Grief Counseling: How It Works, What It Costs, & What to Expect

Different Types of Grief

Different types of grief include “normal” or uncomplicated grief, complicated grief, persistent complex bereavement disorder (PCBD), delayed grief, disenfranchised grief, and anticipatory grief:

Normal (Uncomplicated) Grief

A natural response to loss can be experienced through emotional or physical symptoms of grief. It might negatively impact a person’s abilities to function for a time.¹ It’s also normal that some individuals might not experience significant distress reactions at all.⁴ Despite some theories, it’s been clearly demonstrated that there is no one way to grieve, nor must one go through a clear five stages of grief.^2,3

If there was a death, normal grief is usually characterized by a feeling of acceptance accompanied by a yearning for the person who has died. In normal grief, distress typically peaks and starts to decrease at around 6 months following the loss.²

Grief often comes in waves. Soon after the loss those waves might be very high, and quite frequent. Over time, though, these waves will begin to decrease in height and frequency, only increasing again when triggered by significant reminders. For example, dealing with grief during the holidays or around the date of death anniversaries can be intense.

Complicated Grief

Complicated grief refers to grief that continues to cause significant distress and disruption in a person’s life after six months. It is estimated that up to 20% of individuals who are grieving, either a death-related or non-death-related loss, will experience complicated grief.⁵

Here are other symptoms of complicated grief:^6,7

• Persistent yearning for the loved one who has died
• Frequent images or thoughts of the loved one
• Feelings of emptiness and lack of meaning in life without the loved one
• Withdrawal
• Difficulty managing distressing emotions and thoughts
• Behaviors that focus on either actively avoiding reminders of the loved one who has died, or trying to hold onto reminders of the deceased in an attempt to feel closer to them

Persistent Complex Bereavement Disorder

A diagnosis of persistent complex bereavement disorder (PCBD) might be made if a person is suffering from ongoing grief that has become debilitating and continues to last after 12 months and on.

PCBD is characterized by the following criteria:⁸

• At least 12 months have passed since the death of the loved one (for children, it would be 6 months)
• Persistent longing for and preoccupation with the deceased loved one
• Possible distressing preoccupation with the way in which the loved one died
• Difficulty accepting and believing that the loved one has died
• Bitterness or anger related to the loss
• Active avoidance of memories of the loss
• Distressing memories of the loved one
• Feelings of self-blame, guilt, shame, etc. related to the deceased and/or their death
• Wanting to die to be with the loved one
• Feeling alone and that life has no meaning or purpose without the loved one

Delayed Grief

Delayed grief is when grief processing happens after the loss or death. This can take place from weeks to months after the loss. It can be hard to grieve right away as the shock of the loss can make your brain protect itself from the pain and grief, so it delays grief until the brain, body, and soul are able to address it.

Disenfranchised Grief

Disenfranchised grief is a feeling of grief that society doesn’t consider as a valid reason to grieve, which makes the grief process more complex and can last longer. The loss of a distant relative or a year-long relationship break up can trigger grief; however it can appear to others that these situations, for example, don’t warrant the full emotional reaction of how we understand grief.

Anticipatory Grief

Anticipatory grief is a grief response that comes up in preparation for the grief you may feel, or in response to loss that is ambiguous. This happens before the loss of a loved one and can be hard to understand–but it’s important to remember that grief can occur at any point, and grief isn’t reserved for death situations.

Why Go to Grief Counseling?

The goal of grief counseling is determined by the client. Broadly, one goal may be to carry on with your life without any major distress or disruption caused by grief.

Examples of the types of goals that clients might bring to grief counseling are:^10,12,13

• Gain relief from persistent pain and distress (e.g., emotional, physical, spiritual)
• Find a way to experience joy again (without feeling guilty)
• Identify and increase the use of healthy coping responses and behaviors
• Resolve sleep issues
• Adjust to the direct and indirect changes that have occurred in their life as a result of the loss
• Rebuild their understanding of the world and their purpose in it (as this is sometimes shattered in the face of significant loss)
• Figure out how they feel about the loss, ways to cope, and how to move forward
• Integrate the loss into their beliefs about life and death
• Replace unhealthy thoughts and/or behaviors that they might have been using to cope with the loss
• Accept the loss — including traumatic losses (e.g., unexpected death due to suicide/violence/accident/terrorism, death of a spouse or child)
• Reduce and/or resolve prolonged, intense distress, as well as functioning difficulties (e.g., at work, socially, with family)
• Identify ways to feel connected to a loved one who has passed away

Grief Counseling Vs. Psychotherapy

Grief counseling that focuses on providing education and/or emotional support is not psychotherapy. This type of grief support might be offered through a peer group of people who have experienced a similar loss, or by a pastoral counselor who hasn’t completed a professional designation in a mental health field.

Grief counseling can be a form of psychotherapy if offered by a qualified mental health professional. State licensed mental health professionals such as psychologists, professional counselors, social workers, or psychotherapists, and some pastoral counselors, will provide grief counseling that is based in psychological theory and utilizes evidence-based therapeutic interventions.

Grief Counseling for Children

Depending on their age, a child may not have an understanding of what happens when someone dies. Young children especially may not understand that death is forever and will be a permanent loss. Children may have difficulty verbalizing how they feel and understanding the impact on their lives when a close loved one has died. They may have angry outbursts not even recognizing their behavior may be connected to a death. They may have nightmares about the death of a loved one.

A child’s ability to cope is partially contingent on their relationship to the person who has died, the level of support they get from close loved ones, and the manner of the death. Other factors include their ability to understand what death is, their age, being in a non-stressful environment, and being in a non-judgemental space that allows them to express their feelings in any ways they can.

These are some of the strategies that are used when counseling children who are grieving a significant loss:

• Play therapy and observation: Opportunities must be given to help children to express their grief through play therapy and observing their behavior.
• Grief and Trauma Interventions (GTI): When a loved one dies it is traumatic for a child as well as adults. The goal with this therapy is to decrease the stress related symptoms and increase social support. GTI also uses developmentally appropriate activities like art, play, and drama as ways to help kids cope with and express their grief.
• Trauma Focused Cognitive Behavioral Therapy (CBT): TF-CBT combines trauma interventions which work on coping skills, restructuring thinking, and altering negative behaviors patterns. It also helps normalize feelings related to grief and teaches skills for regulating affect and relationships. It also can focus on family communication and parenting skills.
• Adults can model for children by sharing their feelings: It is OK for a child to know you are sad or to cry in front of them. It will help them to share their thoughts and feelings and normalizes their similar feelings and reactions.
• Helping a child process their anger: Anger is a common emotion that children experience with grief. A therapist may help them express anger through physical exercise, punching a pillow or balloon, or drawing, and ask them what is making them angry and what happens in their bodies when they are feeling angry. It will help identify causes and triggers for the anger and assists kids with being proactive about dealing with anger when it arises.

Family Grief Counseling

Family grief counseling may be needed when significant losses have impacted all family members. In addition to the death of a loved one, grief counseling can be helpful with the death of a beloved pet, the loss of a home, divorce, or a family member suffering a serious illness.

Family grief counseling helps family members communicate about their loss and its impact on them individually and as a family. It can strengthen familial relationships and bonds, and teaches family members new coping skills and how to support each other through the loss. The goal is to help family members come to terms with a loss in their own ways and begin to move forward in creating acceptable new norms  and relationships within their family unit.

Grief Counseling Techniques

Grief counseling might be offered individually, in groups, or in families. It might be offered more informally through non-professional peer support (by someone who has experienced a similar loss) or pastoral counseling. It might also be offered more formally in a therapeutic way by a licensed counselor or psychologist.

Examples of therapeutic techniques used in grief counseling include:¹²

• Funeral planning: This is a way to say goodbye to the person who has died and express what the person who has died means to you. People gain strength from mourning with their community. Many people find comfort in the rituals offered by their faith when planning a funeral.
• Allowing permission to grieve: It is important to give people permission to grieve and express their feelings without judgment. People may grieve in different ways and that should be acknowledged and accepted.
• Screening for depression: Grief and depression can be hard to separate. Depression is a normal stage of grief. Sometimes the symptoms of depression get worse and remain for an extended period of time, causing hopelessness and debilitation. When people isolate, can’t function, concentrate, sleep, or eat, a mental health professional can do an assessment for depression.
• Writing letters to the deceased: This can help to feel closer to the person who has died and clarify their emotions. Putting words to paper helps reduce the intensity of the emotions. It helps to express grief in meaningful ways.
• Facilitating a memorial project: Creating a memorial for a person is an important way to help mourn them and honor their memory. Sharing this time with other people who knew and loved the deceased can bring strength and support to all that participate.
• Deciding on future remembrance rituals: In the days ahead after the death of a loved one there will be birthdays, holidays, and anniversaries that come up. Creating ways to remember and honor the memory of the person who has died can bring comfort to those that knew and loved them. Having a ritual or a plan for what to do on their death anniversary can help prepare people emotionally when these dates come up.
• Imaginal revisiting: the counselor asks the client to talk about the death of their loved one and they work together to identify and explore the parts of this event that the client finds hard to accept. They then work toward resolving these areas.
• Situational revisiting: the counselor and client identify how the client has begun to avoid people, places, things, and/or situations that they used to enjoy. The client is challenged to re-engage in these areas of their life.
• Imaginal conversation: the counselor works with the client to experience an imagined conversation between the client and the loved one who has died. Doing so may help resolve outstanding concerns or issues that continue to cause distress.
• Cognitive restructuring: the counselor and client identify thoughts or beliefs related to the loss that are continuing to cause significant distress. They then work to shift these beliefs to be more compassionate and adaptive.

Signs That You Should Talk to a Grief Counselor

People grieve in unique ways and it is normal to grieve after a significant loss. However, there are warning signs that grief may become overwhelming and inhibit someone’s ability to function.

Here are signs to watch for that can signal the need to reach out to a mental health professional for grief counseling:

• Increased isolation
• Symptoms of grief like depression, anger, or hopelessness continue to go on or worsen in intensity with time
• An inability to find joy in anything
• An ongoing yearning for the person who has died that intensifies with time
• Ongoing loss of interest in self care
• Inability to concentrate or focus on tasks
• Lack of future orientation
• Increased physical symptoms like body aches, headaches, digestive issues, loss of appetite, inability to sleep
• Increased alcohol or drug use

How Much Does Grief Counseling Cost?

The cost of grief counseling will depend on the credentials of the grief counselor or support person, the setting in which the service is offered, and whether the client has access to health benefits.

Informal Grief Counseling

Informal grief counseling offered by a non-licensed faith-based counselor (e.g., a clergy member in a religious setting) might be offered free of charge if the person is a member of the community. Similarly, grief support might also be offered free of charge if it is provided by non-professionals who have had a similar experience, or if it is offered in a peer support group.

Formal Grief Counseling

Health insurance might cover all or part of the cost of visits to specific licensed mental health practitioners (e.g., professional counselors, psychotherapists, social workers, psychologists). Typically, with health insurance coverage, the cost to the client will be $20-$50 per session.¹⁴

Some larger employers offer Employee Assistance Plans that provide confidential counseling services to their employees and their dependents. This type of plan would allow access to specified mental health professionals, usually for a limited number of sessions, with no charge to the client.

How to Find a Grief Counselor

There are many ways you can find a grief counselor, such as working with a hospice social worker or a medical social worker in a hospital setting, or by using an online therapy directory. It is important to talk to people about what you are feeling to process and move forward in a healthy way, but knowing you are experiencing any type of grief is a good enough reason to find a grief therapist to talk to.

Finding a Grief Counselor Online

There are many places online to look for a grief counselor. Here are some good resources to investigate:

• The Substance Abuse and Mental Health Administration (SAMHSA) is a 24 hour daily hotline to go for local referrals for counseling.
• Compassionate Friends for Loss of a Child.
• Grieving.com offers online support groups for loss of parents, a pet, child, miscarriages, a sibling, or partner.
• Peer Collective provides online trained peer counselors to help with grief and loss.

What to Expect at Your First Appointment

If you are attending a grief counseling appointment with a mental health professional, at the first appointment you might expect that your counselor will introduce themselves and begin to explain their approach.

Here are other things you can expect at your first appointment:

• They’ll provide information on administrative processes such as session duration and frequency, fee payment, how they deal with missed appointments, etc.
• They’ll answer any questions you might have
• They’ll go over any intake information if provided prior to the session
• They’ll ask about your loss(es) and how you have been impacted
• They’ll ask about your goals and begin to suggest a treatment plan

Questions to Ask a Grief Counselor

Consider asking a potential grief counselor these questions:

• Are you a licensed mental health professional?
• Do you have specialized education and experience in dealing with complicated grief?
• Do you offer services to individuals, groups, or both?
• What are your fees? Do you accept health insurance? Do you offer a sliding scale for fees?

Is Grief Counseling Effective?

The effectiveness of grief counseling depends on the type of grief being experienced. Research indicates that counseling for normal or uncomplicated grief is not beneficial since normal grief is natural and not a disorder that requires treatment.¹² In fact, for some people, participating in grief counseling for normal grief has been found to lead to deterioration.¹¹

In extenuating circumstances, however, where an individual has a history of mental illness, is lacking social support, and/or has experienced a number of significant losses within a short time, grief counseling might offer some benefits.⁹

Grief counseling is most beneficial for individuals who are suffering from complicated grief, which is a prolonged (more than six months), intense, debilitating, and sometimes life-threatening response to loss. Therapeutic approaches that target the areas in which an individual is feeling “stuck” can help to resolve grief symptoms and allow the client to begin to move forward in a healthier, more adaptive way.^5,10,11,13

Grief Counseling Examples

Due to the fact that grief counseling is most appropriate and beneficial for those who are experiencing complicated grief, the examples provided will be related to these types of situations.

Death of a Mother After Long Battle With Cancer

Taylor’s mom died at home after a 2-year battle with cancer. During the last nine months of her life, the family wasn’t able to afford the expensive chemotherapy and radiation treatments she needed. They had already lost their home due to the costs of treatment. 28-year-old Taylor moved back with her family a year into her mom’s illness to help with expenses and take care of her younger sisters.

Eighteen months after her mom’s death, Taylor is still struggling. She feels her grief is just as strong now as it was in the days directly after her mom passed away. She doesn’t understand why she can’t get past this. Her friends have told her she needs to “let go” and get on with her life.

Taylor meets with a social worker through a local community agency. She tells the social worker that she doesn’t know what is wrong with her and she feels guilty she hasn’t been able to move on. The social worker explains what complicated grief is.

Taylor is relieved to hear that she isn’t doing anything wrong and it isn’t her fault. She and the therapist work together to begin to identify the multiple areas of loss that Taylor has recently suffered. By acknowledging and validating her many losses, the weight of her grief begins to make sense to her, and Taylor begins to experience a sense of relief.

Loss of a Brother to Suicide

Anna, who is 18 years old, is dealing with complicated grief related her 15 year-old brother’s suicide. He passed away 7 months ago. Anna has been unable to attend her college classes. She is having trouble sleeping. She finds she doesn’t want to be around friends because she feels like they are talking about things that don’t really matter.

All she can think about is losing her brother. She is constantly fearful that the people she loves are going to suddenly die. Her family had no idea her brother was so distressed, so she’s convinced she must have missed some sign, and believes if she had been paying better attention, she would have been able to stop it from happening.

Anna meets with a psychologist who asks her about how her brother’s death has impacted her. They identify how she has been affected physically, emotionally, socially, and behaviorally. They explore her fears as well as her coping strategies. They also explore the areas she feels stuck, including her guilt. The therapist provides information about a peer support group for the siblings of individuals who have died by suicide.

Death of a Brother From Police Violence

Lamar’s younger brother, Jordan, a 40-year-old African American man, was beaten to death by attending officers at a traffic stop. The assault was videotaped by a by-stander, and went viral on the internet. Lamar is haunted by the images. He can’t get them out of his mind and heart. There were protests around the country as a result of the death. The attending officers were not charged.

For months, Lamar was able to channel his anger and pain into protests, as well as taking care of his brother’s wife and children. Lately, however, he is having trouble functioning. His anger has been overwhelming and is coming out in his close relationships. He doesn’t like the person he is becoming.

Lamar meets with a professional counselor who listens to his story and concerns. They work together on developing goals for therapy. The counselor explains to Lamar that he seems to be experiencing both trauma and grief, and provides education on how these can lead to complicated grief.

They work to identify the ways Lamar has been impacted, both directly and indirectly, by the loss of his brother. They take note of the symptoms he has been experiencing, as well as the supports and coping strategies he has been using.

The counselor reflects on the tremendous strength and courage Lamar has demonstrated by supporting others, while at the same time acknowledging his exhaustion and pain. Lamar feels like he is seen and heard. He feels hope for the first time in a long time.

Final Thoughts on Grief Counseling

Grief can feel heavy and be a lot to deal with, but there are ways to cope and work through these feelings. Talking with friends, family and a grief counselor is a great way to learn about the grief and find ways to cope and move forward.