grief counseling for adult pet loss; a primer (PDF)

Grief counseling for adult pet loss: a primer for mental health professionals Item Type Other Authors Sherman, Dawne G. Download date 01/07/2022 11:47:18 Link to Item http://hdl.handle.net/11122/7982  GRIEF COUNSELING FOR ADULT PET LOSS: A PRIMER FOR MENTAL HEALTH PROFESSIONALS by Dawne G. Sherman, B.A. A Project Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Education in Clinical Mental Health Counseling and K-12 School Counseling University of Alaska Fairbanks May 2017 APPROVED: Valerie M. Gifford, Committee Chair Brenda J. Henze-Nelson, Committee Member Samantha G. McMorrow, Committee Member Cindy Fabbri, Chair School of Education Graduate Department  Abstract Grief counseling receives minimal attention in mental health training programs. Many mental health professionals are unprepared to support adult clients with pet loss and the associated bereavement process. Pets fill many vital roles in the lives of adults and the loss of a pet can be a profound experience. Adults sometimes develop intense attachment bonds with pets, and the quality of the human-pet attachment may influence the grief resolution process. Bereaved individuals may experience complicated grief reactions, including co-occurring mental health disorders. Understanding key clinical issues associated with pet loss can both help clinicians provide appropriate client support and facilitate positive treatment outcomes. As an outcome to this research, an educational webinar highlighting key findings gained from the literature review has been developed to assist clinicians with adults whose presenting concerns relate to pet loss. Keywords: attachment bonds, bereavement, complicated grief, disenfranchised loss, grief, grief counseling, grief education, grief models, human-animal bonds, loss, pet loss ADULT PET LOSS ii  Table of Contents Page Abstract ................................................................................................................................................. ii Table of Contents................................................................................................................................. iii Grief Counseling for Adult Pet Loss: A Primer for Mental Health Professionals............................1 An Overview of Grief Counseling........................................................................................................6 Definition of Terms...................................................................................................................7 Attachment Theory and Grief.................................................................................................. 8 Components of Grief.............................................................................................................. 12 Physical........................................................................................................................12 Cognitive......................................................................................................................13 Emotional.................................................................................................................... 13 Social............................................................................................................................14 Spiritual........................................................................................................................14 Grief Theories and Models.....................................................................................................14 Kubler-Ross................................................................................................................ 15 Rando...........................................................................................................................15 Freud............................................................................................................................16 Lindemann.................................................................................................................. 17 Parkes and W eiss........................................................................................................18 Bowlby.........................................................................................................................18 Worden.........................................................................................................................19 Stroebe and Schut...................................................................................................... 20 Klass............................................................................................................................ 20 ADULT PET LOSS iii  Neimeyer..................................................................................................................... 20 Grief Variables........................................................................................................................ 22 Understanding Complicated Grief.........................................................................................23 Clinical Grief Assessment in the DSM................................................................................. 25 History of clinical grief diagnosis............................................................................. 26 Current standards for clinical grief diagnosis.......................................................... 27 Persistent complex bereavement disorder....................................................28 Differential diagnosis.................................................................................... 29 Assessment Instruments..........................................................................................................32 Grief Interventions..................................................................................................................33 Uncomplicated grief................................................................................................... 33 Grief techniques.............................................................................................34 Counselor self-awareness.............................................................................. 35 Complicated grief....................................................................................................... 35 Interpersonal therapy (IPT)........................................................................... 36 Cognitive-behavioral therapy (CBT)........................................................... 36 Pet Loss Counseling.............................................................................................................................39 Human-Pet Relationships....................................................................................................... 40 Components of Pet Loss.........................................................................................................43 Pet Loss Models...................................................................................................................... 44 Essential Factors of Pet Loss.................................................................................................45 Attachment bonds with pets.......................................................................................45 Disenfranchised grief.................................................................................................48 ADULT PET LOSS iv  Circumstances of pet loss...........................................................................................50 Complicated Pet Loss.............................................................................................................52 Pet Loss Assessment Instruments..........................................................................................55 Interviewing the Bereaved Pet Owner...................................................................................56 Pet Loss Support Model..........................................................................................................57 Pet Loss Interventions.............................................................................................................58 Intended Audience...............................................................................................................................64 Application........................................................................................................................................... 65 Conclusion........................................................................................................................................... 66 References............................................................................................................................................ 69 List of Appendices...............................................................................................................................87 Appendix A: Application.................................................................................................................... 90 Appendix B: Proposed Diagnostic Criteria for Persistent Complex Bereavement Disorder 190 ADULT PET LOSS v  Grief Counseling for Adult Pet Loss: A Primer for Mental Health Professionals Counseling preparation programs typically fail to provide adequate training in the area of grief counseling (Doughty-Horn, Crews, & Harrawood, 2013; Pomeroy & Garcia, 2009). More specifically, the Council for Accreditation of Counseling and Related Educational Programs (CACREP), the primary accreditation board for counseling education programs in the U.S. (Wilkinson, 2014), does not include grief education in its explicit curricular requirements for counseling training programs (CACREP, 2015; Doughty-Horn et al., 2013). As such, it is not surprising that many counseling trainees and licensed mental health professionals feel unprepared to deal with the clinical issues associated with either human or pet bereavement (Cicchetti, 2010; Doughty-Horn et al., 2013). Given that death and the associated bereavement process are universal human experiences (Chan & Tin, 2012; Clark, 2004; Fox & Jones, 2013; Hooyman & Kramer, 2006; Pomeroy & Garcia, 2009), mental health professionals should anticipate the need to provide bereavement support to clients (Chan & Tin, 2012; Doughty, Wissel, & Glorfield, 2011; Hooyman & Kramer, 2006). Moreover, since the ACA Code of Ethics (ACA, 2014) mandates that counselors work within the parameters of their educational training and professional competence (Standard C.2.a), the availability of resources that educate mental health professionals on how to best support clients through the pet bereavement process is crucial. Grief can be a particularly devastating experience, one that significantly impacts an individual’s ability to function across multiple life dimensions: physical, cognitive, emotional, social, and spiritual (Cicchetti, 2010; Mallon, 2008; Pomeroy & Garcia, 2009). Moreover, the pain associated with bereavement is often disabling and profound (Shear & Mulhare, 2008). Although most individuals are capable of processing and integrating this type of loss without ADULT PET LOSS 1  clinical intervention (Neimeyer & Currier, 2009), others experience a protracted period of severe, unresolved grief, which the literature most frequently refers to as complicated grief (Boelen, 2006; Daneker & Aiello, 2015). In working with bereaved clients, mental health professionals need to know how to distinguish a normal, uncomplicated grief response from a complicated one (Boelen & van den Bout, 2008). Further, in order to facilitate an understanding of complicated grief, clinicians should be familiar with the primary complicating factors (Jeffreys, 2005) as well as the associated risk factors (Chiu et al., 2010; Goldsmith, Morrison, Vanderwerker, & Prigerson, 2008; Laurie & Neimeyer, 2008). The literature suggests that individuals process the experiences of human bereavement and pet bereavement very similarly (Alstat, 1997; Archer & Winchester, 1994; Bobier, 2011; Clements, Benasutti, & Carmone, 2003), and that the grief associated with the loss of a pet can be equal to or greater than the intensity associated with the loss of a person (Carmack, 1991). Moreover, the experience of losing a pet could be among the most significant losses people experience in their lifetimes (Butler & DeGraff, 1996; Watt-Aldredge, 2005). Unfortunately, many helping professionals tend to minimize or pathologize human-pet attachment bonds (Brown, 2006; Turner, 2003), and suggest that such bonds are inferior to those experienced in interpersonal human relationships (Morley & Fook, 2005). Given this attitude, many mental health professionals may not fully comprehend the repercussions associated with losing an animal companion (Brown, 2006; Gage & Holcolm, 1991). This lack of understanding may explain why so few professional training resources are offered for pet loss support (Clements et al., 2003), and why many professional helpers are unprepared to counsel individuals experiencing this type of loss (Sharkin & Bahrick, 1990). ADULT PET LOSS 2  With the numerous vital roles that pets play in our lives, and the thousands of American adults who experience pet loss every year, it seems essential that mental health professionals have a basic understanding of the core issues associated with pet bereavement (Beder, 2013). Moreover, given the deficits in counseling preparation programs related to the general topic of grief counseling (Doughty-Horn et al., 2013), and the more specific issue of pet loss counseling (Sharkin & Bahrick, 1990; Sharkin & Knox, 2003), it seems critical to bridge this training gap by providing counselors and other mental health professionals with information that helps them both understand the profound sense of loss an individual might experience following a companion animal’s death, and prepares them to respond in an appropriate and compassionate manner (Donohue, 2005). To that end, this paper explores the following research question: “What do mental health professionals need to know in order to competently assess and treat issues associated with adult pet loss?” To answer this question, a comprehensive literature review was conducted that examined the history of grief counseling, including theoretical orientations, grief factors, how to distinguish normal grief reactions from pathological ones, how to assess for co-morbid psychological disorders, and evidence-based intervention models and methods. The literature review further examined grief counseling in the context of adult pet loss. As the validity of Bowlby’s attachment theory as a model for human-pet relationships has been established in the literature (Zilcha-Mano, Mikulincer, & Shaver, 2012), and since the impact of attachment bonds between humans and their pets was widely discussed in the literature (Archer & Ireland, 2001; Archer & Winchester, 1994; Beder, 2013; Brown, 2006; Brown, Richards, & Wilson, 2001; Margolies, 1999; McCutcheon & Fleming, 2002), particularly with regards to how these bonds can significantly influence the grief response in pet bereavement (Archer & Winchester, 1994), ADULT PET LOSS 3  Bowlby’s attachment theory was utilized as the overarching theoretical framework guiding the discussion of the research question. In brief, Bowlby’s attachment theory posits that human infants form attachment bonds with parents or other essential caregivers as a part of a larger security-seeking process, and that any disruption in these bonds creates feelings of distress and elicits behaviors from the infant intended to re-establish the disrupted connection (Hetherington, Parke, Gauvain, & Locke, 2006; Pomeroy & Garcia, 2009; Santrock, 2009). As adults, these same types of innate attachment instincts motivate individuals to form and maintain relational bonds with others, and to seek support through these bonds during times of distress (Archer & Ireland, 2011; Shear & Mulhare, 2008). The literature further indicated that individuals who develop strong pet attachments often have intense grief responses when those bonds are broken (Zilcha-Mano et al., 2012). Whereas some individuals consider it essential for counseling education programs to include grief counseling as an explicit element in their training programs (Cicchetti, 2010), the lack of explicit curricular inclusion for grief training may prevent many mental health professionals from acquiring the requisite experience and tools needed to provide appropriate grief services to clients (Cicchetti, 2010). As such, based on the findings presented in this paper, an educational webinar has been developed to address this training need and to provide an expanded dissemination of the key concepts presented herein. The content of the webinar was distilled from this paper, and it outlines issues associated with providing grief support to adult clients experiencing pet loss. In particular, the webinar discussed a variety of elements pertinent to pet loss among adults, examined the relevant clinical issues associated with pet loss, and presented intervention strategies for assisting mental health professionals in providing appropriate grief support services for adult pet loss. ADULT PET LOSS 4  The intended audience for the findings of this research project is mental health professionals, including licensed professional counselors, marriage and family therapists, psychologists, and social workers. Considering the profound feelings of loss associated with the ending of an important relationship, or the death of a loved one (Heikkinen, 1979), and given the importance of pets in the lives of many individuals and families (Brown, 2006; Cavanaugh, Leonard, & Scammon, 2008; Podrazik, Shackford, Becker, & Heckert, 2000), this comprehensive literature review makes the case that mental health professionals should be prepared to address commonly occurring grief factors in adult populations, particularly those related to adult pet loss. Specifically, the culmination of key findings from the literature reviewed suggests that professional training for pet loss should be designed to increase the counselor’s sensitivity to the needs of clients dealing with this particular type of loss and to prepare counselors to provide appropriate clinical support and interventions (Krause-Parello, 2012). In sum, the literature confirmed a need for mental health preparation for both grief counseling (Cicchetti, 2010) and adult pet loss (Turner, 2003). As such, the literature associated with grief counseling for adult pet loss was examined and distilled into two distinct areas of investigation. First, the literature review focuses on clinical elements concerning the broader topic of grief and bereavement counseling. To begin with, this portion of the literature review outlines the role of attachment in loss and bereavement, the components of grief, grief theories and models, and primary grief variables. Next, the findings describe the presentation of complicated grief, including key complicating factors and identified risk factors. In particular, the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-V) addresses grief complications associated with comorbid mental health ADULT PET LOSS 5  issues. The next segment of this portion of the literature review highlights assessment instruments that can be used to measure factors associated with complicated grief and adult attachment. The final segment discusses grief interventions, including counseling skills and techniques, the importance of counselor self-awareness in the context of grief counseling, and a brief introduction to proven intervention strategies that address complicated grief issues associated with human loss. After examining the general issues of grief work, the literature review details grief counseling in the specific realm of adult pet loss. This portion of the literature review begins with a discussion of the importance of pets in our lives, the essential roles that pets play, and the nature of human-animal relationships. Next, the findings describe models of pet loss, components of pet loss, pet loss assessment, and essential pet loss factors. Then, the literature presents findings associated with complicated grief in the context of pet loss and identifies instruments for measuring targeted pet loss factors. The last section of this portion of the literature review highlights findings related to pet loss interventions. Finally, in order to address the need identified in the research question, a practical application piece was developed to educate mental health professionals about these key findings. An Overview of Grief Counseling Counseling for grief, loss, and bereavement is a vast subfield within the counseling profession. As such, specific concepts and terms exist within this subfield to help guide the efforts of behavioral healthcare providers offering services to clients presenting with these concerns. In order to provide the necessary context for understanding grief experiences associated with pet loss, essential terms within this subfield are introduced and defined below. ADULT PET LOSS 6  Definition of Terms The following key terms guided the discussion of the literature. When companion animals were referred to in the literature on human-animal bonds, the term pet was primarily indicative of a pet dog or cat (Chur-Hansen, 2010). Grief was identified as “(a) an emotion, generated by an experience of loss and characterized by sorrow and/or distress, and (b) the personal and interpersonal experience of loss” (Humphrey, 2009, p. 5). Grieving was further characterized as “the process of separating ourselves from losses so that we can survive, effect necessary life changes, and foster new attachments” (Heikkinen, 1979, p. 46). Finally, the term, grief, was used to describe the internal processes (cognitions and emotions) and external responses (behaviors) that are activated when an individual either experiences or anticipates a loss (Jeffreys, 2005). Loss was identified as “the real or perceived deprivation of something deemed meaningful” (Humphrey, 2009, p. 5). Bereavement was broadly defined as “a period of sorrow following the death of a significant other” (Humphrey, 2009, p. 6), while the clinical definition of bereavement featured in the DSM-V was described as “the state of having lost through death someone with whom one has had a close relationship” (American Psychiatric Association, 2013, p. 818). Mourning was identified as “socially prescribed practices or outward expressions of grief” (Humphrey, 2009, p. 6). It is important to note that bereavement is always death-related, while mourning may be non-death related (Humphrey, 2009). The majority of bereaved individuals experience a normative response to a traumatic loss (Zhang, El-Jawahri, & Prigerson, 2006). However, for some individuals, the pain of bereavement can have a profoundly detrimental impact on their lives (Shear & Mulhare, 2008), such that they experience an ongoing struggle to accept the loss and move on (Hensley, 2006). As such, a primary clinical concern in grief assessment is the need to determine whether the ADULT PET LOSS 7  client’s grief response falls within the parameters of what is considered normal or what is considered pathological (Boelen & van den Bout, 2008). A normative bereavement experience, also referred to as an uncomplicated grief response, typically occurs within a six-month time frame. The resolution of grief is associated with an individual’s ability to complete the following key grieving tasks: to reach some degree of acceptance regarding the loss, to engage in professional activities, to imagine the potential for developing new relationships, and to experience positive emotions (Zhang et al., 2006). Conversely, the term, complicated grief, is used to describe a non-normative grief response, where both the intensity and duration of symptoms exceed expected norms (Botella, Osma, Palacios, Guillen, & Banos, 2008), and the experience of grief interferes with the client’s ability to feel a sense of resolution regarding the loss (Boelen & Prigerson, 2007). More specifically, complicated grief occurs when “acute grief is prolonged indefinitely, accompanied by complicating thoughts, behaviors, and dysfunctional emotion regulation” (Shear & Mulhare, 2008, p. 663). A key clinical distinction of complicated grief is that it typically requires some type of psychiatric intervention in order to reach a successful resolution (McNicholas & Collis, 1995). Numerous terms are used in the literature to describe maladaptive grief responses, including abnormal grief, atypical grief, pathologic grief, traumatic grief, and complicated bereavement (Zhang et al., 2006). More recently, the terms, prolonged grief disorder and persistent complex grief disorder, have been used to describe complicated grief in a diagnostic context (Boelen & Prigerson, 2007). Attachment Theory and Grief Bowlby’s attachment theory described social development in terms of interpersonal relationship bonds, particularly early parental bonds, and their influences on an individual’s ADULT PET LOSS 8  perception of being secure, particularly in stressful circumstances (Ravitz, Maunder, Hunter, Sthankiya, & Lancee, 2010). These attachment patterns have proven consistent across many Western cultures (Hetherington et al., 2006). Bowlby’s theory of attachment has been widely used in the literature to explain both the nature of the relationship and the strength of the relational ties between the bereaved and the lost loved one (Archer & Ireland, 2011; Kominsky & Jordan, 2016). In addition, attachment theory has been used as a model for examining the impact of human-pet relational bonds on the grief process (Archer & Ireland, 2011). The comfort that comes from contact with another human being, and the feelings associated with trusting that a significant other will be there when needed, are core human needs (Young, 2008). As such, the initial attachment that develops between an infant and their caregiver is considered a notable aspect of child development (Hetherington et al., 2006). Further, the process of attachment does not end in infancy; as children age, they start to form relational attachments to peers, siblings, and other family members, while as adolescents, they begin to form attachments with romantic partners (Hetherington et al., 2006). Some individuals form a strong, initial bond with their primary caregiver, establishing them as a reliable source for both personal affirmation and relief from distress (Santrock, 2009). In this type of consistent, interpersonal relationship, the child perceives the caregiver as a secure base from which to explore both themselves and the world around them (Santrock, 2009), as well as a safe haven, a provider of protection, assistance, and reassurance, when facing a crisis or experiencing other types of distress (Zilcha-Mano et al., 2012). Further, the development of a secure attachment bond is predicated on the ability of the attachment figure to act as both a secure base and a safe haven (Zilcha-Mano et al., 2012). Overall, a secure attachment ADULT PET LOSS 9