Companioning vs. Treating:

Beyond The Medical Model of Bereavement Caregiving

by Alan D. Wolfelt, Ph.D.

Editor's note: Alan Wolfelt's keynote at the Association of Death Education and Counseling conference in Chicago aroused a great deal of interest. For those of you who did not have the opportunity to hear him speak, we are printing here the transcript of his presentation.

Sam Leveson once noted that when his father came over here from the old country, he discovered three things:

  1. The streets weren't paved with gold,
  2. Most of the streets weren't paved, and
  3. He had the opportunity to help pave them.

I think it's fair to say that when it comes to our assumptive models of supporting people surrounding grief and loss,

  1. The streets aren't paved with gold,
  2. Many of the streets aren't paved, and
  3. We, as ADEC members, have the opportunity to help pave them.

Many people asked me about the title of my talk for this conference. Everyone was curious how I was going to distinguish "companioning" from "treating." The word "treat" comes from the Latin root work "tractare" which means "to drag." If we combine that with "patient" we can really get in trouble. "Patient" means "passive long-term sufferer", so, if we treat patients, we drag passive long-terms sufferers. (Doesn't sound very empowering to me.)

On the other hand, the word "companion," when broken down into its original Latin roots means "messmate": com for "with" and pan for "bread." Someone you would share a meal with, a friend, an equal. I have taken liberties with the noun "companion" and made it into the verb "companioning" because it so well captures the type of counseling relationship I support and advocate.

More specifically, for me . . .

I suggest that we must be willing to work together to be what I like to call RESPONSIBLE REBELS. For you see, as we approach the millenium, it is time to look in the mirror and question our assumptive models surrounding grief and loss.

I believe we are confronted with three forces that demand our immediate attention. Those three forces might be framed as risks :

Risk #1. That the predominant bereavement care model is a medical model where we assess, diagnose, and treat grief as an illness that demands a cure.

Risk #2. That we, as bereavement caregivers, join our efficiency-based culture by joining in and supporting, without questioning the "managed care" approach to what is really a soul-based journey.

Risk #3. That we anoint ourselves as a privileged class of "master" grief educators, counselors, and therapists.

While all three of these "forces" or "risks" call out for their own dialogues, please come along as I take us on a journey that touches on each of these important areas of discussion. What better place to start than with a need to question our predominant medical model of grief care.

Risk #1: That the predominant bereavement care model is a medical model where we assess, diagnose, and treat grief as an illness that demands a cure.

For many, grief in contemporary society has been medicalized and perceived as if it were an illness that with proper assessment, diagnosis and treatment can be cured. While it is beyond the scope of this presentation to trace the evolution of the medical model of bereavement care, let's review some tenets we may want to question.

I believe the limitations of our clinical, medical models are profound and far-reaching. Our modern understanding of grief all too often projects that for "successful" mourning to take place, the person must disengage from the deceased and, by all means "let go." We even have all sorts of books full of techniques on how to help others "let go" or reach "closure."

Our modern understanding of grief often urges bereaved people ( which means "to be torn apart," "to have special needs") to deny any form of continued relationship with the person who died. For many, the hallmark of so-called "pathology" has been rooted in terms of sustaining a relationship to the dead.

Our modern understanding of grief all too often conveys that the end result of bereavement is a series of completed tasks, extinguished pain, and the establishment of new relationships. In attempting to make a science of grief, we have compartmentalized complex emotions with neat clinical labels.

Our modern understanding of grief all too often uses a "recovery" or "resolution" definition to suggest a return to "normalcy." Recovery, as understood by some, mourners and caregivers alike, is erroneously seen as an absolute, a perfect state of reestablishment.

Our modern understanding of grief for some is based on the model of crisis theory that purports that a person's life is in a state of homeostatic balance, then something comes along (like death) and knocks the person out of balance. Caregivers are taught intervention goals to reestablish the prior state of homeostasis. There is only one major problem with this theory-it doesn't work. Why? Because a person's life is changed forever after the death of someone loved.

Our modern understanding of grief all too often pathologizes other's experiences with disregard for cultural and personality differences. (For example, keening is legitimized in some cultures and is seen as abnormal in others. Gotta watch where you keen; you may be hospitalized.)

Our modern understanding of grief all too often lacks any appreciation for and attention to the spiritual nature of the grief journey. As authors such as Frankl, Fromm, and Jung noted years ago, and Hillman, more recently, academic psychology has been too interfaced with the natural sciences and laboratory methods of weighing, counting and objective reporting. Some of us, often through no fault of our own, but perhaps by the contamination of our formal training, have overlooked the journey into grief as a soul-based journey.

Critical self-observation would suggest that perhaps we rely too much on psychosocial, biological, and psychodynamic constructs such as depression, anxiety, and loss of control. In our attempts to gain scientific credibility, we may have become our own worst enemies!

Yet, the grief journey requires contemplation and turning inward. In other words, it requires depression, anxiety, and loss of control. It requires going to the wilderness. Quietness and emptiness invite the heart to observe signs of sacredness, to regain purpose, to rediscover love, to renew life! Searching for meaning, reasons to get one's feet out of bed, and understanding the pain of loss are not the domain of the medical model of bereavement care. Experience has taught me that it is the mysterious, spiritual dimension of grief that harbors the capacity to go on living until we, too, die.

Yes, our current models desperately need a "supplement of the soul." We need as caregivers, and as fellow travelers in the journey into grief more life-giving, hope-filled models that incorporate not only the mind and body, but the soul and spirit.

Risk #2: That we, as bereavement caregivers, join our efficiency-based culture by joining in and supporting, without questioning the "managed care" approach to what is really a soul-based journey.

I recently wrote a thought-piece on this topic for The Forum, titled "Blessed Are Those Who Mourn Quickly and Efficiently For They Meet Our Criteria For Managed Care." (I've never received so many e-mails, faxes and phone calls in my life!)

Among other things, managed care has us wrestling with issues such as confidentiality, paperwork volume and control over type and number of counseling sessions. However, it is the deeper implications of managed care that keep coming up in my conversations with the many grief counselors and therapists I meet at my workshops or from whom I receive phone calls or correspondence.

Obviously, we as caregivers cannot see people three or four times and "resolve" their grief. While our so-called "advanced culture" would like to think humans can quickly and efficiently overcome grief, reality suggests otherwise. We cannot use short-term models that impose rational and cognitive understanding of what is truly a soul-based journey.

Through no fault of their own, the general public has also been contaminated by this model. Some will approach the counseling relationship and essentially say, "I want you to fix me. The faster, the better. Tell me what I can do to resolve my grief and I'll do it." Yet, to heal in grief one must turn inward, slow down, embrace pain, and seek and accept support.

This current approach to mental health care is actually contributing to an epidemic of "complicated mourning" in North America. Rather than allowing for the creation of safe places where hurting people can mourn in doses when their heads and hearts are ready, this current model encourages people to deny their feelings.

Pain and feelings of loss are all too often, seen as unnecessary and inappropriate. Yet, only in having the safety of people and places where we can move toward our wounds do we ultimately "reconcile," not resolve, death losses. The current philosophy actually reinforces destructive societal messages such as, "carry on," "keep your chin up," and "keep busy." It's as if our current model of care shields its very self from acknowledging the human pain of loss, while not providing places for people to mourn.

Managed care has placed the focus on short-term, overt, measurable "progress" in grief. It's as if getting the person back to work is more important than restoring the soul. In my experience, many utilization reviewers from managed care companies advocate cognitive-behavioral therapy. A major problem with this is that we cannot help people heal in grief by thinking through the experience. As we have come to realize, in matters of life and death we must feel it to heal it. Managed care reinforces trying to "resolve" loss in one's head.

Yet, as Helen Keller, said years ago, "The only way to get to the other side, is to go through the door."

Helping people integrate life's losses means being present to them and observing them-"companioning." Observance comes to us from ritual. It means not only "to watch out for" but "to keep and honor," "to bear witness."

If I quickly moved to do what many in North American culture think I should do, I'd be taking normal grief and mourning symptoms away from people all day long. Instead, I try to "watch out for," "keep and honor," and nurture souls as they encounter the hard work of mourning.

Those of us concerned about this must become what I call "responsible rebels." I believe truly helpful counselors to bereaved people in pain are responsible rebels: they facilitate creative healing as they become fellow travelers in the journey. They do not function as agents of conformity to "get the person over" grief, but instead foster an awareness of how one is changed by the death. They stay in touch with their hearts without becoming contaminated by the formality of professional training. They do not think of themselves as experts, but as companions.

Risk #3: That we anoint ourselves as a privileged class of "master" grief educators, counselors, and therapists.

You see, I believe becoming an expert is dangerous. Implicit in any model of who we think we are is a message to others about who they are. The more we think of ourselves as "experts" the more pressure there is on someone to be a "patient." The largest impediment to providing support to people in grief is the distinction between "us" and "them."

A central arrogance in perceiving oneself as an expert is the perception that one has a superior knowledge of someone else's destination in the grief journey. We can be present, watch, and learn, but we cannot direct, or even guide. Today, more and more people want to be "certified" as grief educators, counselors, and therapists. Our own Association has developed standards and certification is available at different levels of "expertise."

I have supported and will continue to support this certification process. As in any professional discipline, we need some standards to aspire to. Now my warning: Please do not think certification means one is an expert who doesn't need to continue to learn and be open to new teachings. To be perceived, or worse yet, to perceive oneself as an expert grief counselor may be the first step toward unbecoming a creative, growth-oriented grief counselor.

There is a Buddhist teaching that says, "In the beginners mind there are many possibilities; in the experts mind there are few." Let's explore the consequences when others think you are an "expert."

In his lovely book Improvisational Therapy (1990), Bradford P. Kenney writes brilliantly about the hazards of being considered an "expert" or "master" counselor:

"You will find that it no longer matters what you say. Everything uttered will be contextualized as the voice of a master. A casual handshake will be taken as a trance induction. A belch becomes a brilliant intervention. The snoring in a nap becomes the voice of therapeutic wisdom. Avoid the political posturings of "mastery" and return to embracing and cultivating a beginner's mind. Maintain and respect ignorance. Speak to hear the surprise from your own voice."

As you contemplate the risk of being an expert, listen to your own inner voice. What has your personal grief taught you about what helps people heal? What have grieving people taught you? What are your own personal strengths and limitations as a caregiver? Are you an open-learner who is willing to be taught, or are you an expert who treats people like patients?

Many of you out there are not certified grief educators, counselors or therapists. That doesn't mean, however, you aren't resourceful, talented, compassionate people who can help people heal in grief. I encourage you to join us certified grief counselors and therapists, and to pursue your professional development-while at the same time not striving to be an "expert." Certification is not an end-stage of counselor development.

Continual professional development and openness to learning new tools and "ways of being" are essential for each of us.

There is an old saying that still holds true, "The best teachers are those who are always willing to be taught."

So, where do we go from here?

As caregivers to people in grief, I believe we would be well-served to discover our own "self-as-instrument." It was Combs, who years ago introduced the concept of "self-as-instrument" to the counseling literature.

He warned against the strict adherence to a particular model or school of counseling and essentially urged caregivers to discover their unique gifts and make use of them. He warned that we shouldn't become counselors cloned in the image of others, but instead strive to awaken, cultivate, and nurture imagination and creativity in ourselves, in our colleagues, and in our clients.

I believe that counseling people in grief is more of an art than a science. An artist fully embraces his or her personal strengths and limitations to evolve a unique style that becomes a portrait of oneself as a counselor and as a human being.

So, what do I mean by growth undergirding grief? Well, first for me:

Growth means change

My experience has taught me that we as human beings are forever changed by the death of someone in our lives. To talk about "resolving" our own or other's grief, doesn't allow for the growth or transformation I have both experienced in myself and observed in others. Mourning is not an end, but a beginning.

A return to a prior state of homeostasis or old inner balance, doesn't reflect how myself and others have been changed by the experience of loss. In using the word growth, I acknowledge the changes that mourning brings about.

Growth means encountering pain

The death of someone loved naturally brings about emotional, physical and spiritual pain for us as human beings. But encountering the pain of loss all at once would overwhelm us; we must have a "safe place" where we can embrace our pain in "doses." Sometimes we need to distract ourselves from the pain of loss, while at other times we need a "safe harbor" to pull into and embrace the depth of our loss.

Growth means a new inner balance with no end points

While the bereaved person may do the work of mourning to recapture in part some sense of inner balance, it is a new inner balance. My hope is that the term growth reflects the fact that you do not reach some end point in your grief journey. You don't reach "closure."

No one ever totally completes the mourning process. People who think you get over grief are often continually striving to "pull it all together," while at the same time they feel that something is missing.

Growth means exploring our assumptions about life

As many of us know from our personal journeys, growth in grief is a lifelong process of exploring how death challenges us to look at our assumptions about life. The very reason many of us are here at this conference and doing the work we do is grounded in that reality. Yes, our greatest gifts often come from our wounds.

Ultimately, exploring our assumptions about life after the death of someone loved can make those assumptions richer and more life-affirming. Many make new life priorities and find a personal, inner peace they lacked before.

Growth means actualizing our losses

The encounter of grief rewakens us to the importance of utilizing our potentials-our capacities to mourn our losses openly and without shame, to be interpersonally effective in our relationships with others, and to continue to discover fulfillment in life, living and loving. Rather than "dragging us down," loss often helps us grow. Loss seems to free the potential within. Then it becomes up to us as human beings to embrace and creatively express this potential. Growth is a possibility when we discover the resources we have and use them.

Obviously, not every bereaved person experiences the kind of actualizing growth I have just described. As a wise person once said, "Death may not be the greatest loss in life, the greatest loss in life is what dies inside us while we live." Our challenge as death educators and counselors, then, is to fight this cultural tendency and instead extend bereaved people this invitation: teach me about your grief and let me help you discover how this experience can enrich your life. Yes, a large part of the "art" of caregiving to the bereaved is to free them to grow and live until they die. "After all, death may not be the greatest loss in life, the greatest loss in life may be what dies inside us while we live." What an honor to be part of this journey!

It occurred to me recently that bereaved people have consistently taught me from their experiences that they have discovered the kind of growth described above. However, this growth is only encountered if we have safe places to do the work of mourning places of unhurried, self-reflection.

A not-so-secret hope of mine is that this growth-oriented companioning model will eventually replace the medical model, which all too often teaches that grief's goal is a movement from illness to normalcy. The growth model helps people understand the human need to mourn and discover how grief has forever changed them. It understands the normalcy of drowning in your grief before you tread water, and that how only after treading water, do you go on to swim.

There appears to be three general phases that new schools of thought go through as they grow and develop:

The first phase is one of innovation, passion, and enthusiasm. The second, one of hard work and conceptual refinement. The third, one of general acceptance and integration into the mainstream.

While some might see the growth-oriented counseling model in the first phase, I prefer to see it in the second and third phases. I believe a major breakthrough to acceptance and everyday practice is not only possible, it is beginning to take place in many counselors' offices. If those of us committed to this heart-based model meet the challenges ahead with intellectual and spiritual integrity, I believe growth-oriented companioning will take its rightful place as the most basic, sanest, and most comprehensive model of grief support and counseling yet to appear.

So, what is companioning about?

The opportunity to be present to people in grief is a privilege that has allowed me to be drawn into the richness and beauty of life. As companions to them in this process, I have been changed in powerful ways impossible to capture in words.

In sharing myself with you I hope I have engaged your minds and your hearts. For it is in transforming our thinking as we learn that we transform our lives and the lives of those we help.

Alan D. Wolfelt, Ph.D., is a noted grief educator and director of the Center for Loss and Life Transition in Fort Collins, Colorado. Among his many books are Healing The Grieving Heart: 100 Practical Ideas for Families, Friends and Caregivers,  The Journey Through Grief: Reflections on Healing and Healing the Bereaved Child. He is currently at work on a book on the concept and practice of companioning the adult mourner. For more information on this text when it becomes available, please write or call the Center for Loss at 3735 Broken Bow Road, Fort Collins, CO 80526, (970) 226-6050 or e-mail Dr. Wolfelt at wolfelt@centerforloss.com.