Mental health and older adults: working with grief
A guest blog post by Felicity Chapman, Mental Health Clinician and Aged Care Specialist
[This blog is part of series of blogs commissioned by ELDAC to support aged care health professionals and care providers in providing end of life care. You can find more information on the ELDAC website.]
As a mental health social worker who specialises in working with an older adult clientele I find that presentations of loss are common. Although we need to be careful not to unwittingly relate old age to negative experiences, it is hard not to link “age with loss” like they are identical twins. I have met several people like Mrs Fortune (the example story, below) in my contact with older people, and find working with grief a key part of my counselling with them:
Example Story: Mrs Fortune sits over by her window. Her 94-year-old face is predictably creased with age but there is a vitality in how she speaks – vitality marred with pain. How she misses her husband Walter and little dog Miffy. How proud she is about completing a university degree at 70 (!) but how hard it is to find intellectually stimulating conversations with anyone, let alone her peers. She works the Internet but craves one to one. She has interest groups but hearing loss gets in the way and her bad knee makes it difficult for her to drive. Her outlook is more like one 20 years her junior – stuck inside a frail body and a mind that is feeling foggy with age. There is not just one loss, but many. Her independent living unit is neat and her family support her, but I can see the ache of her constriction.
When I review therapy with her at session six Mrs Fortune says with appreciation, “I feel like I can talk to you. I still miss Walter terribly you know. But it doesn’t feel as heavy in my heart. I’m glad I got referred to you.” I feel fortunate too – for being allowed to walk with this charming woman in her grief. “Sometimes I feel as if he is here with us,” she says suddenly, then her mouth widens into a grin, “But not in a strange way.” It is nice to see her smile.
In the above story, not only was Mrs Fortune grieving the loss of her husband and cherished dog, but also all manner of issues ranging from reduced physical capacity to increased social isolation. Mrs Fortune’s story is like many of my older clients’. Even though people of all ages can experience loss related to change, older adults often face an unprecedented level of loss. Furthermore, research indicates that relationship loss (not to mention other losses) increases the likelihood of mental illness developing. 
Grief therapy, therefore, is even more relevant for older adults and the multiple layers of grief and loss can make it “complicated”.  Sometimes therapy can look a lot like peeling away the layers of an onion – once one layer is dealt with, another emerges. But what can make a complicated situation even more complex is when my clients wish to reach the Holy Grail of stage theory – acceptance – yet are equally determined not to let a lifelong love dissolve into nothingness. A client like Mrs Fortune might look sheepishly at me and say, “I just can’t get over Walter’s death, you know, get to that acceptance stage.”
The limitations of stage theory are well known now in clinical circles. The title of an article by psychologist Christopher Hall MAPS, director of the Australian Centre for Grief and Bereavement, says it all: Beyond Kübler-Ross.  Grief is no longer seen as a predictable emotional trajectory leading from distress to recovery and successful grieving is no longer associated with “letting go” of the deceased. Models like William Worden’s four phases of grief, the Dual Process Model and the late Michael White’s saying “Hullo” Again piece all appreciate the complex nature of grief and how important it is to focus on “enduring connections”. 
In the case of Mrs Fortune, I focused on enduring connections by encouraging her current social connections and acknowledging the enduring qualities of her relationship with Walter and Miffy, even though their lives had ended. My work with Mrs Fortune and my other older clients reminds me that while there needs to be some acceptance in loss, it is also important to allow for the ‘messiness’ of grief and encourage ongoing connection or legacies. We are then in a much better position to support older people face a tsunami of change, both as they age and as they near the end of their lives.
Adapted excerpts by Felicity Chapman from her book Counselling and Psychotherapy with Older People in Care: A Support Guide
- Baker AE, Procter NG. 'You just lose the people you know': relationship loss and mental illness. Arch Psychiatr Nurs. 2015 Apr;29(2):96-101. doi: 10.1016/j.apnu.2014.11.007. Epub 2014 Dec 10.
- Kessler D. ‘Grief, complicated grief, divorce, breakup and other losses, participatory workshop.’ Adelaide (SA): Facilitated by TATRA; 2015.
- Hall C. Beyond Kübler-Ross: Recent Developments in Our Understanding of Grief and Bereavement. In-Psych [Internet]. 2011 [cited 2020 Jul 26];33(6). Available from: https://psychology.org.au/for-members/publications/inpsych/2011/dec/Beyond-Kubler-Ross-Recent-developments-in-our-und
- White M. ‘Saying “Hullo” Again: The Incorporation of the Lost Relationship in the Resolution of Grief.’ In White C, Denborough D, editors. Introducing Narrative Therapy: A Collection of Practice-Based Writings. Adelaide (SA): Dulwich Centre Publications; 1998.
Beyond Kübler-Ross: Recent developments in our understanding of grief and bereavement
The Dual Process Model of Coping with Bereavement
Further resources to help you support bereavement for residents and clients can be found in the Residential Aged Care toolkit and the Home Care toolkit on the ELDAC website. ELDAC also has Diverse Population Groups pages to help you provide end of life care for older people from groups including CALD, LGBTI, and Aboriginal and Torres Strait Islander people.
Felicity Chapman works as a mental health social worker at Sonder primarily with residents of care homes and is a sessional lecturer for the University of Adelaide and the University of South Australia