Grief Work Session Structure (Genogram-Focused)

## 1. Current grief models at a glance ### Worden — four tasks of mourning In "Grief Counseling and Grief Therapy" (German edition Hogrefe/Huber), J. William Worden developed the four-task model. It is explicitly **not a linear stage model** — the tasks can be worked on side by side, at different speeds, and recurrently. 1. **Accepting the loss — the reality of the death.** Grasping that the death has actually occurred and that the deceased will not return. Often recognizable in the repeated question about details of the death; in behaviors that act as if nothing had happened (keeping the phone number, maintaining the same routines); in the need to tell the story again and again. 2. **Working through the pain of grief.** Perceiving the emotional, physical, and cognitive pain instead of numbing it. The counselor supports by not warding off the pain, not relativizing it, not rushing it. "This too is part of it" carries more than "You have to keep living". 3. **Adjusting to a world without the deceased person.** Adjusting roles, identity, and meaning. Who was I in relation to the deceased? Who am I now? Which practical tasks (authorities, finances, a new daily routine) need to be restructured? Which identity questions (widower, the bereaved, a mother who has become childless) need to be integrated? 4. **Finding an enduring emotional connection with the deceased while moving forward in life.** This is an extension by Worden in later editions — not a "letting go", but finding a new, livable relationship with the deceased person. They retain their place in the life of the grieving person without blocking the continuing path of life. ### Stroebe & Schut — Dual Process Model Margaret Stroebe and Henk Schut (1999) developed the **Dual Process Model of Coping with Bereavement**, which today is widely regarded as the empirical standard. According to it, grief is an **oscillation** between two coping orientations: - **Loss-oriented coping** — turning toward the pain, the memory, the grief. Telling stories, weeping, looking at pictures, visiting the grave. - **Restoration-oriented coping** — turning toward life after the loss. Practicing new roles, completing practical tasks, maintaining social contacts, sometimes avoiding the grief. Healthy grief oscillates between both modes — it is neither permanent pain nor a permanent functional mode. Anyone who remains stuck permanently in one mode has difficulties: only loss-oriented → frozen in grief; only restoration-oriented → unprocessed grief that returns later. For counseling, this means: both modes are "healthy". The counselor supports the oscillation, not the fixation on one mode.

## 2. Setting and clarifying the assignment in grief counseling **Who comes to grief counseling?** The bereaved after the death of a close person — partner, parent, child, sibling, friend. Also people after traumatic loss (suicide in the family, homicide, pregnancy or infant loss), after anticipated loss (a long dying in care), after multiple loss (pandemic, accident, disaster). Also people facing a foreseeable loss (anticipatory grief, palliative accompaniment). **Setting decisions.** - **Individual setting** is the standard, especially with intimate loss. - **Family setting** is useful when the genogram is to be drawn with the whole family, in grief over a child, or with losses spanning the family. - **Group setting** (grief group) helps above all with isolation and the "nobody-understands-me" experience — but belongs in specialized hands (BVT-certified). - **Online setting** works for many clients; important: a quiet environment on both sides, technically stable. **Frequency and duration.** - The initial phase is often weekly, later every two weeks, then monthly. - A course of counseling usually lasts **3 to 12 months**. Longer with complex or traumatic losses. - If prolonged grief disorder or complication is suspected: refer to a psychotherapeutic setting (see Section 5). **Clarifying the assignment in the first session.** - "What brought you here? Who died, when, under what circumstances?" - "What do you hope for from this counseling?" - "What should my role be here — where should I stand by your side, where not?" - Clarify fee, frequency, confidentiality, and the distinction from therapy.

## 3. Structure of a session — five building blocks Grief sessions follow a typical structure that accounts for the oscillation between loss and restoration mode. ### Building block 1 — Greeting and arriving (5–10 min) Begin deliberately quietly. Grieving people carry a great deal with them — haste at the door makes it harder. "How are you arriving here today? What is on your mind?" — without expectation of a particular answer. Sometimes the answer is "Today is okay" and that would be good. Sometimes grief floods in with the first words — that is good too. ### Building block 2 — Review of the week (10–15 min) "What has happened since our last session?" — deliberately open. Important: do not ask in a symptom-oriented way ("Did you have trouble sleeping again?"), but in an experience-oriented way ("What was especially hard this week, what was bearable, what surprised you?"). This is often where the oscillation between the modes shows itself: accounts of painful memories mix with reports of completed tasks, new acquaintances, small steps. ### Building block 3 — Main work (20–30 min) Depending on need and phase: - **Narrative space** — the client tells about the deceased person, about the relationship, about shared experiences. The counselor listens, asks about details, validates. - **Genogram work** — the deceased person and their position in the family system are visualized. Multigenerational lines of grief become visible (see Section 4). - **Ritual impulse** — together consider a small ritual step (writing a letter, a photo box, a grave visit, a memory card). - **Concrete concern** — sometimes the client comes with an acute question ("How do I tell the children that there will be a Christmas without Dad?") that takes center stage. - **Resource inventory** — deliberately ask about what holds and carries. "Who stands by your side today? What has done you good in recent weeks?" ### Building block 4 — Safeguarding and closing (5–10 min) "What are you taking with you today?" Deliberately not "What have we achieved?" — grief counseling knows no "successes" in the usual sense. Instead: What was important today? A concrete arrangement for the week — often a small, gentle task: "This week, notice once when you remember your mother and it does not only hurt but also warms you." ### Building block 5 — The counselor's follow-up (15 min, after the session) Grief sessions resonate afterward. Your own reflection: What did the conversation stir in me? Which themes were close to me — my own experiences of loss? Is there something I need to bring to supervision? **Concrete example — the ritual impulse.** A widow, six months after the death of her husband, comes to the fifth session. She says she no longer "marks" his birthday — it was a week after the death. The counselor suggests: "Perhaps the birthday needs its own small form this year. What would your husband have liked?" The client reflects — he liked watching old films. She decides to watch his favorite film on his birthday, alone, with a glass of his favorite wine. This is not a "success" — but a step found together that touches reality (task 1), pain (task 2), and a new connection (task 4). **Concrete example — main work as narrative space.** A client grieves for her mother, who died after long dementia. In the third session she needs only one thing: to tell. An hour of narrative about her mother before the illness, about her laughter, her strictness, her favorite meals. The counselor says almost nothing — only "tell me more" and "what comes now?". At the end: "I did nothing today — but I saw my mother again." This is grief work in its most direct, most effective form. **When the genogram comes into the session.** Not in every session. A first genogram sketch belongs in the initial phase, after which the genogram is picked up again selectively — when a multigenerational question arises, when the client asks about patterns, when an aspect of the deceased person has not yet been visualized. The genogram as a grief tool is slow — one person, one relationship, one event per session is often enough.

## 4. Genogram work in grief and multiple losses In grief counseling the genogram is more than a diagnostic tool — it becomes a **map of memory and connection**. Three specifics are important. **The deceased are drawn in, not left out.** In the standard genogram the deceased are marked with X and the year of death is entered. In grief counseling the genogram can additionally be given special markings — an outlined person for "especially important", a double line for "the connection continues". **Multigenerational patterns of grief.** In grief, the question of how earlier generations dealt with loss is highly relevant. Were losses in the family mourned or silenced? Are there ungrieved losses that were passed on as a "family atmosphere"? Who in the family took on the role of bearing the grief? **Suggested questions:** - "Who in your family has lost someone before — and how?" - "Was loss talked about in your family?" - "Are there people in the family whose death was never properly mourned?" - "If your grandmother were here today — how would she look upon your grief?" **Multiple losses.** When several people have died within a short time (pandemic, accident, disaster), the genogram becomes an overview map. Which person has been missing since when? Which losses have gotten "muddled together"? What had to be postponed because too much came at once? **Suicide in the family.** When the deceased person died by suicide, the dynamics of grief and the stigma change. In the genogram this may be named, if the client wishes it so. Frequently: feelings of guilt, shame, family taboo. Specialized help through AGUS (Survivors of Suicide Loss) or local suicide-bereaved groups.

## 5. Crisis indicators and referral to psychotherapy Grief counseling is not grief therapy. There are constellations in which the counseling setting is no longer sufficient and a referral to a psychotherapeutically qualified service should be made. **Indicators of prolonged grief disorder (PGD, ICD-11 6B42).** - The loss occurred at least 6 months ago (adults) or 12 months ago (children) - Intense longing for the deceased or persistent preoccupation with them - At least one of the following symptoms to a clinically relevant degree: emotional pain, feelings of guilt, anger, denial, difficulty taking up new activities or relationships, loss of meaning, numbness, social isolation - Considerable impairment of functioning in work, family, or the social sphere If these criteria appear to be met: refer for psychotherapeutic diagnosis. Specialized grief therapy (e.g. Complicated Grief Therapy after Shear) is effective. **Indicators of acute suicidality.** - Active suicidal thoughts with plan, means, time - "I want to be with my husband/child" — as a concrete wish to act, not as symbolic longing - Preparation (will, giving away belongings, farewell conversations) - Previous suicide attempts, psychiatric history In acute suicidality, immediately: medical on-call service (116 117), in case of imminent danger emergency call (112) or psychiatric emergency admission. The duty of confidentiality is superseded under § 34 StGB; document the weighing of interests. **Indicators of traumatic grief.** - Loss through violence, suicide, accident, disaster - Presence of the client at the death under traumatic circumstances - Repeated intrusive images, flashbacks, physical tension symptoms - Avoidance behavior that massively restricts daily life Here trauma-focused psychotherapy (EMDR, cognitive behavioral therapy for PTSD, schema therapy) is indicated. Grief counseling can be useful in parallel but does not replace the therapy. **How is a referral made?** - Clearly and respectfully: "I believe that what you are experiencing right now needs a different kind of help than the one I can offer." - Concrete referral: the name of a practice or counseling center, not just "Find someone for yourself". - If needed, offer parallel-running counseling if the client wishes it. - Never phrase it as a rejection — the referral is an act of care, not of giving up.

## 6. Self-care for the counselor Grief counseling touches one's own experiences of loss — those already experienced, those still to come. Anyone who works in this field without paying attention to it burns out. **Three practices that help.** 1. **Know your own losses.** Anyone who has not reflected on their own loss biography will be unconsciously triggered in the counseling conversation. Reflecting on one's own grief is part of grief counseling training (BVT, grief institutes) — and should be refreshed regularly, because new losses follow. 2. **Make use of supervision.** Grief counseling belongs in regular supervision — case supervision or a group. Not because something is "not going well", but because the field is systematically taxing. 3. **Conscious boundaries in everyday life.** Close sessions — symbolically, physically. A walk after a difficult session. Tend to areas of your own life that have nothing to do with death and loss. Free yourself from the notion that you must "rescue" a person. **Warning signs of being overwhelmed.** - Difficulty leaving sessions — the conversation echoes for hours. - Your own sleep problems, exhaustion, irritability. - Thoughts circling outside the session around particular clients. - Avoidance behavior — certain sessions are "postponed" or "canceled". With several of these signs over several weeks: your own therapy or an intensification of supervision. In acute exhaustion: reduce the client load, possibly take a break from the grief field.