Journal Research Corner: Grief Groups
Shannon Hill, Ph.D.

Thanks to the existence of our wonderful psy chology interns, The Baddour Center is able to offer counseling, a fairly popular service to our residents. As more residents, families, and staff members came to understand how to access that service, we started receiving referrals specif ically to counsel with people struggling with grief issues. To be honest, this was a little bit scary for us. Grief counseling has a different purpose and approach than most other forms of counsel ing and I didn't have much training in it. Nei ther did the students. So, before we committed to it, we set out to educate ourselves about it.

Grief counseling for the general population incorporates a number of concepts, including reviewing the story, understanding the relation ship, dealing with "unfinished business" with the person who has passed away, facilitating the expression of emotions, and eventually moving to acceptance (often through spiritual beliefs). That is a lot to do, and it is an intensely emo tional experience for both the griever and the counselor.

Once we had learned about grief therapy in gen eral, we set out to learn about how to adapt it for our population. We had a number of con cerns of our own, and we encountered others in reviewing the literature. First, it is known that people with intellectual disabilities often have a delayed expression of grief and it sometimes manifests itself in ways that are different from the population at large. That is, the person with a disability may not immediately understand that death means the person is gone forever. This is especially true if the person lives at a dis tance from the person who died. It may take a year or more of expecting to see them and being disappointed before the grief settles in. Because many people with ID are not good at explaining their emotions, the people around them may not understand why they are suddenly crying a lot or becoming irritable. When changes happen, we usually look to the immediate past for an explanation rather than a year ago. So, ques tion one became "when isthe right time to bring a person into grief therapy?"

The next question we had actually came from our staff and families. Is it good for people with ID to sit around talking about death? We don't want them to dwell on it forever; we want them to move on and be happy. On a related note, how do you know if they are really distressed or just enjoying the attention that comes from grieving a loss? Some of the people who were referring themselves for grief therapy were talk ing about deaths that happened years ago. They seemed to be functioning fine. Would we be doing them more harm than good by including them?

The third question was more technical. The methods used for resolving unfinished business and for moving toward acceptance might be too hard to implement with this population. Reso lution usually comes from talking or writing to the person, who obviously can't answer back. Would our residents get that? And can they understand the cycle of birth-life-death-afterlife? Would we be able to explain it well enough? When it came to spiritual factors, how could we address their questions without "pushing" our own spiritual/religious beliefs on them?

Despite our fears, and despite the fact that we could find very little published guidance, refer rals continued to roll in. After an exhaustive literature review, we discovered a few (less than five) people who seemed to be doing good work in this area. We decided to bring one of them in to teach us, so we invited Jeffrey Kauffman to come and lead one of our symposia. Jeffrey did one day's training with staff and families, pro viding general guidance on what to expect and how to be helpful after a resident experiences a loss. The following day he did a workshop for therapists, teaching techniques for the counsel ing session.

Jeffrey was a godsend for us. Admittedly, the training was draining. However, he allowed us to take his protocols and adapt them for our own use. He was a great resource for us as we start ed our own project. Our first decision was that we were going to adapt Jeffrey's individual therapy approach to group therapy. We did this for a number of reasons. The first was pragmatic; we had more referrals than we could get to quickly if we did them one at a time. Second, grief work is often done in groups because it helps people to feel less alone. Third, we thought it might keep the therapist from having too much influence in the realm of spiritual beliefs.

Next, we had to decide how to match people together in a group. We'd had some experience with this already as we had explored the best ways to do social skills training. What seems to work best for us is the use of Verbal IQ. After all, groups are about talking, so it helps if everyone in the group has similar communication skills. We wondered if we should also match them based on how long it had been since the death occurred. Ultimately, it was too hard to get enough people into a group if we did that, so we ignored that factor. Finally, we had to decide how often the groups should meet, and for how long. After developing the curriculum, it appeared the group could conclude in six ses-sions. Initially, the frequency was driven by practical concerns. The best way to work around the residents' work schedules was to meet no more than twice per week. The primary counselor, intern Carly Gardener, was in her seventh month of pregnancy, so we needed the groups to meet as often as possible. Therefore, we set the sessions at twice per week.

The curriculum is fairly simple. Group members are taught about the life cycle, described ear-lier. Posterboards are created for each cycle, and the group places artwork on the boards depict-ing how they understand each component. Members also create a memory book of the person who has passed away, which they keep once the group concludes. Each session has a topic (such as identifying emotions, coping skills, ways to keep the person alive in your heart, etc.). As the topics are introduced, the group members use their stories about the person they have lost to show their understanding of the day's concept. The last group session is a memorial service planned by the group members. This is done because so often people with ID are excluded from the planning or at-tendance of memorials, or they simply may not have been emotionally able to absorb the meaning the first time around.

Eighteen months later, we have refined our curriculum and learned a great deal. It turned out that twice a week was the perfect schedule. The best time to enroll in group is three to six months after the death. Verbal skill is a very important factor in matching groups. We need at least eight ses-sions to move through the curriculum. Residents are wonderfully adept at sharing their own spiri-tual beliefs and listening to those of others. Finally, although the storytelling is important, it ap-pears that the tangible things (memorial service and memory books) make the most difference.