You’re sat with a client. They’re telling you about scan results, or a medication change, or the latest thing physio said, and then, almost as an aside, they say it: “I’m just not the person I used to be”. It slips out quietly, but it’s doing a lot of work. If your instinct is to offer reassurance, you’re about to miss the deepest part of the session. That sentence is grief, and it deserves to be treated as grief.
Say the word grief to most people and their mind goes straight to bereavement: funerals, death, the loss of a person. But grief shows up everywhere and in physical health work, it is usually uninvited and almost never called by its name. It shows up when a diagnosis takes someone’s career away or when a body stops doing the thing that made a person feel like themselves. Treat grief as a niche add-on to ‘the real work’ and you lose sight of something crucial: for a huge number of clients, it is the real work.
Loss is bigger than death
Grief describes a response to significant loss, and loss comes in more shapes than we usually credit it with. Yes, it’s the loss of a person. It’s just as much the loss of a role, a way of life, a function, a state of health. A musician who develops a lung condition and can’t play their instrument anymore is grieving, every bit as much as someone mourning a parent who has died. Someone who’s always been “the fit one,” “the driven one,” “the one who copes,” and who can no longer hold that identity because of illness, is grieving too.
If you only reach for the word grief when somebody has died, an enormous amount of what’s happening in front of you goes unnoticed, and you risk dismissing something that’s an entirely proportionate response to real loss. It’s worth remembering how ordinary this territory actually is. Anyone who lives long enough, and cares about anything, will lose things more than once. Every culture, every faith, every school of psychology has had something to say about it. That’s good news for us as clinicians. There’s a huge amount of hard-won wisdom already out there. ACT doesn’t need to reinvent grief work. It needs to sit alongside it well, and bring something useful of its own.
Forget the stages
Most of us carry an intuitive model of grief as a sequence of stages: shock, denial, anger, and eventually, tidily, acceptance. It’s a compelling story with enormous cultural reach. It’s also not really how grief works, and the evidence for a fixed sequence doesn’t hold up. People feel all sorts of things at all sorts of points, moving forwards and backwards through them, sometimes within the same hour.
Perhaps a more clinically useful account is the dual process model of grief, developed by Margaret Stroebe and Henk Schut (1999). Instead of stages, they describe two orientations people swing between, like a pendulum. Loss orientation is the direct experience of pain: remembering, yearning, crying, taking part in rituals. Restoration orientation is everything to do with the secondary fallout of loss, sorting the practical stuff out, building new roles, learning to do things differently, looking ahead. Crucially, these aren’t sequential. A client can be full of energy and sorting out admin one moment, then in floods of tears twenty minutes later, both against a backdrop of perfectly ordinary things like eating breakfast or going to work. That’s not a sign anything has gone wrong. That’s what grief looks like.
This has an immediate use in the therapy roombecause t gives clients a way of making sense of an experience that otherwise feels frightening. “I think I must be going mad” , or “I should be doing better” is something you’ll hear a lot. Naming the swing between what psychologist Julie Stokes (2021), in her work with bereaved children, calls the land of loss and the land of rebuilding gives people permission to feel both at once, and reassurance that swinging between them isn’t a malfunction. Clients can get stuck predominantly on one side, which is itself a useful thing to notice clinically. But the aim isn’t to stop the swing. It’s to make sure both sides get room.
That matters enormously in physical health work, because there’s a very natural clinical pull toward the restoration side. When a client can’t do what they used to do, the instinct is often to move quickly toward fixing it: new activities, new routines, new ways of getting the same values met. Althoguh that instinct isn’t wrong per se. if you move too fast toward rebuilding and you risk sending a subtlemessage of avoidance: don’t dwell on it, that’s gone now, look at all this good stuff instead. ACT gives us tools to help the client first slow down and make room for the pain first. There is also an invittation for you, as a therapist, to sit with your own discomfort about someone else’s distress before you rush to fix it.
When the story of who you are gets interrupted
A lot of grief in physical health work is grief about identity. “I’m not the person I used to be” deserves to be taken seriously rather than gently talked out of. ACT’s model of self as context vs self as content is genuinely useful here. For example, consider a client whose whole sense of self has been built around being a performer, a musician who has lived for their music, and who develops a health condition that ends their ability to play. What’s often happened is that “I am a musician” has stopped being one true thing among many and become the entire story, so losing the activity feels like losing the self completely. That self-as-content story, I’m a teacher, I’m a carer, I’m someone who never gives up, matters enormously to people and deserves respect.. But help a client contact self-as-context, the sky holding all kinds of weather, or a stage on which many things get performed, and something shifts. The performer identity doesn’t need erasing or minimising. It becomes one important, valued, still-grievable part of a bigger person, who also has other roles and relationships and values, some of which are still fully theirs.
This is where continuing-bonds thinking from the wider grief literature sits naturally alongside ACT technique. The idea of continuing bonds pushed back against an older assumption that healthy grieving means “letting go” and reaching some clean point of detachment. Instead, it holds that we go on having a relationship with what we’ve lost, which can be one that changes shape over time rather than ending, and that this is a normal, often sustaining part of grief rather than a failure to move on. Applied here, you’re not asking anyone to forget who they were, or to stop having a relationship with that part of themselves. A client can still have a real, ongoing relationship with their performing self, in memory, in the moments it shaped, in what it taught them about what matters to them, while also building new ways of living those same values out: teaching at a different level, mentoring, finding another route into creativity or connection. Those new avenues don’t need to be just as good to be worth doing. They’re not nothing. None of that lands well, though, unless you’ve first made proper room for the fact that it isn’t the same, and that it hurts that it isn’t the same. None of the rebuilding work will go very far if a client can’t extend themselves basic kindness.
It is worthy to note some caution here; this kind of self-story work needs real care when it touches identities bound up with faith, culture, or gender. The technique is the same, but a client can quite reasonably hear a brisk “it’s just a story” as dismissing something that matters enormously to them. So this isn’t work to do to a formula. It’s worth slowing down and asking the client directly how they think and talk about this part of themselves, and finding language together that fits, rather than importing the therapist’s.
Self-compassion is the rate-limiting step
Self-compassion doesn’t have its own point on the hexaflex, but it sits right at the centre of the therapeutic stance: approaching clients, and helping them approach themselves, with compassionate, respectful curiosity. One useful working definition treats compassion as the overlap between kindness (caring about someone’s wellbeing and being willing to help) and empathy (being able to perceive and connect with what they’re thinking and feeling). Self-compassion asks for the same two things pointed inward: self-kindness, and self-empathy, actually being able to notice and connect with your own experience in the first place.
The clients who need this most are often the ones most allergic to it: high achievers, competitive athletes, ex-forces personnel, anyone whose sense of worth has been built on relentless self-criticism as fuel for performance. Tell someone like that to be kinder to themselves and watch the pushback arrive almost instantly. A route in that tends to work better, and stays consistent with how ACT approaches relational framing more broadly, is perspective-taking: varying the interpersonal (how would this look if it were happening to someone else), the spatial (how does it look from over there, looking back), and the temporal (how might this look in five years, or how did it look five years ago). Shifting the angle a client views themselves from is often far more workable than asking them, point blank, to be gentler with themselves.
To summarise, grief in physical health isn’t a detour from the real therapeutic work. For a lot of clients, it is the work. The job isn’t usually to move someone through it and out the other side. It’s to help them tolerate the swing between the pain of loss and the effort of rebuilding, to hold a more spacious sense of who they are that has room for both what’s gone and what remains, and to meet themselves, often for the first time, with some of the same compassion they’d hand straight to anyone else going through exactly what they’re going through.
References
Stokes, J. (2021). You Will Be Okay: Find Strength, Stay Hopeful and Get to Grips with Grief. Wren & Rook.
Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197–224.