Segments of this article were contributed by Amanda Tan, a clinical psychologist.
There is no 'correct way' of dealing with loss - everyone has different ways of coping with grief. Sometimes, we are able to resolve grief on our own; at other times, we may need help from others - this is where grief counselling may be useful.
Some people may hesitate to seek help as they may compare their situation and wonder why they are unable to resolve their grief while others can. They may also worry about being seen as "weak".
However, it is important to realise that:
Grief cannot be compared. Each grieving individual faces a different set of circumstances and challenges.
Acknowledging that you require help and taking steps to seek help is a process that should be encouraged because you are actively working to improve your situation
Even with counselling, the grieving process still takes time. There is no consensus to what working through grief entails but the process consists of at least three fundamental segments (read more about it here):
Acknowledging the death
Working through the emotional and physical manifestations of grief
Accommodating the death (reconstitution)
Successful reconstitution usually leads to a decrease in the frequency and intensity of grief.
Before continuing with this article, do note that:
There is no fixed criteria to determine when one should seek grief counselling
The approach in this article is my personal suggestion and should not be taken as professional advice.
Alright, let's dive in!
Content
When should you seek help?
In general, you should consider seeking help if your grief affects your ability to function. This may be demonstrated in the following ways:
You are unable to carry out work duties e.g. having difficulties concentrating on a task or taking longer than usual to complete tasks
Your ability to care for yourself is compromised e.g. spending majority of the day in bed, skipping showers or not brushing your teeth
Your interpersonal relationships are affected e.g. getting into more arguments
You have lost the motivation to continue living
You have thoughts of harming yourself
You have thoughts of wanting to join the deceased by leaving this world
You experience persistently low mood and have lost interest in daily activities
You feel perpetually on the edge and worry that bad things are about to happen
You feel worthless and hopeless e.g. feeling that you are not good enough for anything and have nothing to look forward to
You have unresolved anger, guilt or regret that frequently bothers you
You have hallucinations
You have frequent intrusive and distressing thoughts or images in your mind
You are dependent on potentially harmful things/activities to cope with your emotions e.g. not being able to go without alcohol
If grief does not affect your ability to function, you may still consider seeking help if you feel that the grief causes recurrent problems in your life but you are not able to completely resolve them on your own.
Who can you seek help from?
Psychiatrists, psychologists and counsellors differs in terms of professional qualifications and services provided. There are some areas of overlap in terms of the services provided. However, certain services can only be provided by certain professionals that are trained in that area (the most distinct example: only psychiatrists have the licence to prescribe medications) and not every grieving individual requires help from all the professionals.
Psychiatrists
Psychiatrists are doctors. They hold a Bachelor Degree in Medicine, Bachelor Degree in Surgery (MBBS) and a postgraduate Master of Medicine (Psychiatry) (M.Med (Psychiatry)). In Singapore, the minimum number of years required to complete both degrees is 11 years.
Psychiatrists are qualified to diagnose mental disorders, prescribe treatment (including pharmacological therapy) and order medical investigations.
Depending on your health insurance policy and whether inpatient hospitalisation is required, consultation and treatment under a psychiatrist may be covered.
Psychologists
Psychologists hold a general degree in psychology and a postgraduate Master in Applied Psychology (or its equivalent or higher degree). They also have to complete a period of supervised clinical training.
Psychologists assess and treat mental, emotional and behavioural disorders. They are qualified to use and interpret the results of psychometric tests, personality tests, observations and interviews to make a diagnosis and guide treatment.
They also can utilise psychotherapy. Psychotherapy is a method that therapists employ to help people understand the root of their problems and develop healthy thought processes and behaviours e.g. adopting new ways of thinking and cultivating healthy habits. This tends to be useful for people with complicated problems and difficulties unpacking their past.
There are many different approaches to conducting psychotherapy. The approaches that are selected would be based on the psychologist's skills and preference and what they feel would work best for their client.
Psychologists do not prescribe medications.
Counsellors
In Singapore, all professional counsellors must hold at least a postgraduate counselling diploma (that is recognised by Singapore Association for Counselling (SAC)) and complete a certain number of clinical and supervision hours.
Counsellors help their clients to identify and understand the emotional and psychological challenges they are currently facing, and develop personalised strategies to help them cope and/or overcome these challenges.
Counsellors can also employ psychotherapy (see above) if they have underwent training to do so.
How do you decide which professional to see?
The presence of certain symptoms should prompt you to see a psychiatrist over a psychologist or counsellor
Normal grief is not considered a pathological response and does not usually require medications. Hence, in general, grieving individuals would not need to seek help from a psychiatrist and can look for a counsellor or psychologist instead.
However, the presence of certain symptoms would tilt the scales in favour of seeing a psychiatrist or psychologist early:
Symptoms of mental illnesses:
You have lost the motivation to continue living
You experience persistently low mood and have lost interest in daily activities
You feel perpetually on the edge and worry that bad things are about to happen
You feel worthless and hopeless
You have hallucinations
Suicidal thoughts or thoughts of self-harm
Your ability to care for yourself is compromised
Regardless of which professional you decide to see, if their assessment is that you require the assistance of another mental health professional, they should refer you to (or advice you to seek) the appropriate providers.
In general, the more severe the symptoms and potential consequences, the more urgently you should seek help. If you or someone you know is in immediate risk of harm (either self-inflicted or by someone else), you should not wait to seek help and contact one of the hotlines provided below.
If the problem does not require attention from a psychiatrist, you can consider a psychologist or a counsellor
There is any algorithm that dictates when one should see a psychologist or counsellor over the other. In fact, most places use the term "therapist" interchangeably to refer to psychologists and counsellors.
These are some of the things you can look out for in order to narrow your search:
Area of expertise: If you are looking for someone that can provide grief counselling, you would want to look out for terms like "grief", "loss" and "bereavement" in their profile
Costs: In general, expect the costs to be approximately $100 and above per session. If you would like to seek help in the public healthcare sector, you can obtain a referral to see a psychiatrist or therapist at a subsidised cost. If you require grief counselling but face financial difficulties, there are other centres that can conduct means-testing to determine if you are suitable for their subsidies.
Availability: There may be long waiting times to see certain therapists.
Mode of sessions: Many therapists provide the option of counselling over video conferencing platforms. These sessions tend to be slightly cheaper compared to face-to-face consultations.
Language: Do check that the therapist is able to converse fluently in the language that you are comfortable. This helps both parties to be able to understand each other better.
Number of years of practice and working experience: Having a therapist with a decent amount of practical experience is useful (although it is not always positively correlated with skilfulness) but do note that booking sessions with a more experienced therapist may also be more expensive.
Qualifications: Ensure that the therapist has valid credentials supporting who they claim to be.
Use the first session to assess your suitability
Many therapy centres offer the option of having a pre-consultation phone consult or trial session that is free or charge or charged at a lower rate compared to their normal consultations.
When seeking therapy, it is important that:
You trust your therapist
You feel that your therapist understands you and can help you
This rapport can sometimes only be assessed through real-time interactions with the therapist. Rapport is not always an indicator of how effective therapy will be, but it helps to build trust and aid communication.
During your first session, there should also be discussion of a treatment plan - this could involve an estimate of how many sessions you will require and at what frequency, and what each therapy session will consist of.
What happens during grief counselling?
When we experience loss, multiple changes happen to our lives.
Grief counselling uses a variety of techniques to help people cope with the psychological and social responses to loss. It entails (but is not limited to):
Providing an avenue for people to talk about their experiences and release their emotions
Recounting the death of their loved one e.g. the events leading up to it, what they were doing when they found out about the death, what happened after
Expression of sadness, anxiety, confusion, anger and guilt
Sharing about the relationship and experiences they have had with the deceased (both positive and negative)
Helping individuals to identify the root cause of their problems, gain greater self-awareness and new perspectives
Exploring their past e.g. upbringing, previous experiences with loss
Exploring how things have changed and how they feel about it
Immersing in hypothetical scenarios and exploring their responses to it
Developing strategies to cope with the life changes resulting from the loss
Coming up with ways to reduce unhelpful ways of thinking and encourage healthy thoughts and behaviour
There is no ideal number of grief counselling session that one should attend as each person's grief is unique. However, in general, a series of sessions is more helpful than a single session.
The recommended number of sessions an individual should go for is usually discussed during the first consult (this number may change depending on each individual's progress).
How is therapy different from talking to friends?
Therapists are neutral parties
Family, friends and colleagues may stand to benefit if you overcome grief earlier as your ability to function may have a positive impact on their lives - this may subconsciously influence the recommendations that they give you. A therapist does not have any vested interest in your life and will not rush you to achieve certain end outcomes.
Our loved ones may hold back on making certain remarks about us for fear that they might hurt our feelings and change the relationship. A therapist has the capability to objectively analyse our situation and offer different perspectives in a non-judgemental manner.
The focus is on you
In a friendship, both parties are equally important. Both sides need time and space to express themselves. However, both parties also need to be considerate of one another: Friends may not always be ready to deal with topics regarding death. Friends may be dealing with their own problems that are, in our eyes at that moment, not equivalent to the severity of death. This may lead to inability of both sides to properly empathise with each other in the ways required.
In therapy, 100% of the space belongs to you. You can discuss whatever topics you need to in order to solve your problems.
The discussion during therapy sessions is confidential
There are some thoughts of ours that we do not wish to share with our family and friends. This may be because they are controversial or because we do not want our loved ones to have a different impression of us (because it affects the roles we play in their lives).
Therapists have to uphold their professional and ethical code of conduct of confidentiality. This means that what is said during therapy sessions does not get out unless we consent to it.
There is only one instance in which confidentiality can be breached: it is when you or someone you know is in immediate risk of harm. Do proceed to Emergency Helplines to find out more about the helplines that you can call in this situation.
Emergency Helplines
If you or someone you know is in immediate risk of harm (either self-inflicted or by someone else), you should not wait to seek help. These are some of the helplines that you can call:
Emergency medical services: 995
Samaritans of Singapore (SOS) for suicide prevention and crisis: 1800 221 4444
Institute of Mental Health (IMH) for mental health crisis: 6389 2222
Conclusion
Grief counselling uses a variety of techniques to help people cope with the psychological and social responses to loss by:
Providing an avenue for people to talk about their experiences and release their emotions;
Helping individuals to identify the root cause of their problems, gain greater self-awareness and new perspectives; and
Developing strategies to cope with the life changes resulting from the loss.
When choosing the type of mental healthcare professional to see, consider:
Type and severity of symptoms
The qualifications, expertise and experience of the professional
Costs and availability
Whether to mode of communication suits you e.g. video conference, language
Rapport
Remember that each individual's grief is unique (do not compare!) and that there is no timeline to grief. Thus, be patient in your journey or healing and be aware of when you (or others around you) need help.
Resources
References
PDQ Supportive and Palliative Care Editorial Board. Grief, Bereavement, and Coping With Loss (PDQ®): Health Professional Version. 2020 Dec 3. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK66052/
Borins M. (1995). Grief counseling. Canadian family physician Medecin de famille canadien, 41, 1207–1211. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2146191/pdf/canfamphys00089-0077.pdf
Robin L, Omar H.A. (2014). Adolescent Bereavement. Pediatrics Faculty Publications. 121. Available at: https://uknowledge.uky.edu/pediatrics_facpub/121
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