Tools and Techniques for Establishing Trust in Virtual Therapy

MacBook Pro near white open book and coffee

Written by Kerem Okumus,

Now that virtual therapy seems to be becoming a common practice among therapists, there appears to be a question of establishing and maintaining a trusting relationship with patients.

It is much easier to establish trust and create a sense of intimacy during a face-to-face conversation than online. Nuances in body language, eye contact, and facial expressions can be easily missed or misinterpreted when communicating via a screen.

Moreover, you do not have the advantage of creating the right environment for sharing, e.g., using nice lighting, candles, or cushions for comfortable sitting.

It is much harder to create a comfortable environment when providing online therapy, but there are ways to do it successfully.

In this article, you will find some tips and tools that may help you create a peaceful atmosphere and develop trusting relationships with your patients. Hopefully, our guidelines will help you provide effective online counseling!

Creating a Truly Confidential Online Environment

Confidentiality is essential for the creation of a therapeutic alliance. Therefore, to establish trust, you should pay special attention to creating a safe environment in which the client knows that their privacy will be protected.

Platform Choice and End-to-End Encryption

The first thing to consider when choosing the platform for providing online therapy is the issue of the platform’s compliance with HIPAA.

Luckily, today there are many HIPAA-compliant teletherapy platforms that can help you with the provision of online therapy. Such platforms as Doxy.me, Zoom for Healthcare, and SimplePractice use end-to-end encryption that provides security.

Discussing the platform and its advantages and features can help you to create a safe environment.

Authenticated Access

Two-factor authentication (2FA) for the teletherapy account may be a very useful tool for improving the privacy of online therapy.

This method requires the user to complete an additional step of authorization (e.g., entering a verification code). Thus, even if the password was somehow stolen, the account will not be available to any third parties.

Privacy Tools to Protect Client Data

Along with the usage of a HIPAA-compliant platform, one more step that you may take to protect client data and create a confidential environment is the use of additional privacy tools.

If you conduct online therapy or receive any sensitive information on the computer, using a VPN service for PC can be helpful for protecting your internet connection from any interceptions.

Using general privacy tools can be an additional measure that will help you to create a more protected online environment.

Therapeutic Alliance: Tips for Creating Rapport Online

The success of therapy is often dependent on the therapeutic alliance that a therapist creates with his or her patient. Moreover, in order to create such an alliance, therapists spend a lot of time.

In the era of virtual therapy, when more than half of sessions are conducted remotely (either online or over the phone), creating a rapport without meeting patients face-to-face takes even more effort.

So, what may be helpful in such cases?

Being Verbal and Listening Actively

Every therapist knows that active listening is essential for the process of therapy. However, in-person interaction gives us the opportunity to read the client’s nonverbal signs and react to them. In the case of virtual therapy, these nuances can be missed.

Thus, being verbal and listening actively becomes more important in the case of virtual therapy. Tone, pauses, and choice of words become more significant in the process of communication. The demonstration of your engagement also becomes more important.

The repetition of the client’s words or the summarization of what he or she said can be very helpful in demonstrating that you are really paying attention to him or her.

Such words as “I hear you” or “that makes sense” can also be very useful in the case of virtual therapy to help the client realize that he or she is understood.

Nonverbal Communication

Establishing eye contact is another important thing to build trust with the client, but it becomes harder in the case of virtual therapy. Nevertheless, there are some things you can try.

For instance, positioning your camera at eye level can help you in the process of communication, as well as being visually present and engaging.

Not every client can feel comfortable being on camera, and it should be respected, but, nevertheless, video and audio can help in the process of creating rapport.

Some platforms, such as Zoom, have the “hide self view” option so that the client does not see himself or herself but still sees you. At the same time, you can still see him or her.

In the case of virtual therapy, the more expressive you are, the better. Some subtle cues cannot be easily understood by clients during the process of virtual therapy; thus, being more engaged and expressive, and using some nonverbal cues such as hand gestures can be very useful.

Setting Expectations and Boundaries

Talking about boundaries, the duration of the session, and the expected response time can be helpful in creating the right environment. In addition, it is important to discuss the confidentiality of the communication and protection of the client’s personal data.

It may also be helpful to have a simple backup plan so that you both know what to do in case of any problems with the connection or platform.

Conclusion

Providing therapy online definitely changes the way of building trust but makes it no less possible. It is just necessary to be more thoughtful and purposeful in the way you are communicating and creating a safe environment for your client.

Even small things become more important in the virtual environment. How you listen, how you react, how present you look, and how clearly you handle the issue of confidentiality all influence the feeling of your client about the safety of the environment.

About the author

Kerem Okumus is an Outreach Executive at Intseo Media, where he focuses on SEO outreach, publisher communication, and digital content partnerships. He has experience working with content covering technology, online privacy, cybersecurity, and other digital topics. 

 

 

 

Please also review AIHCP’s Grief Counselor Certification program and CE courses see if it meets your academic and professional goals.  These programs are online and independent study and open to qualified professionals seeking a four year certification

How to Specialize in Grief Counseling for Life-Altering Injuries 

Sad woman in a wheelchair suffering with grief. Written by Deepika,

Grief is a complex process, one that involves some type of loss in most cases. Not everyone possesses the internal resources needed to deal with overwhelming or crippling grief. While this emphasizes the demand for grief counselors, it’s important to understand that their role is not confined to a box. 

Many people only think of bereavement when a major loss is discussed. What about a life-altering injury that can leave someone grieving abilities they once had, a career they valued, or a future they had dreamt of? These losses can be just as important to address as the physical effects of the injury. 

Healthcare professionals interested in this area can specialize in grief counseling to support patients through a part of recovery that medical treatment may not suffice for. This article explains how to prepare for a specialization in grief counseling to support people after catastrophic injuries. 

Understand How Grief Works When Life is Forever Changed by Injury 

The first thing about injury that every healthcare professional must understand is that it is not always the same. As the Loewy Law Firm notes, a catastrophic injury causes permanent damage to the body and makes the victim unable to return to their former life or work. 

What differentiates a catastrophic injury from other kinds is the duration and the intensity of medical care required. Here, instead of losing another person, the individual may be coming to terms with changes in their body, abilities, independence, or the future. Such losses can continue to affect them long after the initial injury and medical treatment. 

At the heart of it, a patient may be grieving several changes at the same time, including:

  • The loss of mobility, strength, coordination, and other physical abilities
  • The need to seek help with activities that were previously normal or private 
  • Being unable to return to a former career or support themselves in the same way 
  • An unexpected change in responsibilities and relationships because of the injury 
  • The internal struggle with changes in appearance or the roles that once shaped their sense of self 
  • Having to reconsider plans or goals that once seemed achievable 

The reason such injuries are called life-altering is that their physical and emotional effects are severe. A 2025 study of people with moderate-to-serious brain injuries found that almost half of the participants continued to experience symptoms of anxiety/depression eight years after their injury. 

Moreover, difficulty dealing with the effects of the injury was also associated with higher emotional distress and poorer quality of life. Family and friends can provide valuable support, but they may not know how to deal with the situation. Motivating a patient to ‘stay positive’ or focus only on physical health leaves no room to process their loss. 

For healthcare professionals counseling victims of catastrophic injuries, this means looking beyond the immediate physical consequences of the injury. A counselor also needs to help clients express difficult emotions, work through changes in identity, and understand how their losses are affecting their relationships/future. 

 

Build the Skills to Guide Others Through Grief 

A general understanding of grief is not enough to counsel someone after a life-altering injury. There are several things patients often deal with at once, including physical disabilities, family responsibilities, changes in work, and plans for the future. 

A counselor must be able to understand such different concerns without assuming that every patient experiences them in the same way. So, what are some important skills professionals interested in becoming a grief counselor for catastrophic injuries must develop? They include the following:

  • Active listening, as patients require time and room to open up about their difficult experiences and emotions 
  • Empathy without reservations, as two people with similar injuries may grieve very differently 
  • Trauma-aware communication, where calm, respectful language is used without any pressure on patients to discuss their painful experiences 
  • Respect for independence, as patients need opportunities to make choices wherever possible to retain a sense of control 
  • Awareness of serious emotional concerns, since counselors must recognize when grief may occur alongside major depression, anxiety, or thoughts of self-harm 

A 2026 CBS News report showed how recovery can continue long after the initial injury. It shared the story of Hannah Strom, who survived a 2020 crash that injured 10 students and their coach. The incident left her with a broken leg and pelvis, a collapsed lung, and a traumatic brain injury (TBI). Over six years later, she was working as a rehabilitation aide at the same hospital where she had recovered. 

The report also highlighted the importance of looking beyond the immediate treatment of a serious injury. From the outside-in, a bird’s-eye view would suggest the need to prevent such injuries in the first place. 

Joseph Nugent, a fourth-year resident neurosurgeon at Oregon Health and Science University and a former paramedic, said, “When I was a paramedic, I brought countless patients to the hospital with traumatic brain injuries.”

He continued, “Skilled neurosurgeons can accomplish a lot, but my fire department and public health mentors showed me the best way to optimize outcomes for trauma is to direct efforts toward preventing the injury in the first place.” Indeed, prevention and grief counseling address different parts of the recovery process, but the crux is to extend care beyond the immediate injury. 

Finally, one cannot neglect the limits of grief counseling. Some patients may require assessment or treatment from another qualified mental health professional, especially when emotional challenges become severe. Even then, knowing when to involve others from the care team is an important part of preparing for this specialization. 

 

Lay the Groundwork for a Counseling Specialization 

Once you know your interest is in the area of grief counseling for life-altering injuries, it’s time to materialize that interest. What this means is that professionals need a strong foundation in grief, counseling, trauma, and the way serious injuries affect a person’s daily life and sense of self. 

The right preparation will depend on your existing healthcare background and professional goals. For instance American Institute of Health Care Professionals (AIHCP) has been offering grief counseling certification and CE courses in grief/bereavement for over 25 years. Receiving specialized continuing education and certification is a great way to increase your knowledge and lay the groundwork for your own grief practice. 

Be mindful that even college level healthcare training may not always give you the extensive knowledge/experience you need for dealing with grief. A 2026 exploratory survey of US medical schools found that, among the 10 schools that responded, 60% devoted fewer than five hours to teaching students how to cope with grief. Where as a certification with AIHCP is worth 100 continuing education hours.  

What’s more, 60% did not formally include physician grieving or coping in their curriculum. Only 20% reported offering specific clinical experiences involving end-of-life care during the preclinical years. Now, the survey had a low response rate, so it cannot be treated as representative of every US medical school. 

However, the findings make it clear that general healthcare experience does not always provide all the specialized knowledge needed to support people through a major loss. Deliberation on your part is a must. Therefore, consider preparing in the following ways:

  • Familiarize yourself with how people cope with different forms of loss. 
  • Strengthen your ability to listen attentively, ask useful questions, and communicate with empathy. 
  • Learn how traumatic experiences can affect emotions, behavior, relationships, and a person’s ability to recover after an injury. 
  • Understand the different types of complex grief responses. 
  • Develop a clear understanding of confidentiality, informed consent, and professional boundaries. 
  • Look into the emotional demands of working with people experiencing grief and how they may affect your ability to provide care. 

It is equally helpful to connect your grief counseling education with the type of injuries you may encounter. For example, someone working with people who have traumatic brain injuries may benefit from learning more about cognitive and behavioral changes. Similarly, those likely to work with people experiencing spinal cord injuries may require a deep understanding of changes in mobility and daily living. 

Gain relevant practical experience by exposing yourself to rehabilitation settings, hospitals, support groups, and community services. No matter the course you choose, do not forget to earn a proper license, especially when your role demands it. 

 

Join Hands With the Patient’s Wider Circle of Care 

The process of recovering from any sort of trauma is so complex that it cannot happen in a vacuum. Patients often have to work with physical therapists, social workers, rehabilitation specialists, and other healthcare professionals. If you plan to specialize in this area, it’s vital to understand how a host of professionals contribute to recovery. 

That’s the key to knowing where grief counseling fits into the big picture. Let’s consider a 2025 study that analyzed data from 79,604 people with moderate-to-severe traumatic brain injuries in the US Traumatic Brain Injury Model Systems database. Researchers compared 4,620 people who began rehabilitation early with 2,722 who joined much later. 

Earlier rehabilitation was found to be associated with improvements in productivity and life satisfaction. The latter included aspects like regaining independence, rebuilding relationships, and participating in daily activities. As you prepare for the specialization of grief counseling, learn to understand where your role stands amid the work of other professionals. 

Here’s an example: A patient who gets frustrated with rehabilitation may need a physical therapist to address a functional problem. At the same time, a counselor can help the patient work through the grief and frustration surrounding that limitation. Once you develop an understanding of how everything is interconnected, it will help you in the following ways:

  • You will know the role and contribution of each healthcare provider in the patient’s recovery. 
  • It becomes easier to understand the patient’s goals, such as what they wish to accomplish for themselves. 
  • Communication becomes smoother as you learn to share information between team members while preserving patient privacy. 
  • The changing needs of the patient are easier to spot, which may shift from surviving the injury to dealing with relationships or their future expectations. 

 

FAQs 

What does a grief counselor do for someone with a life-altering injury? 

A grief counselor helps patients process losses related to independence, abilities, relationships, work, identity, and future plans. They provide emotional support, help patients understand their changing circumstances, and recognize when additional mental health care or support may be needed. 

What skills are required to counsel people after catastrophic injuries? 

Important skills include active listening, empathy, respect for patient independence, trauma-aware communication, and asking thoughtful questions. Professionals should also understand grief, trauma, professional boundaries, and how emotional challenges affect recovery. 

What preparation is needed to work with patients experiencing injury-related grief? 

Preparation to work with patients experiencing injury-related grief may include education in grief and counseling, trauma awareness, relevant healthcare knowledge, practical experience, and ongoing professional development. Professionals must also understand their licensing requirements and learn how to work with a multidisciplinary care team. 

 

Key Data Points to Consider 

2025 study of people with moderate-to-severe acquired brain injuries  Almost half of the participants continued to experience symptoms of anxiety/depression eight years after their injury. 
2026 exploratory survey of US medical schools 
  • 60% devoted fewer than five hours to teaching students how to cope with grief. 
  • 60% did not formally include physician grieving or coping in their curriculum. 
  • Only 20% reported offering specific clinical experiences involving end-of-life care during preclinical years. 
2025 analysis examining 65 studies for group-based psychosocial interventions for adults with acquired brain injury The meta-analysis of 48 studies involving 2,653 participants found a small but statistically significant improvement in psychosocial outcomes. The outcomes considered were anxiety, depression, emotional distress, quality of life, and social support. 

Healthcare professionals cannot afford to rip apart the emotional and social aspects of recovery after a catastrophic injury. A 2025 analysis examined 65 studies for group-based psychosocial interventions for adults with acquired brain injury. In the meta-analysis, 48 studies involving 2,653 participants were included. 

The review discovered a small but statistically significant improvement in psychosocial outcomes. The outcomes that were examined included anxiety, depression, emotional distress, quality of life, and social support. Now, this does not mean that a single counseling approach will work for every patient. 

However, it does bring our original exploration full circle: recovery has to do with more than the immediate injury. So, your goal is not just to help someone feel better about what happened. It is to support them in working through the losses and discovering new ways to participate in family life, work, relationships, and the community. 

References 

  1. Lgoe Anna et al. 2025. Psychological outcomes following moderate-to-severe acquired brain injury: A longitudinal study. PubMed

https://pubmed.ncbi.nlm.nih.gov/40521926/

  1. Robinson, Erik. August 2026. Causes of traumatic brain injury vary widely worldwide, study finds. Oregon Health and Science University. 

https://news.ohsu.edu/2026/08/19/causes-of-traumatic-brain-injury-vary-widely-worldwide-study-finds

  1. Vishwanath Vineet, Plummer M Maria, et al. March 2026. Grief and coping education in US preclinical medical curricula. Findings from an exploratory survey. PubMed Central

https://pmc.ncbi.nlm.nih.gov/articles/PMC13039567/

  1. Thomson Kate, Haslam Catherine, et al. August 2025. Group Psychosocial Interventions Following Acquired Brain Injury: A Systematic Review and Meta-analysis of Group Process and Outcomes. Springer Nature Link. 

https://link.springer.com/article/10.1007/s11065-025-09670-w

Author Bio

Deepika has over six years of experience as a writer and editor. Passionate about words and learning, she takes an interest in a variety of niches. Her knack for turning complex ideas into relatable narratives allows her to resonate with the reader. When her pen falls silent, you can find her engrossed in a novel or getting her hands messy with fine arts. Through these, Deepika is committed to keeping her curiosity and creativity alive. 

 

 

Please also review AIHCP’s Grief Counselor Certification program and CE courses see if it meets your academic and professional goals.  These programs are online and independent study and open to qualified professionals seeking a four year certification

Why Feeling Better Doesn’t Always Mean You’ve Recovered

Is your teen depressed? Please also review AIHCP's Child and Adolescent Grief Counseling Certification

Written by Marko,

After a long time, you’ve slept through the night and, when your friend made a joke, you actually laughed at it. You have plans for the weekend and, for the first time in forever, you’re looking forward to it instead of thinking about how to get out of it. 

It seems like you’re back to being yourself. It was a long way to go, but you did it. You’re okay.

Then… Well, then you realize you won’t make the deadline at work and the same thing happens again. And this is unfortunately something that (likely) resonates with a lot of people.

You feel this knot in your stomach, and you get overwhelmed by panic. It all rushes right back, as if it never left. As if you never made any progress whatsoever. As if you haven’t recovered.

By triggering the HPA axis and increasing your cortisol levels, stress can reactivate previously reduced symptoms. – Harvard Health, Stress Response and Mental Health

That whiplash can be terrible in more ways than one, but it certainly doesn’t mean that you haven’t made serious progress. This is a normal part of the process, so it’s weird that it’s not talked about more. What feels like recovery doesn’t have to mean actual recovery, and what feels like a failure isn’t failure in the vast majority of cases.

Strange, isn’t it?

Let’s see why this happens.

Feeling Better and Being Recovered Aren’t the Same Thing

You no longer feel heavy, and the dark thoughts seem to be gone. 

And while this definitely is a good thing, this is still not what we consider ‘recovered’; it’s only progress towards this goal.

Clinical mental health recovery requires two things: symptom remission and restoration of functioning (work, social, cognitive). – National Institute of Mental Health (NIMH), Mental Illness & Recovery

Maybe you don’t feel that paralyzing panic anymore, but you can’t focus on the book you’re reading for more than 2 minutes. Sure, our mood might be better, which is great, but you still don’t feel motivated enough to shower or run errands you should’ve completed days/weeks ago; you’re procrastinating. 

It’s great that you feel less emotional pain, but that doesn’t necessarily mean that you can function normally again, which is why people tend to get stuck at this stage. It’s also the reason why feeling awesome for a few days can be so deceptive.

Recovery is complicated. Well, that goes without saying, really. 

But what makes it complicated?

People are different, and it comes as no surprise that the recovery process isn’t equal for everyone. There are some things that everyone does share – that’s the fact that there’s no moment where you instantly go from zero to hero. 

There’s no switch.

Mental health recovery is non-linear, meaning it has periods of improvement, periods of relapse, and periods of stabilization. – Substance Abuse and Mental Health Services Administration (SAMHSA)

Recovery is (usually) slow and messy, with a decent amount of back and forth, where you feel like you’re okay one day, and then the next, you feel like everything you did is wrong and all the work was for nothing. 

So, once you get that string of good days, it’s tempting to just declare you’ve recovered and move on with your life.

Relapse rates for mental health conditions (e.g., depression, anxiety) have recurred in 50-80% of people. – National Institute of Mental Health (NIMH), Depression Recurrence Studies

But no mental health professional would agree with you. 

They’ll pat you on the back for having a few good days, but they’ll also want to see if those days become months, especially when something stresses you out. They’ll want to see that you’re still stable even under pressure because, if you are, then you’re truly okay.

This is also why treatment can change at this point. 

Once the worst is over, the focus goes to building something that lasts.

These early improvements can be quite misleading because people start feeling relief, which is both real and welcome, to the point that they assume they’re healed (or at least mostly healed), while in reality, they’re nowhere near full recovery.

One good thing to remember is that you can always ask for help – in fact, it’s encouraged. 

Being among people who know how to help and people who’ve been where you are right now can be the difference between success and failure. This is why hospitalization institutions come in handy. You can find partial hospitalization in Delaware, Ohio, Texas, Maryland, etc. – all over the country. These types of institutions were designed to make your recovery process as efficient and as easy as possible. 

If you’re struggling, then professional help is the answer.

Recovery Happens in More Than One Area

There’s a lot of misinformation out there about recovery, so it’s really no wonder that many people assume it’s this big moment where you wake up one day, and you’re suddenly great. 

But that’s not how recovery works.

Emotional Relief Doesn’t Mean You Can Function Normally

On the one hand, you feel calm. Or at least calmer than you’ve been recently. 

But on the other hand, you find yourself staring at a computer screen for an hour without doing anything. This happens a lot – panic and sadness ease up, but concentration and motivation are nowhere to be found. This is normal. 

Your brain has been running on empty for so long, it makes sense that it needs a while to rebuild cognitive muscles.

You Have to Rebuild Healthy Routines

Behavioral activation is one of the most effective evidence-based methods for sustaining mental/emotional recovery. – American Psychological Association

When things start to go downhill, the first thing people forget about are routines. And it makes sense, because who wants to go to the gym when you feel like your life is falling apart? 

You no longer sleep well, you don’t eat on time, and when you do, it’s not anything healthy because you don’t feel like cooking.

Once your mood picks up, none of this will be magically fixed. 

What you’ll need to do is force yourself to exercise again, to cook, to run errands on time, to go to bed at a certain hour, and so on. 

It won’t feel too good, and you might still end up doomscrolling on TikTok until 3 A.M., but if you keep at it, all of this will become normal again.

Relationships Recover at Their Own Pace

Just because you no longer feel depressed 24/7 doesn’t mean you want to reach out to your friends and family. It’s been so long since you stuck to a plan without flaking or since you were in the company of other people without feeling irritated, so it’s no wonder this feels awkward.

This will take time, probably more than you think.

Get ready to have some awkward conversations with the people around you because they don’t know what to expect of you or even how to act around you. 

Just be honest and let time do its thing. There’s really nothing else to be done here.

Confidence Gets Back Little By Little

Repeated successes increase self-efficacy, which is linked to sustained long-term mental health recovery. – American Psychological Association

If you feel better, that’s a great sign. But the question is, “How are you doing mentally REALLY?” Do you believe in yourself again? Do you feel good about yourself?

Once you’ve managed to tackle these heavy emotions, that doesn’t automatically mean that confidence is back. 

The way you get back your confidence is by being consistent and steady. 

Keep giving yourself small and achievaeable/realistic goals. 

The more you complete them, the better you’ll feel because this will train your mind that progress is REAL. It’s not some abstract concept. Once you realize that your actions can make a difference, your confidence will (slowly) return.

What Actual Recovery Looks Like

As you may have figured out by now, recovery doesn’t look perfect. It actually looks kind of basic, with a little bit of chaos here and there. 

True/proper recovery you’ll find in the form of consistency.

One bad day is just that – a bad day. It doesn’t unravel into something that lasts for weeks, so one bad day is actually progress.

If you want to know about the biggest sign of recovery, it’s simple. 

It’s in how someone handles stress once it shows up. The important thing here is that they’ll deal with it instead of running away. They’ll sit with the discomfort they feel because they’re strong and don’t have to hide from the bad stuff anymore.

Another thing that happens once a person starts to recover is that they notice more meaningful stuff in their life. 

Like their job, for example. 

It no longer feels soul-sucking but worthwhile. 

All these relationships start becoming a source of comfort and connection instead of something that constantly drains you and makes you feel uncomfortable. Stress and the struggle won’t disappear. Everyone gets stressed out, and everyone struggles at one point or another. It’s how we face those things that change (for the better).

Conclusion

Someone who now sleeps better and laughs at jokes is winning life.

Don’t take feeling good for granted. This doesn’t mean that you don’t deserve feeling good – you do. But keep in mind that it takes a lot of work (whether you realize it or not) to keep feeling good and staying positive even though the odds might be against us.

We can do it, of course. 

But once we start feeling a bit too comfortable; once we start getting lazy, all those bad things in life will again start knocking harder at our doors.

The main takeaway here is that you now KNOW that it’s possible; and it’s not THAT difficult once you know what to do and how to do it. You just have to be aware at all times, and you have to train yourself.

2 Interlinking Opportunities:

From https://aihcp.net/2025/10/22/emotional-healing-process-in-counseling/ with anchor approach to emotional recovery

From https://aihcp.net/2024/11/21/psychological-recovery-after-crisis/ with anchor limitations of recovery

Author Bio 

Marko is an adamant and eager content writer with a decade of experience in various niches,  with healthcare being one of them. With his way of implementing storytelling, comparisons, and examples into hard-to-grasp topics, Marko’s able to make complex things sound interesting and relatable – key ingredients to make something understandable. As a hobby, Marko enjoys offroading, board games, and spending time with his family and his dog Cezar.

 

 

Please also review AIHCP’s Grief Counselor Certification program and CE courses see if it meets your academic and professional goals.  These programs are online and independent study and open to qualified professionals seeking a four year certification

Grief Counseling: Mood Disorders and the DSM-V-TR

Mood disorders transcend the usual care of pastoral or non-clinical grief counselors.  Most grief counselors deal with the natural phenomena of loss that follows a natural grief trajectory.  Clinical professionals, who may also be grief counseling certified, deal with pathological issues surrounding mood.  Any instability of extremes, whether due to mania or melancholy can disrupt natural life and harm mental health.   Sometimes, moods can be directly affected by an acute grief or loss and this leads down a trajectory of complications due to grief, while in other cases, there is no triggering loss that causes the pathological mood.  Instead it involves an in-depth investigation into the etiology of the disorder reviewing biological, genetic, psychological, social and spiritual issues to explain the condition.

The DSM-V-TR lists numerous mood disorders ranging from Major Depressive Disorder to Bi-Polar Disorders. Please also review AIHCP’s Grief Counseling Certification

The DSM-V-TR groups together a variety of mood disorders which in this blog will highlight Major Depressive Disorder, Persistent Depressive Disorder and its numerous specifiers, as well as Bi-Polar 1 and Bi Polar 2 disorders and finally, Prolonged Grief Disorder.  It is important to remember that for the pastoral or non-clinical grief counselor, one should have a strong understanding of these mood disorders to help refer clients to the appropriate clinical specialists.  A non-clinical grief counselor cannot diagnose or treat mood disorders but they can be trained to spot these disorders and work with clinical professionals in assuring the necessary therapy and medications are received for the client.

Please also review AIHCP’s Grief Counseling Certification, as well as its numerous other Grief Programs.

Etiology of Mood Disorders

Mood disorders find their etiology from numerous factors.  Biologically, whether mania or melancholic, there is a strong connection of genetic inheritance of these pathologies tied to the neurotransmitters (McRay,2016).   When the neurotransmitter, serotonin, is low, depressive states can exist.  Serotonin is the a critically important neurotransmitter for mood stability (Barlow, et. al., 2023).   In regards to mania, the synapses between neurons fire to fast, and a euphoric state overtakes the person.  This is usually due to higher levels of  the neurotransmitter norepinephrine and lower of levels of serotonin, although higher levels of serotonin can also lead to states of mania (McRay, 2016).

Depression can be caused by an internal trigger but also a stressor or external loss.  Hence unipolar mood disorders can be both have a direct external stimuli as well as an internal disruption.   Many times the diathesis or culmination of internal and external events that overcomes a person to the disorder can be attributed to external factors that activate it.  As similar to anxiety disorders, a loss, or lack of social support in that loss, or distorted cognitive thinking can unravel a person’s natural reactions into a pathological state (Barlow, et. al. 2023).

When considering psychological etiology for mood disorders, many aspects involve self image, cognitive distortions, as well as learned helplessness in situations.    When individuals engage in self negative talk and think the worst, then it can affect a person’s overall mental paradigm.  In addition, when a person feels they have no control or power to prevent bad things from continuing, then the person becomes susceptible to pathological mood disorders (McRay, 2016).  In addition to how one thinks, social and cultural and spiritual aspects play a key role.  A person’s support system is key in any mood stabilization because it determines the foundation one has to face multiple problems before succumbing to the issue.  In addition, culturally and spiritually, how one views loss can play a key role in how one reacts to loss.

As one can see, mood disorders are a complications of genetic but also psychological, social, cultural and spiritual aspects of the person.  Sometimes, the mood disorder, such as depression, has a visible trigger, but other times, it is purely at the chemical level of the brain.  Every individual is different and what causes diathesis and activation of a mood disorder, or even anxiety is not a simple equation but a very complex one.

Mood Disorders and the DSM-V-TR

In this blog, we will follow the order of the DSM-V-TR and how it lists and discusses the nature of mood disorders.  We will primarily focus only on the above mentioned disorders.

Bi Polar I & Bi Polar II Disorder

Polarity of symptoms Depression euthymia mania subsyndromal hypomania. Vector illustration

Bi polar disorders are characterized by cycles of depression and euphoria (mania) with symptoms that can greatly affect one’s ability to function in life (McRay, 2016).   The DSM-V-TR states that mania is a period of abnormal and persistent moods of high levels of energy with the possibility of also irritability which lasts at least 1 week (2022).   During this phase of mania, the DSM-V-TR notes these types of characteristics with three needed for diagnosis or four if the mood is only irritability.

  1. inflated self esteem or grandiosity
  2. deceased need for sleep
  3. more talkative or need to talk
  4. flights of ideas or subjective experiences that are racing through the mind
  5. distractibility
  6. increased goal directive activities that can be social, work, academic or sexually
  7. excessive engagement in activities with high potential for bad outcomes.  Such as foolish business investments, spending sprees or sexual activitiy

The DSM-V-TR continues that these states cause severe impairment to social and occupational functioning and has no association with other psychotic, psychological, substance or medicated purposes (2022).  Within itself, these are conditions for mania, which albeit rare, can exist as an issue alone apart from Bi-Polar I or II.

Ironically, Bi-Polar I does not require a depressive cycle although that is very rare for one not to be present in diagnosis.  When we discuss Major Depressive Disorder and a depressive episode we will list its diagnosis as well which would be utilized with any Bi-Polar disorder.

For Bi-Polar I, as well as Bi-Polar II, the DSM-V-TR provides many specifiers since it affects individuals with so many additional subjective aspects.    It can be mild, moderate, severe, possess psychotic features, be in partial remission or full remission, or also include anxious distress, mixed features, rapid cycling, melancholic features, mood congruent psychotic features or mood incongruent psychotic features, catonia, peripartum or seasonal (2022).

Bi-Polar II differs from Bi- Polar I in that there is no state of mania but there always must be a depressive state.  What replaces mania is referred to hypomania.  Hypomanic episodes shares the same characteristics of mania but not as severe or impairing to the individual (only 4 days as opposed to at least a week) but it still manifests a change in functioning that is not characteristic of the individual when not symptomatic (2022).  In addition, the mood shift is observable by others but not enough to cause extreme distress (DSM-V-TR, 2022).

The primary differing diagnosis factor from Bi-Polar I over Bi-polar II is one has not ever been diagnosed with a true mania state ever in life.

It is important to note, some individuals who suffer from Bi-Polar mood disorders cycle more rapidly than others, with 4 mood shifts a year being considered high but there can be less cycles and individuals can move through them quickly (Barlow, et. al, 2023).

Major Depressive Disorder

While depressive episodes are part of bipolar disorders, the same criteria for Major Depressive Disorder that diagnoses an episode of depression for Bi-Polar disorders is also diagnosis Major Depressive Disorder but without any mania or states of euphoria.  Major Depressive Order can find its origins biologically or also be a reaction to a loss or severe stressor.  It is a unipolar mood disorder without a switching from extremes but a state of melachony

Facing Major Depressive Disorder

According to the DSM-V-TR depressed moods or loss of interest in pleasure must persist for periods of 2 weeks or longer (2022).  Diagnostic characteristics include the following and requires five or more symptoms for diagnosis.

 

  1. Depressed mood for most of the day or nearly everyday.  Feelings of sadness, emptiness and hopelessness
  2. Diminished interest in pleasure
  3. significant weight loss
  4. Insomnia or hypersomnia nearly or everyday
  5. psychomotor agitation that is observable by others
  6. fatigue and lack of energy nearly everyday
  7. feelings of guilt or unworthiness
  8. diminished ability to concentrate or think or make decisions
  9. recurrent thoughts about death, recurrent suicidal ideation without a specific plan or with a plan, as well as suicide attempt

These symptoms impair the individual in all aspects of life and are not due to any other psychological, medical or use of substance (2022).

Like bi-polar mood disorders, Major Depressive Disorder also has specifiers that dictate mild, moderate, severe, with psychotic features, partial or full remission, with anxious distress, mixed features, melancholic features, atypical features, mood congruent or mood incongruent psychotic features, catonia, post partem, or seasonal patterns (SAD) (DSM-V-TR, 2022).

Overall, Major Depressive Disorder is one of the most common mental maladies.  It is considered the common cold of mental health (McRay, 2016).  Women are 2 to 1 more likely to develop it, while Bi-Polar Disorder is equal (McRay, 2016).

Mentally, an individual suffering from depression faces the depressive cognitive triad that perceives negative connotations about self, the world and the future (Barlow, et. al., 2023).

Persistent Depressive Disorder

Persistent Depressive Disorder differs from Major Depressive Disorder in that is lasts longer than the normal minimum of 2 weeks but untreated can persist for months to years to decades.  It is not as intense but it leads to numerous health and mental issues.  Diagnosis requires a consistent 2 year period.  It includes poor appetite or overeating, insomnia or hyperinsomnia, low energy, low self-esteem, poor concentration and feelings of hopelessness, (DSM-V-TR, 20220).  Individuals can also suffer from both Persistent and Major Depressive.

Other Mood Disorders

Other mood disorders include Disruptive Mood Dysregulation Disorders that deal with frustration and anger outbursts, as well as Cyclothymic Disorder which does not meet criteria for mania, hypnomania or depressive episodes but still possess similar traits at a less severe level but for a period of 2 years with impaiment.

Ironically, Prolonged Grief Disorder is not associated with mood disorders in the DSM-V-TR but is a stress related disorder to acute grief which resembles depression but is a complex grief reaction.  The trajectory of normal reaction to loss is distorted due to severity of the loss, or various subjective factors involving the person.  AIHCP has numerous blogs on Complicated Grief as well as Prolonged Grief Disorder.

Treatments for Mood Disorders

Treatment for mood disorders should also include a integrated approach that includes medication as well as therapy.  Medication only masks the problem and without life skills and abilities to understand distorted thinking, then long term healing and mental health is not possible.  Also, some medications have complications which involves alternate trials and errors of different medications.  In addition, many individuals feel a mental stigma when diagnosed with depression or bipolar disorders.  This leads to hiding these feelings, or refusing to take the appropriate medications.  This leads to continued chaos, impairment, broken relationships, loss careers, and wasted time.  It is important to face mood disorders as any health condition.

SSRI help stabilize serotonin and mood

Medications

Anti-depressants are utilized to help most individuals with mood disorders, especially melancholy.    There are three types.  First, SSRIs are the most common and most used in modern medicine.  Second, tricyclic and third, monamine oxidase (MAO).  The tricyclics are rarely used with the advent of SSRI’s since tricyclics had more side effects.  SSRI’s stand for Selective Serotonin Reuptake Inhibitor.  They prevent the transfer of serotonin from one neuron to another hence preserving a higher level of serotonin to the body to help maintain mood.  MAO’s help dissolve the break down of Serotonin (Barlow, et. al., 2023).   Barlow notates that 60 to 70  percent of individuals who take medication for depression experience improvement, with half of that meeting full to close recovery to full functioning (2023).  A common SSRI’s include Prozac (fluoxetine).  Others include Celexa, Lexapro, Luvox, Paxil and Zoloft. Sometimes, individuals must go through a regiment of different SSRI until they find the best fit and dosage necessary to manage the depression.  Some need to be on SSRI longer, while others are dosed and gradually let off as needed.

Those who face treatment resistant depression can also turn to other methods to treat depression.   Holistic and natural remedies under the guidance of a primary physician such as St. John’s Wort or hypericum have shown benefits as well (Barlow, et. al., 2023).  Other more direct methods include Transcranial Magnetic Therapy (TMT) as well as Electroconvulsive Therapy (ECT) which directly sends impulses into the brain and neurons (Barlow, et al., 2023).

In regards to bi-polar disorders, a lithium based medication is utilized to help with mania.  Lithium, a common salt in  the natural environment, needs to be carefully dosed but has success with controlling mania states.  It is associated with weight gain which is another reason many individuals with bi-polar disorders wish to avoid their medication (Barlow, et. al., 2023).

Psychotherapy

Psychotherapy when supplemented with medication is the best combo for treating mood disorders.  It is important to fix the chemical issue but one also needs to have a strong understanding of self and ways to think differently.  Cognitive Behavioral Therapy plays a key role in helping individuals reframe and rethink distortions and negative connotations about self.   An individual who is depressed already has negative connotations about self, the world and the future.  AIHCP has blogs about CBT and its importance as a behaviorist therapy stemming from Aaron Beck and Albert Ellis that looks to help individuals think more healthy for better behavior and mental functioning.  In addition, human centered therapies which gravitate towards self esteem and congruence and fulfillment are important.  Karl Rogers and his person-centered therapy looks to support the client in meeting fulfillment through empathy, genuineness and unconditional positive regard.  AIHCP also has a blog to review on human-centered therapies.  Finally, interpersonal skills and support is key.  Individuals suffering from loss need support.  An individual with better support systems can overcome different losses with more success.  Some have stronger internal systems of meaning and spirituality, while others may have more family or friends or financial means to overcome loss.  Basic grief counseling in these ways can help individuals become more resilient when depressed or sad.

Conclusion

Please also review AIHCP’s Grief Counseling Program

Mood disorders can be stable with only one extreme or unstable and shift from mania to melancholy.  They are among, with anxiety, the most common psychopathologies.  Unfortunately, many individuals avoid treatment due to social stigma.  It is important to find the time to take care of one’s mental health if afflicted with a mood disorder.  Mood disorders can be genetic or causal but most all have solutions via medication, psychotherapy and counseling, or an integrated approach.

Please also review AIHCP’s Grief Counseling Certification as well as AIHCP’s multiple other behavioral health certification programs.

Additional Blogs

Anxiety Disorders:  Access here

Grief Video: Grief: The Price of Love.  Access here

Additional Resources

Bipolar Disorder. Mayo Clinic.  Access here

Clinical Depression (Major Depressive Disorder). (2026). Cleveland Clinic.  Access here

Dimaria, L. (2026).  “Types of Mood Disorders”. VeryWellMind.  Access here

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorder” DSM-5-TR (5th ed., text revision). American Psychiatric Association Publishing.

Barlow, D.H., Durand, V.M., & Hofmann, S.G. (2023). Psychopathology. An integrative approach to mental disorder (9th  ed.). Cengage Learning

McRay, B.W., Yarhouse, M.A., Butman, R.E., & Kiple, C. (2016). Modern psychopathologies: A comprehensive Christian appraisal. (2nd, ed.) IVP Academic

The Unspoken Nursing Skills of End-of-Life Conversations 

health care worker comforting a patientWritten by Marchelle Abrahams.

Some conversations are hard to have. And nothing can prepare you. Not a textbook. Not an online tutorial. Not a deep breath before delivering the bad news.

Once you have taken the Nurses’ Pledge of Service, talking to a patient about the end of their life is part of the package. Maybe you were warned how difficult it would be. Maybe you thought you’d cross that bridge when you got there.

The truth is that it doesn’t get easier. Sometimes the opposite. As long as you treat your patient and their family with dignity, the right words will form. Also, there are certain skills nobody has taught you until now.

Words Have Gravity

To you, words are something you speak to share information. An individual who doesn’t have the luxury of time can find comfort or hurt in them.

The journal Federal Practitioner published a paper titled The Meaning of Words and Why They Matter During End-of-Life Conversations several years ago. The advice still holds.

Author Grace Cullen goes into extensive detail on how essential effective communication is in healthcare delivery. However, misinterpretation can influence the quality of the care. 

The former palliative care nurse practitioner (NP) says that discussions must be handled with accuracy and precision. They must be conducted in a timely fashion and require skills that take practice to sharpen.

So, what are those skills?

With her years of experience, Cullen has learned that nurses don’t control how the conversation flows. 

“We approach patients with a blank canvas, open to receive messages that will be shared and reacted to accordingly.” – Grace Cullen, DNP, FNP-BC, ACHPN, AOCNP, RN-BC.

That’s why end-of-life (EOL) talks require compassion, an inherent human trait that isn’t taught in textbooks. Instead, it’s cultivated with training and application, advises Cullen.

Suggested Communication Phrases

Do not use medical terms. Talk in simple language and repeat the information. The truth should be gradually introduced to the patient.

Don’t leave families to their own devices. Offer administrative help, such as suggestions for hospice or palliative care. (Flugelman MY. How to talk with the family of a dying patient. BMJ Supportive & Palliative Care 2021;11:418-421.)

When speaking about advanced planning, Healthier Washington Collaboration Portal suggests the following:

  • What’s your understanding of your current situation?
  • If there ever came a time when you couldn’t make decisions for yourself, who would you trust to do that for you?
  • When you think about dying, have you thought about what the end would be like or how you would like it to be? 

Look to Mentors for Advice

You’ll probably get the best advice from your mentors. And yet, they’ll admit that no matter how many times you have the conversation, it still stings.

That’s why it’s important when finding a preceptor for a nurse practitioner to latch onto someone with years of experience in the EOL field. They can guide you on the best practices and share their wisdom on what works and what doesn’t.

In most cases, a nurse practitioner (NP) preceptor is a proficient clinician. They bridge the gap between classroom theory and real-world practice. In other words, you’re in good company.

ClickClinicals advises using professional NP preceptor matching services to ensure you’re matched with a preceptor aligned with your goals. They’re a sound option for nurse practitioner clinical placement help, and they’ll find you an NP preceptor fast.

Missed Opportunities for EOL Care Discussions

Timing is everything. Having the conversation too late can do more harm than good. A qualitative study published in the JAMA Network revealed a few insights. 

About 140 oncology patients were surveyed. Only 21 (5%) of encounters included EOL discussions. The study found that early EOL care preferences improve clinical outcomes. Unfortunately, most talks occur a month before death, despite most patients wanting information earlier.

Discussions about end-of-life care shouldn’t wait until a patient needs hospice, psychiatrist Natalie Jacobowski tells the Cleveland Clinic. She views it as counterintuitive.

Ask for permission to speak about the “what ifs” when starting treatment to prolong a patient’s life, advises Dr Jacobowski.

Create a Safe Space

Talking about someone’s imminent death is taboo, to say the least. It’s also uncomfortable and morbid.

A patient might not want to broach the topic, as it may appear weak or negative. Dr Jacobowski suggests taking your cue from them. Watch their body language. Acknowledge their fears. 

Take this as a step in the right direction. 

Frame the conversation as: “I imagine there are a lot of thoughts and worries. Is there anything that’s standing out to you that’s worrying you the most?”

That way, the patient will know you’ve created a safe space for them to voice their concerns.

Validate and Respond

Not every conversation goes according to script. Emotions are fraught. Anger. Sadness. Frustration. Grief. Patients are feeling them all at once.

Don’t gloss over their response and carry on like normal. Recognize their emotion and name it. For example: “I can see that this is incredibly difficult and upsetting to hear.”

Always lead the conversation, but also prioritize open-ended questions, because they’ll have many.

Validate their feelings. No judgment needed. Allow for silence. Remember, they’re only just processing the news. It takes time.

 

FAQs: End-of-Life Conversations in Clinical Practice 

  1. Why are end-of-life conversations delayed in healthcare settings?
    Many clinicians hesitate due to discomfort, fear of removing hope, or uncertainty about timing. 
  2. What is the most important communication skill during end-of-life discussions?
    Clarity paired with compassion. Using simple, non-medical language helps patients and families better understand and process the situation.
  3. How can clinicians create a safe space for these conversations?
    By asking open-ended questions, observing body language, and validating emotions without judgment.
  4. How do preceptors help nurse practitioners improve in end-of-life care?
    Experienced preceptors provide real-world exposure, model difficult conversations, and offer feedback that helps refine communication skills.

Key Statistics at a Glance 

Topic Finding Insight
EOL Discussions in Oncology Encounters  5% (21 out of 140 patients)  Very few clinical encounters include EOL discussions.
Timing of EOL Conversations  Often, within one month before death  Conversations are happening too late, limiting patient autonomy and preparedness. 
Patient Preferences  The majority prefer earlier discussions  Patients want transparency sooner, not at critical decline stages. 
Communication Risks  Misinterpretation affects care quality  Poor wording or unclear messaging can negatively influence patient understanding and care decisions. 

 

Parting Words

You chose to become an NP for a reason. And that reason is to care for and help people heal. Keep that in mind whenever sensitive patient discussions arise.

Lectures and textbooks can only teach so much. The rest is up to you. 

Whether you’re at the start or in the middle of this big, bold, beautiful journey called nursing, never forget why you are here.

References:

 

Author bio

Marchelle Abrahams is an award-winning writer (RDMA Awards 2019) who found her voice after carving a niche as a features writer for Independent Media. Currently, she freelances for various print and online publications, while ghost-writing blogs for several clients. 

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

Grief Counseling: Death of an Estranged Loved One Video Blog

Unfortunately, when someone dies it does not always occur under the best family conditions.  Some families may be divided, estranged, or not speaking.  In some cases, the estrangement between the deceased and the living family member.  These situations add complications to already a sad and grieving situation.  This video reviews some of the complexities associated with death of a estranged loved one.

Please also review AIHCP’s Grief Counseling Certification Program

The Creative Grief Cycle: Stage 1 – Creation

Where Grief First Finds Language

Written by Daniel Stern

A Conceptual Model Emerging from Lived Experience

The Creative Grief Cycle is a conceptual framework that emerged from my own experience of grief and the process of writing through it. In the time following loss, I found that writing did not begin as expression or communication, but as something more immediate—an attempt to give form to experience before it could be fully understood. What I describe here reflects that process. It is not a formal clinical model, but an effort to articulate a pattern that became visible through lived experience, considered alongside existing research in expressive writing, narrative psychology, and grief theory.

In a previous article, I introduced what I call The Creative Grief Cycle—a way of understanding how grief moves through creative expression. In that earlier piece, I described how grief often begins in silence; this stage begins at the point where that silence first breaks into language. This article focuses on that transition: the moment when experience first enters language.

The cycle has three stages:

  • Creation — where grief first takes form in language
  • Communication — where that expression connects with others
  • Rediscovery — where the work can be revisited over time, allowing meaning to evolve

Here, I want to focus on the first stage: Creation.

Research in expressive writing and grief has shown that writing about emotional experience can improve psychological and physical well-being (Pennebaker & Chung, 2011). This aligns with work in expressive and therapeutic writing (Mazza, 2017; Stepakoff, 2009), and with research emphasizing the role of narrative in helping individuals organize and make sense of loss (Neimeyer, 2001; McAdams, 2001). What receives less explicit attention, though, is an earlier phase—the point before writing becomes expressive or communicative, when pre-verbal emotional experience first begins to take form in words. While elements of this transition appear across existing research, they are not typically isolated as a distinct phase in grief writing itself.

 

Writing Begins as Pressure

In my experience, grief did not begin in words. It began as something closer to pressure—diffuse, persistent, and not yet nameable.

This pressure did not feel like a thought or even a clearly defined emotion. It was more constant than that—something ambient, but insistent. It did not organize itself into sentences or ideas. It accumulated.

At times, it felt physical: a weight in the chest, a tightening, a sense of something pressing inward or outward without direction. At other times, it was harder to locate—an internal density, a sense of saturation, as though experience had nowhere to go.

Research in trauma and affective processing suggests that overwhelming emotional experience is often encoded in sensory, bodily, and affective forms before it becomes available to language (van der Kolk, 2014). Putting feelings into words can also change how those experiences are processed (Lieberman et al., 2007). In this sense, what I describe as pressure may reflect a stage where experience is present but not yet organized in language.

What defines this state is not just intensity, but a lack of structure. Something is there—persistently—but it cannot yet be articulated or fully understood.

It is this pressure, rather than intention, that seems to initiate writing.

Writing does not begin here as expression. It begins as a response. Something pushes toward language—not clearly or steadily, but in fragments that appear, recede, and return.

Words surface incompletely: a phrase, an image, a line that will not leave. There is often hesitation, even resistance. The act begins not because there is something clear to say, but because something can no longer remain entirely internal.

In practice, this early movement often appears in small, recurring fragments before anything fully forms. For example:

From “A Picture on the Wall”

A small square of pigment
leaned out of its silence
and took me by the collar.

Or:

From “Between Two Gravities”

Between what demands I shine
and the gravity that pulls me inward…

These lines do not yet explain, resolve, or interpret the experience—they simply hold it in place. What they do is more immediate: they allow something to remain present long enough to be encountered.

At this stage, what appears on the page is not meaning in the usual sense. It is better understood as what I call proto-meaning— the earliest linguistic shape of an experience before it has become explanation, insight, or story.

Experience begins to take shape in language, but it is not yet narrative, explanation, or reflection. What emerges instead are fragments—images, lines, repetitions—that allow experience to exist outside the self for the first time.

This shift is subtle but significant. What was previously diffuse and internal begins, however slightly, to cohere.

Seen this way, fragmented or image-based writing is not a failure of clarity, but the beginning of it.

At this point, writing is not oriented toward communication or interpretation. Its function is more basic. It brings experience into form—giving it just enough structure to be encountered rather than only endured.

This is the first movement of Creation: not clarity, but necessity.

 

When Language Creates Distance

Once experience begins to take form in words, something shifts.

Language introduces structure. Even a single line creates a boundary—this word instead of another, this image held long enough to be seen. What was previously diffuse begins, however slightly, to take shape.

This does not immediately produce understanding. The experience may still feel unclear. But something important changes: distance becomes possible.

Not detachment—but perspective.

The experience is no longer entirely internal. Some part of it now exists outside the self, where it can be returned to. The writer is no longer completely inside the feeling. Something has been set down, even if only partially.

Research on expressive writing shows that, over time, people begin to organize emotional experience into more structured language—connections, causality, and meaning (Pennebaker & Chung, 2011; McAdams, 2001). Before that happens, a more basic shift occurs: experience becomes something that can be held and revisited (Neimeyer, 2001).

Writing begins to do more than respond—it begins to shape.

That shaping is not linear. It circles. It revisits. It approaches the same experience from different angles. But even in fragments, something changes: what was uncontained is now being held, line by line.

 

Why Grief Turns to Metaphor

Even as writing begins to create structure, it rarely does so through direct explanation.

Grief often resists that kind of language. Statements like “I feel empty” or “I am overwhelmed” may be accurate, but they flatten the experience. They fail to capture its movement, its contradictions, and the way it shifts over time.

So the writing moves toward image.

This is not simply stylistic. In early grief writing, metaphor may become necessary because direct language can feel too limited.

In early drafts, grief often appears not as a statement, but as a force. The fragment returns, unchanged:

From “Between Two Gravities”

Between what demands I shine
and the gravity that pulls me inward…

Here, the experience is not named directly. It is approached through something else—gravity, pressure, distance. Not because these are more precise, but because they make the experience possible to hold.

This aligns with work in poetry therapy, which suggests that metaphor provides an accessible structure for experiences that resist direct articulation (Mazza, 2017; Stepakoff, 2009). Cognitive linguistics similarly proposes that metaphor acts as a bridge between emotional and conceptual experience (Lakoff & Johnson, 1980).

In early grief writing, metaphor functions less as ornament and more as a tool.

By mapping internal experience onto something more concrete, metaphor creates a structure capable of holding what would otherwise remain diffuse. It gives shape without requiring full understanding. It allows movement—an image can shift, return, and evolve in ways a direct statement cannot.

Through metaphor, writing does not simply express experience—it begins to uncover it.

 

Writing as Discovery: Aphelion

In my own experience, the first poem I wrote after loss—Aphelion—began without intention. It did not start as an effort to express or explain anything. Instead, it emerged in fragments: isolated lines, images that appeared without context, and a persistent sense of movement that I could not yet name.

The central metaphor developed gradually rather than by design. Aphelion—the point in an orbit where a body is farthest from the center it moves around—became a way of approaching an internal state that resisted direct articulation: a simultaneous sense of distance and attachment, of being pulled away while still held in relation.

An early passage reflects this movement:

Some slip the constellations we hope to trace,
following a hidden geometry,
their own unseen law.

And when they reach aphelion—
that farthest point
where distance feels eternal—
we feel their silence
more sharply than their light.

Early lines did not explain this. They circled it. Images of distance, gravity, and motion appeared before any clear conceptual link was made. The metaphor did not begin as meaning; it functioned first as a container—something stable enough to hold a shifting internal state.

As the poem developed over several weeks, that structure allowed movement. The metaphor could shift, return, and reconfigure in ways that direct language could not. What had been entirely internal began to exist externally—not as a coherent narrative, but as something visible and revisitable.

By the time the poem was complete, the experience itself had not resolved. But it had changed form. What had been diffuse became structured enough to be encountered.

This pattern is not unique to a single piece. Across early grief writing, metaphor often emerges not as stylistic choice, but as necessity—providing the first framework capable of holding experience before it can be interpreted.

At this stage, there is often:

  • no audience
  • no intention to explain
  • no clear endpoint

 

The process itself is the point. Writing is not expressing experience—it is creating the conditions under which experience can be known.

 

The Function of Creation

It is important to be clear about what writing in this stage does—and does not—do.

Writing does not resolve grief.
It does not produce immediate understanding.
It does not yet create stable meaning.

What it does is more foundational.

It transforms experience from something uncontained into something structured enough to be encountered. It brings experience into language—not as explanation, but as form.

What emerges at this stage is not fully developed meaning, but something closer to proto-meaning—the first structures capable of holding experience in language.

This can be understood as a process of linguistic emergence, in which pre-verbal emotional experience begins to take early linguistic form. Through this process, experience becomes something that can be returned to, engaged with, and gradually understood over time.

From this point, the later stages of the Creative Grief Cycle become possible:

  • Communication, where expression becomes relational
  • Rediscovery, where meaning evolves across time

But neither occurs without this first shift.

Before grief can be shared or understood, it must first take form in language.

 

Author’s Bio:

Daniel Stern is a retired engineer turned astronomer and astrophotographer whose poetry explores grief, silence, memory, and renewal. His work lives at the intersection of science and emotion, where observation becomes reflection and language reaches for what cannot be measured. He is the author of Aphelion, his debut book of poetry, and the chapbook The Roar of Silence, a collection born from personal loss and the search for meaning in its wake. In his work as an astronomer, his astrophotography has been recognized numerous times by NASA (APOD). He has discovered deep-sky objects and, in collaboration with others, has been published in peer-reviewed astrophysics journals. Stern lives in Delray Beach, Florida, with his wife, Randie.

Website:           Http://www.theroarofsilence.com

Email:                dstern@mea-obs.com

 

 

 

References

Baikie, K. A., & Wilhelm, K. (2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11(5), 338–346.

Lakoff, G., & Johnson, M. (1980). Metaphors we live by. University of Chicago Press.

Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words: Affect labeling disrupts amygdala activity in response to affective stimuli. Psychological Science, 18(5), 421–428. https://journals.sagepub.com/doi/10.1111/j.1467-9280.2007.01916.x

Mazza, N. (2017). Poetry therapy: Theory and practice (2nd ed.). Routledge.

McAdams, D. P. (2001). The psychology of life stories. Review of General Psychology, 5(2), 100–122. https://journals.sagepub.com/doi/10.1037/1089-2680.5.2.100

Neimeyer, R. A. (2001). Meaning reconstruction and the experience of loss. American Psychological Association.

Pennebaker, J. W., & Chung, C. K. (2011). Expressive writing: Connections to physical and mental health. In H. S. Friedman (Ed.), The Oxford handbook of health psychology (pp. 417–437). Oxford University Press.

Stepakoff, S. (2009). From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief. The Arts in Psychotherapy, 36(2), 105–113. https://doi.org/10.1016/j.aip.2009.01.007

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.

 

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

Narrative Therapy and Grief

There are numerous modalities and therapies to help individuals face grief and loss in a healthy way.  Most psychotherapies share equal positive results in helping individuals deal with anxiety, grief, or other mental problems.  In the case of depression, as well as prolonged grief disorders, they also share in efficacy but many counselors prefer integrated approaches sharing from one discipline and incorporated another.  One type of therapy that many grief counselors find effective for grief and loss is Narrative Therapy.  While Narrative Therapy may not be for everyone, nor the sole answer, it can play a part in helping individuals understand their loss in a more constructive and adaptive way.

Narrative Therapy helps the client find new meaning in the loss. Please also review AIHCP’s Grief Counseling Certification

Please also review AIHCP’s Grief Counseling Certification Program and see if it meets your academic and professional goals.

What is Narrative Therapy?

Narrative Therapy is a type of constructivist therapy with postmodern philosophies developed by Michael Kingsley White and David Epston (Tan, 2022).  According to Tan, postmodernism is a world view that truth is not objective or tied to merely observation or within the systems of language in which is described and hence is open to subjective experience (2022). Social Constructionism applies this principle that the client is the expert on what one  experiences and understands one’s own subjective truth best without judgement of others (Tan, 2022).  Narrative Therapy falls under this type of philosophy, albeit, many of its techniques can be applied outside its rigid definitions.

Narrative Therapy is closely tied to meaning making and in that regards in some ways to Existentialist Therapy and the importance of finding subjective meaning to one’s issues.  Meaning is then created through social relationships, especially in one’s use of language in stories or narratives one shares.  Due to this, meaning and subjective reality can be rewritten or reframe or re-understood by the client through Narrative Therapy (Tan, 2022).  Narrative Therapy views human nature as basically positive and able to form new and better constructive directions through formulating healthier meanings about the past and present.  This is especially true regarding grief, trauma and loss.  Narrative Therapy opens the door for others to rewrite the story and replace past narratives that are saturated in negative and oppressive overtones.

Narrative Therapy finds many of its uses in David Neimeyer and his work utilizing meaning making and meaning reconstruction in grief counseling and loss.

Narrative Therapy at Work

A strong therapeutic relationship between client and counselor is required in Narrative Therapy.  It borrows this from many Rogerian concepts that utilize empathy and understanding and a true connection.  This type of connection is key in any type of grief counseling regardless of therapy and should be a fundamental concept for any one hoping to console the bereaved.    Due to the fluid nature of grief, Narrative Therapy does not propose a guide book of handling grief or emphasizing one technique over another.  It instead teaches that there is no true right or wrong way to conduct the therapy again applying to Rogerian person centered theories, as well as its social constructivist ideals (Tan, 2022).

Still, there are tools that are generally applied to individuals to help them move beyond their oppressive past narratives.  The attempt is to better understand the past or loss or whatever narrative, reframe it with new meaning, and incorporate it into the overall life of the person.  Much like any meaning reconstruction, where a person’s life is a likened to a book with various chapters, some good, some bad, but all delivering a theme and message of the wholeness of the person.

Journaling and reconstructing oppressive past narratives is key in Narrative Therapy and critical in Grief Couneling

First, question is key in Narrative Therapy.  The therapist or grief counselor will ask a variety of questions to help assist the person in understanding oneself.  The attempt is to help identify past oppressive narratives and to help the person become unstuck from those perceptions.  The second tool is externalization and deconstruction.  In this, the therapist hopes to help the person realize that he or she is not the problem, but the problem is the problem (Tan, 2022).    The problem or attribute is detached from the individual and seen as an independent and external parasite in itself.  This externalization serves as the starting point in facilitating deconstruction from the oppressive narrative (Tan, 2022).   Narrative Therapy will help the client map the problem and its influence on one’s life and how profoundly or deeply it has negatively altered one’s life.  Many times when  mapping, the counselor will look to label the problem and again externalize it from the person during the deconstruction phase.  A third tool is searching for unique outcomes.  This is more solution based and the therapist helps the client identify times the client dealt successfully with the issue and how this can be incorporated again and at a more efficacious result. Fourth, therapists help clients reauthor their story and find different future outcomes from what they feel by the past oppressive narrative.  They are also aided in reframing that story and taking control of it and finding meaning in that story.  Finally, documenting the evidence of client’s progress is key.  Therapist will include letters that the client later re-read that reinforces and summarizes the therapy when they are feeling less or discouraged.

Highly involved also in healing is writing.  Clients are encouraged to journal, write letters to oneself or unsent letters to others, similar to Gestalt Therapy.  Journaling is key to identifying oppressive feelings and themes, as well as controlling the narrative through the power of the subjective reality of the person writing their story.  This is not to dismiss the event, or even to dismiss facts, but to reinterpret these events and meanings in a more conducive way to healing which sometimes means looking at the loss, event, or problem in a different light.

Ultimately the therapy looks to help clients to control their own narrative through cognitive processes and writing processes to form a new narrative.  The client names the problem, explores how the problem has adversely affected him/her and explores new ways to interpret the the issue or find different meanings.  In addition, the counselor helps the client identify times when he/she successfully dealt with said issues, as well providing the client with encouragement on imagining a sound and healthy future beyond the problem (Tan, 2022).

Conclusion

One can see the useful elements of Narrative Therapy and some of its independent tools in helping individuals, especially with grief.  Individuals suffering from loss, or in some cases, pathological and traumatic loss need a therapeutic relationship that is filled with patience and empathy but they also need ways to face the past loss.  They need to remove the negative narrative that haunts them regarding the loss and find new meaning about the loss and how to incorporate it into one’s life.  This type of Meaning Reconstruction is a key element in Narrative Therapy and helps the person not only understand the past and find new meaning and authority over it, but also how to cope and develop a meaningful future that respects the past loss but also adjusts to it in a healthy and secure way.

New narratives can help individuals move forward from loss in a healthy way. Please also review AIHCP’s Grief Counseling Certification Program

Grief Counselors who are clinically licensed can utilize this therapy for those suffering from prolonged grief disorder, while in some cases, elements of it can be used for those not suffering from pathological or complicated grief reactions.  Journaling is a healthy element of Narrative Therapy for any case in understanding a loss and finding meaning in it.

Please also review AIHCP’s Grief Counseling Certification Program which is applicable for both non-clinical professionals as well as clinical professionals.  Of course, only clinical professionals can utilize Narrative Therapy with those suffering from complicated, traumatic or prolonged grief disorders.

Reference

Tan, S-Y. (2022). Counseling and psychology: A Christian perspective (2nd Edition). Baker Academic.

AIHCP Blogs

Honoring Endings-Access here

Grief Journaling- Access here

Additional Resources

Ackerman, C. (2026). “What Is Narrative Therapy? Techniques & Worksheets”. PositivePsychology.com.  Access here

Clark, J. (2025). “How Narrative Therapy Works”. VeryWellMind.  Access here

Guy-Evans, O. (2025). “Narrative Therapy: Definition, Techniques & Interventions”. Simple Psychology.  Access here

Narrative Therapy. Psychology Today.  Access here