“What would they think?”: how grief models can show up as actions in therapy sessions.

Guest blog from Dr Ray Owen – Practical actions using the empty chair approach for dealing with grief

You might have heard of the saying “there’s nothing so useful as a good theory”. In an area like grief, where there are many different theories – some of them well known – it sometimes feels like there’s a gap between the models and what you can actually DO to help people, other than explain things.

Useful models of grief

I think that two of the most useful models of grief are ‘the dual process model’ , originally described by Stroebe and Schut and ‘continuing bonds’ Klass & Silberman.

The dual process model suggests that, in grief, we tend to swing between being mainly focussed on the loss itself and on trying to restore a life without the person / thing that has gone. In the original they were labelled “loss orientation” and “restoration orientation”, though in a book for children and teenagers1, Dr Julie Stokes (Psychologist and founder of child bereavement charity Winston’s Wish) renamed them “the land of loss” and “the land of rebuilding”, which makes sense. The point is that we will swing between the two, often many times a day, whereas people often expect that they will be dealing with just the pain, the memories and the emptiness of loss for a time, THEN start rebuilding a life. As most people who have grieved know, it’s not usually that predictable.

The continuing bonds model suggests that grief is not usually about “letting go” of the person who dies, but rather about successfully finding a way of carrying them with you through life. Or, as the authors say, “renegotiating the relationship with the person who died”. This fits well with idea that grief for someone we’ve loved dearly tends to be a lifelong process, even though the experience of it is likely to change over time.

 

Challenges with rebuilding and decision-making

Image of an older couple sitting on a bench in a park

Accepting that we can’t put off rebuilding a life until the loss is somehow “over’”(because it never is), there is then the problem of how we do that in practice. How do we make decisions, develop new skills, and choose where to put our energies whilst holding the immense pain of grief?

And here we hit a specific problem – what if the person who has died was an important part of your decision-making? Maybe you took decisions together, or you asked their advice, or they gave their advice whether you asked for it or not! Now you are, say, trying to decide whether to sell the house and move closer to your children, and your partner isn’t here to help make that choice….

Except, in (at least) one sense, they are.

People will have various beliefs about whether the person they’ve lost still exists in an afterlife, be that somewhere else or near to hand, but I’m not talking about that: I mean the sense in which we always carry people that have been significant to us around inside our minds. Even ones we didn’t love or even like.

 

The internal model in our minds

Picture of a family sitting in a parkMy personal opinion is that much of the time, our relationships – even with a living person – are actually a relationship with our own mental representation of them, rather than the person themselves.

Imagine a situation where you’re watching TV with your partner, or a close friend. If they leave the room to make a cup of tea, you still know how they would probably react if something they particularly like or hate comes on. That’s because you carry an internal model (or some might say simulation) of them in your mind.

While our model of that person can get obscured by the pain of grief, it doesn’t actually go away just because someone has died, so neither need the relationship, so long as it can change to take account of the reality of that person no longer being present. Which fits well with the Continuing Bonds model which acknowledges that grief is an ongoing process, rather than a one that ends abruptly.

 

Supporting clients in making predictions

Painting of a couple sitting on a park benchOne benefit of this is that, when faced with the kind of decision I described above, it’s often possible to make a prediction of what that person would have thought. As a therapist, it can be as easy as saying “And what do you think [person who died] would have thought was the right thing to do?”

If the client is willing, it sometimes pays to go further than that. Because asked that simply, the client may not ‘access’ the model of the person fully, and you might be more likely to get a “don’t know” response.  If instead we ask, with permission, something like “Would it be OK if we try something? If we imagine [person who died] were – somehow – here now (I might gesture to an empty chair in the room at this point) and listening to the dilemma that you’ve just told me about, what do you think they might say? What might they think was the right thing to do?”

This might not be a comfortable exercise, so here are some really important tips if you’re going to try this:

  • Make sure you’re getting the agreement of your client to proceed. “Would you be willing to give that a go?”
  • This could be very emotional – so don’t try it if you already know that directly thinking about the lost person tends to provoke overwhelming upset. Remember we might not be just talking about sadness here – anger, guilt and anxiety are also common components in grief, depending on the relationship to the deceased and the circumstances of the loss.
  • I wouldn’t try this near the end of a session in case there is a strong emotional reaction, as you might need time to work with any upset before they leave the room.
  • Emphasise that “even if you do get a clear idea of what their opinion would have been, it doesn’t mean you have to go along with it. After all, you may have disagreed with them sometimes in life”. It might be that your client says that they always felt / still feel obliged to go along with the other person’s opinion. That’s valuable information and well worth exploring as part of the therapy.

Many times, I’ve found this has helped people move forward with decisions when they had felt stuck with in grief (and not always ‘in agreement’ with what they thought the deceased person would have said – sometimes the exact opposite!)

 

Using and developing this practical approachImage of a younger woman placing their hand over an elderly womans' hand

In terms of the models we looked at above, you can see that we’re not simply talking about the balance of loss and rebuilding (dual process model) or finding a place for the lost person in your life going forward (continuing bonds). We’re actually doing them alongside a little gentle exposure work to mental images and possibly exploration of the dynamics of the relationship, if those are relevant.

Although I’ve been describing this work in the context of a choice or dilemma, we can go further with this ‘empty chair’ approach for other aspects of grief – unresolved questions, conflicts or even ill treatment from the person who died. These are potent sources of the more complicated grief responses that many of you will work with. As therapists, though, we have to proceed very cautiously in that kind of intense work, in order for it to be safe and effective, even alongside inevitably being upsetting.

If you’re interested in learning more, we discuss these kinds of technique in more detail in the Using ACT to support grieving people, available on demand.

Dr Ray Owen

Image of Dr Ray Owen

Reference

Julie Stokes, 2021, “You Will be OK”, published by Wren & Rook Press

“Grief is a tricky subject to explain to kids, but this book is a wonderful go-to expert toolkit!”  Dr Ranj Singh

“The book I wish someone had read with me when I was young” Kristin Scott Thomas