal or negative. Task 4 can mean finding a place for the relationship rather than keeping it close.
    • Abuse histories may need trauma-focused care.
  • Disenfranchised grief (loss not socially recognised, e.g., ex-partner, pregnancy loss, stigmatised death):
    • Explicitly validate the loss.
    • Help the client find recognition and ritual (C2).
    • Consider peer groups.
    [source: Brainscape notes citing Lazare for socially unspeakable or negated losses; synthesis for the responses]
  • Externalised bonds causing distress (frequent sensory experiences with disbelief):
    • Assess whether the experience comforts or frightens.
    • Screen for PGD and psychosis.
    • Do not challenge culturally normative experiences of the dead.
    [source: Wikipedia "Continuing bonds" for internalised vs externalised bonds and cultural variation; synthesis for the responses]
  • Family members grieving at different rhythms:
    • Normalise the differences.
    • Address protective silence (B5).
    • Agree shared rituals.
  • Cultural or religious mismatch:
    • Ask what mourning normally looks like in the client's community and faith.
    • PGD criteria require reactions to exceed cultural norms. [source: Kaplow et al. 2024]
    • Consult community or faith leaders with consent.
  • Unrealistic expectations of stages or timelines:
    • Correct stage myths [source: Stroebe handout; Ministry review].
    • Explain that tasks are revisited and that grief oscillates.
  • Ending treatment:
    • Treat ending as a further loss.
    • Plan ahead for difficult dates (A14).
    • Offer a review session around the anniversary.
  • Counsellor's own grief:
    • Worden's book has a chapter on the counsellor's own grief (ch. 9) [source: Springer page]. Its content is not drawn on here [uncertain].
    • Use supervision, track your own losses that a case activates, and limit your bereavement caseload when needed.

Sources

Sources:

Further reading (not drawn on):

  • Worden, J. W. (2009). Grief Counseling and Grief Therapy (4th ed.). Springer.
  • Worden, J. W. (2018). Grief Counseling and Grief Therapy (5th ed.). Springer.
  • Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197-224.
  • Stroebe, M., & Schut, H. (2005). To continue or relinquish bonds. Death Studies, 29.
  • Klass, D., Silverman, P. R., & Nickman, S. L. (Eds.) (1996). Continuing Bonds: New Understandings of Grief. Taylor & Francis.
  • Field, N. P. (2006). Unresolved grief and continuing bonds: An attachment perspective. Death Studies, 30.
  • American Psychiatric Association (2022). DSM-5-TR.
  • World Health Organization (2019/2022). ICD-11, 6B42 Prolonged grief disorder.

Further reading (not drawn on): the publisher sample chapter of Worden's 5th ed. (doi.org/10.1891/9780826134752.0001). Worden's grief-therapy procedures for complicated mourning (ch. 6) and the full mediators list (ch. 3) are therefore not covered from the primary source [uncertain].

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