Because of the uniqueness of an individual’s perception of grief and loss and the expression of grief, it is imperative that hospice bereavement programs (or anyone else seeking to offer grief support services) provide a variety of services to promote effective healing. The National Hospice and Palliative Care Organization’s (NHPCO) “Guidelines for Bereavement Care in Hospice” discuss the following under their chapter on “Availability and Scope of Services”:
Scope of Hospice Bereavement Services:
- Identify family members in need of bereavement support
- Assess patient and family strengths, bereavement risk, concerns and needs related to grief and loss
- Empower families to recognize and develop skills to manage grief by exploring ways they have effectively coped in the past and identifying areas of strength and resilience, assisting families in identifying social and spiritual resources for support
- Provide basic grief information and support through:
- Written materials
- Audiovisual educational resources
- Individual contacts
- Support groups
- Commemorative activities such as memorial services
- Counseling sessions with a bereavement counselor
- Social events
As one can see, there are numerous elements which comprise a comprehensive bereavement support service, and an understanding that it is not “one size fits all.”
Most hospice programs offer some form of supportive or educational materials which are mailed to the bereaved at minimum, along with regularly scheduled phone outreach. Additionally, some hospices offer varying amounts of individual counseling. Most also offer grief support groups.
There are numerous theories related to the grief process. A few that validate the concept and value of grief support groups are outlined here.
William Worden described grief as a process and suggested that people need to work through their reactions or feelings to achieve full healing or adjustment to the loss. In Worden’s model, there are overlapping tasks to be accomplished, necessitating the bereaved to work through their emotional pain, while at the same time, adapting to the changes in their lives resulting from the loss (such as financial, role identity, etc.). The tasks of mourning are complete when the bereaved has assimilated the loss into their lives in a manner which enables them to move into the present and look to the future.
Stroebe and Schut’s model suggests that grief is a more dynamic process which moves between focusing on the loss (referred to as loss orientation) and avoiding it (referred to as restoration orientation). Seen through a support group lens, individuals may benefit from efforts aimed at restoration-oriented coping, which offers the following to the bereaved:
- Distraction from grief
- Focus on new roles/identity/relationships
- Efforts to adapt to changes in life circumstances
Similarly, the social–functional perspective discussed by Bonanno emphasizes a shift of attention away from focusing on the expression of negative emotion. Instead, this model suggests that healing occurs when the “grief-related distress is minimized and positive emotion is activated or facilitated.”
Each of these models suggests that a bereavement support program, which enables the bereaved to learn new skills as they adjust to the changes in their lives, has some benefit. While engaging in a program or group which emphasizes this skill development, the bereaved are also provided an opportunity to learn new roles and develop new relationships, simply by virtue of their participation in a group with other people. At the same time—at least while participating in this experience, if not beyond it—they are also offered the chance to be distracted from what may be some of the more intense feelings associated with their grief.
A few considerations about bereavement groups are relevant here. A support group is not the same as a therapy group. While a support group can be therapeutic, it is distinct from therapy groups in that it does not focus on the psychological growth of the individual members, as most therapy groups would. Because we live in a society which often frowns upon “too much” emotion, or grief which lasts “too long,” and because many people live far away from supportive family, support groups can offer grieving individuals a supportive environment in which to work through some of their grief issues. For many individuals, there may be few places in their lives where they can receive this support or allowed to be themselves as they grieve. By introducing people to others who are going through a similar experience, support groups offer a way to “normalize” the grief experience. Groups offer participants the opportunity to learn new roles, problem-solving techniques, or coping strategies through discussion with the group facilitator and from listening to the experiences of other members. Furthermore, people who are grieving often benefit from the opportunity to reach out and help others; thus, participation in a group not only offers members the chance to be helped, but also to help others.
Support groups allow for a very cost effective way of providing services to numbers of people, particularly when resources may be limited. They also provide people with a place to share their story and talk about their loved one. It allows a safe place to express emotion and “try out” new ideas or new ways of behaving. Groups can provide individuals with an opportunity to develop new friendships by bonding with other group participants. Often, support groups provide people with a chance to laugh, learning that not all grieving needs to be sad and painful.
While traditional bereavement support groups have significant value—whether they are ongoing, drop-in (open) groups or time-limited, sign-up (closed) groups—the following suggestions offer ideas about how to make more traditional groups unique, as well as ideas which go above and beyond, or outside, the norm of these offerings.
Because many symptoms of grief are like those of stress, it is helpful to make this connection for bereaved people and help them to learn ways to manage their stress more effectively. This can include gentle stretching and deep breathing, meditation, gentle yoga, and sharing lists of stress reduction or self-care suggestions. There are fun self-assessments people can take to determine their stress level or how well they are taking care of themselves currently.
An example of a group activity which supports this concept is for participants to write suggestions for self-care strategies on slips of paper. These suggestions are subsequently placed in a basket. Next, each participant selects 2-3 slips of paper from the basket. They are instructed to implement the self-care strategies noted on the slips of paper they have selected over the course of the next week and to discuss their experiences at the next meeting. (Participants may re-select their self-care strategies if they have drawn a suggestion which is not feasible or unappealing).
Many groups have participants bring a photo of their deceased loved one to “introduce” him/her to the group. The photo can also be used to reminisce or share a memory. Sometimes, participants are asked to share the story related to the photo or just a memory of their loved one.
Many groups incorporate letter writing activities. Participants may write a letter to the deceased, write a letter to oneself from the deceased (what s/he might say to you now), or write a letter to the grief (making it a real entity).
Recognizing the importance of saying the name of the deceased and how often this is ignored, group facilitators can ask participants to write the name of their loved one on a piece of paper. Participants may write the name in any way they like (i.e., James Raymond Smith, Jr., Jimmy Smith, Big Jim, etc.). The names are subsequently placed in a basket. Then, each participant selects a slip of paper and the names are all read aloud.
Group facilitators may ask participants to bring a memento which reminds them of, or represents their loved one, and to tell the story about it.
Another meaningful group activity is passing around scraps of fabric or a variety of picture postcards. Each participant chooses one which reminds them of their loved one or of a story about him/her they would like to share. Then, each person takes a turn explaining their choice and telling their story related to it.
Some groups encourage participants to make collages which remind them of their loved one, or of what they envision the future might hold for them. This exercise can be completed as a group activity or as a homework assignment and brought to the group for discussion. For some people, having an activity which focuses their hands, eyes, etc. can make sharing their feelings a little less threatening. Thus, completing this exercise as a group activity may facilitate the sharing of emotions more effectively. Also, having a homework assignment can be intimidating for some individuals, so group facilitators should discuss this with the participants. Sometimes, a comfortable compromise may be to have participants prepare their materials during the week and to bring them to the group session for assembling together. Examples of items which may be incorporated into collages are photos, clippings of pictures, phrases from magazines or poems, pieces of fabric taken from a loved one’s clothing, and buttons or small pieces of jewelry.
Some groups, especially if they are time-limited, end by asking participants to write a letter to the next group of participants describing their experience, what to expect, and words of encouragement. These letters are subsequently read by the participants to the new group during its first session.
Open-ended questions which may generate dialogue during group sessions can include:
- How are friends and family members responding to your loss?
- Where are you finding the support you need?
- Can you share some of your fears?
- What do you wish you had done differently before or after the death?
- Are there times when it doesn’t seem real? What is that like and how do you deal with it?
- What did you gain from your loved one that you will always have?
- What special quality did they have that you would like to develop in yourself?
- Since no one is perfect, what was your loved one’s most irritating trait?
- What is the most difficult time of day? How do you manage it?
- What are your most difficult reminders (such as a favorite restaurant, the place where the loved one died, loved one’s favorite chair) and how do you deal these?
- What new role is most difficult for you?
- Where can you go for help?
What else can I do besides run groups?
Many organizations offer educational workshops as an alternative to bereavement support groups. These can be geared to the bereaved, those who care about them (their “natural helpers”), or both. Workshops can be one-time offerings or a short series. While workshops may have a supportive and therapeutic element, unlike groups their focus is educational. Most workshops are 2-3 hours in length. Examples of topics include:
- Coping with the Holidays
- Raising Grieving Children
- Spirituality and Loss
In the same vein as one time workshops are short educational series. While people may be encouraged to attend all of the programs in a series, many may select specific sessions(s) based on their interest and/or availability. Ideas for educational series include:
Expressing Grief Creatively:
- Healing through Creative Writing
- Art as Healer
- Let the Music Heal
- Relax and Renew
- Yoga to Heal
- Journal Writing
- Chair massage or Reiki
Mastering New Roles:
- Simple Car Maintenance
- Simple Home Maintenance
- Financial Management
- Shopping and Cooking for One
- Starting Over: New Relationships
Some programs offer a version of social gatherings. One idea is “Meal and More” where a meal is offered along with a speaker or other presentation. Some programs organize this themselves while others have volunteers (often peers who have had a loss) take ownership for organizing it. Another option is a walking group, either outdoors or walking inside a mall, and then gathering afterwards for coffee and conversation. Since many men find participation in traditional support groups uncomfortable, some programs have instituted groups such as a Men’s Breakfast Club which, as the name implies, is an opportunity for men to meet over breakfast (held typically at a restaurant) while talking about current events in their lives. The information and thoughts shared here provide ideas of how to be responsive and creative in meeting the needs of those who are grieving. Knowing your community, soliciting feedback and ideas from them, and partnering with others who have the skills and resources to supplement yours, are the best ways to ensure you are being most receptive and resourceful in meeting the needs of those you seek to serve. Be reminded that you are privileged to walk beside those who are grieving, as they often entrust us with the rawest of emotions and in some of their darkest moments, seeking our expertise as well as our compassion.
Bonanno, G. A. (2001). Grief and emotion: a social-functional perspective. In M. S. Stroebe, R. O. Hansson, & W. Stroebe (Eds.), Handbook of bereavement research: Consequences, coping and care (pp. 493-515). Washington, DC: American Psychological Association.
Synder D. C. (2017). Guidelines for bereavement care in hospice. Alexandria, VA: National Hospice and Palliative Care Organization.
Stroebe, M. S. & Schut, H, (2001). Meaning making in the dual process model of coping with bereavement. In R. A. Neimeyer (Ed.), Meaning reconstruction and the experience of loss (pp. 55-76). Washington, DC: American Psychological Association.
Worden, J. W. (2009). Grief counseling and grief therapy. New York, NY: Springer Publishing Company.