NewIndispensable survival guide for Therapistthe thinking psychotherapist March/April 2014
The Grief Edition 90 Editorial note: The content for this edition of New Therapist was coordinated and managed by Darcy EDITOR Harris, one of the contributors. We are deeply John Söderlund grateful to Darcy for generously providing her astute and efficient editorial management of thisedition. MANAGING EDITOR Lee-ann Bailey
FEATURES EDITOR Features Sue Spencer CONTRIBUTING EDITORS 6 Good Grief: A Contemporary Dylan Evans Orientation to Bereavement Graham Lindegger Jacqui de Mare Counseling Julie Manegold Tim Barry Robert A. Neimeyer with John Tom Strong Kelly Quayle Soderlund Robert Langs Simone Descoins Robert Waska A fate less than death: 14 CONTRIBUTIONS Supporting clients through non- Submissions for inclusion in New Therapist are welcomed. death loss and grief New Therapist reserves the right to edit or exclude any submission. Names and identifying information of all individuals mentioned in case material have been changed to By Darcy Harris protect their identities. The views expressed herein do not necessarily represent those of New Therapist, its publishers or distributors.
Coming to grief: What you ADVERTISING 20 need to know about grief in Advertising deadlines for New Therapist are six weeks prior to the first Monday of the month of publication. Please call or DSM-5 email for a media pack and rate card, or visit our web site at www.NewTherapist.com. By Phyllis Kosminsky SUBSCRIPTIONS Subscription charges are $48 per year to all international destinations (including postage). To South African Getting grief working: A guide destinations, subscription charges are R320 per year 25 (including VAT and postage). If you would like New Therapist for the new grief therapist delivered to your door every second month, please send your payment (by Master or Visa card or cheque) and full postal By Dale Larson address to New Therapist Subscriptions, 27 Kitchener Road, Clarendon, Pietermaritzburg, 3201, South Africa. For further information, call +27 (0)33 342 7644 or visit our website at www.NewTherapist.com to subscribe online. Please allow up Regulars to 10 weeks for first delivery. CONTACT NEW THERAPIST Tel/fax: +27 (0)33 342 7644 Email: [email protected] 3 Drug Watch Web: www.NewTherapist.com 27 Kitchener Road, Clarendon, Pietermaritzburg, 3201, South Africa Research 4 New Therapist (ISSN 1605-4458) is a professional resource published by New Therapist Trust every second month and distributed to psychotherapists around the world. 30 Book reviews Copyright © New Therapist 2014. All rights reserved. No part of this publication may be reproduced or disseminated by any From the therapist's chair means whatsoever without the prior permission of the 32 publishers.
A publication of New Therapist Trust. 35 I'm a cake, you're a cake Drug watch
in the elderly. The company told doctors that Risperdal was safe and effective for this unapproved indication and population. The FDA maintains that physicians may, within the practice of medicine, use a drug to treat patients for symptoms or diseases even when the drug is not FDA-approved for such uses. However, if a pharmaceutical manufacturer intends its drug to be used for a new use, not approved by the FDA, and introduces the drug into interstate commerce for that use, the drug is then considered “misbranded.” Introduction of that misbranded drug into interstate commerce is a violation of the law. The U.S. Department of Justice action also alleges that Janssen and Johnson & Johnson were aware that Risperdal posed serious health risks for the elderly, including increased risk of stroke. The companies, according to the government’s Janssen pleads guilty to allegations allegations, downplayed those risks by combining against Risperdal negative data with other studies in order to support a perception of decreased risk from using the drug. he U.S. Department of Justice announced a Janssen had received repeated warnings from the $400 million criminal fine in addition to a FDA regarding its misleading marketing messages $1.25 billion civil settlement against Janssen targeted to physicians. After a whistle blower TPharmaceuticals of Titusville, N.J. for introducing complaint was filed, the FDA Office of Criminal a misbranded drug, Risperdal (risperidone). Janssen Investigations initiated a criminal investigation into Pharmaceuticals is a Johnson & Johnson company. The Janssen’s conduct. settlement was made on behalf of the U.S. Food and Director of the FDA’s Office of Criminal Drug Administration (FDA). The findings of the study Justice, John Roth says “Our investigators devoted appear online in PsychCentral in November, 2013. considerable time and resources to this case, to help The combined criminal plea and civil settlement ensure that pharmaceutical companies do not mislead agreement related to Risperdal totals $1,673,024 healthcare providers and the general public about the billion. safety and efficacy of their medicines. We stand ready FDA Commissioner Margaret Hamburg says, to take similar action in the future, if warranted, to “When pharmaceutical companies ignore the FDA’s protect public health.” requirements, they not only risk endangering the Janssen also marketed Risperdal for use in public’s health but also damaging the trust that patients children with behavior challenges, despite known have in their doctors and their medications.” health risks to children and adolescents. Until late in Hamburg says, “The FDA relies on data from 2006, Risperdal was not approved for use in children rigorous scientific research to define and approve the for any purpose, and the FDA repeatedly advised uses for which a drug has been shown to be safe and the company that promoting its use in children was effective. Today’s announcement demonstrates that problematic and could be evidence of a violation of pharmaceutical manufacturers that ignore the FDA’s the law. regulatory authority do so at their own peril.” Janssen and Johnson & Johnson will also submit The FDA approved Risperdal in 2002 for the to stringent requirements under a corporate integrity treatment of schizophrenia and in 2003 for the short- agreement with the U.S. Department of Health and term treatment of acute mania and for mixed episodes Human Services’ Office of the Inspector General. associated with Bipolar 1 Disorder. The agreement is designed to increase accountability In March, 2002 Janssen began to market the drug and transparency and prevent future fraud and for the treatment of agitation associated with dementia abuse.
Indispensable survival guide for the thinking psychotherapist 3 Research
Obesity in children influenced by attached often experience feelings of anxiety and parent’s relationship with their parents uncertainty in close relationships. As adults, they are especially at risk for ineffective parenting surrounding he quality of an individual’s attachment to some of the factors that are implicated in pediatric their parents may increase their own childrens’ obesity, she said. risk for obesity, according to researchers at the The study comprised 497 primary caregivers of University of Illinois. The research findings appear in 2½- to 3½-year-old children. Participants completed T a widely used questionnaire to determine adult the Journal of Developmental & Behavioral Pediatrics in February, 2014. attachment, answering 32 questions about the nature Lead author of the study Kelly Bost says, "If your of their close relationships. They also rated themselves mother regularly punished or dismissed your anger, on a scale that measured depression and anxiety. anxiety, or sadness instead of being sensitive to your Parents then responded to questions about how they distress and giving you strategies for handling those handled their children's negative emotions; whether feelings, you may be insecurely attached and parenting they engaged in emotion-related, pressuring feeding your children in the same way. A child who doesn't styles known to predict obesity; frequency, planning learn to regulate his emotions may in turn develop of, and communication during family mealtimes; and eating patterns that put him at risk for obesity." estimated hours of television viewing per day. Bost notes that the study tracks the association Bost says, "The study found that insecure parents between a parent's insecure attachment and their were significantly more likely to respond to their child's consumption of unhealthy foods, leading to children's distress by becoming distressed themselves weight gain. or dismissing their child's emotion." Bost says, "We wanted to discover the steps that That pattern of punishing or dismissing a child's sad connect attachment and obesity. Scientists know that a or angry emotions was significantly related not only to person's attachment style is consistently related to the comfort feeding but also to fewer family mealtimes and way he responds to negative emotions, and we thought more TV viewing, which led to children's unhealthy that response might be related to three practices eating, including self-reported sugary drinks, fast that we know are related to obesity: emotion-related foods, and salty snacks, Bost said. feeding styles, including feeding to comfort or soothe; "One explanation might be that insecure moms mealtime routine; and television viewing." are more easily overwhelmed with stress, find it more Bost explains that children form secure difficult to organize family mealtimes, and allow their attachments when their caregiver is available and children to watch more television as a coping strategy," responsive. That attachment gives the child a secure she suggested. base to explore his environment, protection in times of The study's findings provide valuable information distress or uncertainty, and a source of joy in everyday for health professionals who are working with parents interactions. and children, Bost noted. When that secure base isn't there, an insecure attachment can result, and children who are insecurely
4 New Therapist March/April 2014 Research
Relationships between parents Menopause experienced more acutely and teens affect teen dating among women with HIV success ot flushes, depression, and most of all, anxiety, he love between parents and teenagers— affect the thinking skills of midlife women with however stormy or peaceful—may HIV, so screening for and treating their anxiety influence whether those children are Hmay be especially important in helping them function, successful in romance, even up to 15 years later, according to researchers at University of Illinois, Chicago. T The study appears online in the journal Menopause in according to researchers at the University of Alberta. The research findings appear in the February, 2014. Journal of Marriage and Family, in February The reproductive stage, whether it was premenopause, 2014. perimenopause or postmenopause, did not seem to be Lead author of the study Matt Johnson related to these women's thinking skills. shares advice for those who had rocky relations The researchers analyzed data on 708 HIV-infected and 278 HIV-uninfected midlife women from the Women's with their parents while growing up: don't Interagency HIV Study (WHIS), a national study of let it spill over into your current romantic women with HIV at six sites across the US. partnership. Johnson notes his co-authored US statistics show that nearly 52% of people with HIV/ study highlights a "small but important link AIDS are between 40 to 54 years old. Because more between parent-adolescent relationship quality women with HIV are now living to midlife and beyond, and intimate relationships 15 years later. The it is important to understand what challenges menopause effects can be long-lasting." poses for them. A study published in Menopause in July While their analysis showed, perhaps not suggests that women with HIV face a bigger menopause surprisingly, that good parent-teen relationships challenge than uninfected women because they have worse resulted in slightly higher quality of romantic menopause symptoms. relationships for those grown children years Large-scale studies of healthy women indicate later, it poses a lesson in self-awareness when that the menopause-related thinking deficiencies are nurturing an intimate bond with a partner, modest, limited to the time leading up to menopause Johnson comments. ("perimenopause"), and rebound after menopause. But "People tend to compartmentalize their in these women who underwent mental skills testing, relationships; they tend not to see the menopause symptoms and mood symptoms did affect connection between one kind, such as family thinking skills. relations, and another, like couple unions. Mental processing speed and verbal memory were more But understanding your contribution to the related to depression, anxiety, and hot flashes in both HIV- relationship with your parents would be infected and healthy women than the stage of menopause. important to recognizing any tendency to Hot flashes in particular correlated with slightly lower replicate behaviour—positive or negative—in an mental processing speed, a skill that is also affected by intimate relationship." HIV. Depression correlated with decreased verbal memory, That doesn't mean parents should be blamed processing speed, and executive function (such as planning for what might be wrong in a grown child's and organizing). relationship, Johnson added. "It is important to Of all the symptoms measured, anxiety stood out as recognize everyone has a role to play in creating having the greatest impact on thinking skills, and the a healthy relationship, and each person needs to impact was much greater on women with HIV. Anxiety take responsibility for their contribution to that particularly affected their verbal learning skills. So treating dynamic." anxiety may be key to improving the lives of midlife The study comprised 2,970 individuals who women with HIV, concluded the investigators. were interviewed at three stages of life from "Unfortunately, HIV infection is associated with adolescence to young adulthood, spanning ages modest deficits in multiple domains of cognitive function, 12 to 32. even in women who regularly take their HIV medications. These depression and anxiety symptoms add to those cognitive vulnerabilities, but can be treated," says senior author of the study Pauline M. Maki. An interview with James Grotstein Indispensable survival guide for the thinking psychotherapist 5 Features Good Grief
Good Grief
A Contemporary Orientation to Bereavement Counseling
Robert A. Neimeyer with John Soderlund
6 New Therapist March/April 2014 Features Good Grief
ow do complications in grieving review, and often revision or present themselves in the course replacement. In their place, new, of therapy with the bereaved, and empirically informed models how can practicing therapists have gained currency, which view Hrespond to them? In this article one grieving as a multidimensional prominent grief therapist, theorist process of meaning making that and researcher reflects on the unfolds not only within people emerging diagnosis of complicated but also between them, with grief in light of more adaptive adaptive outcomes embracing trajectories through loss, and the reconstruction of attachment outlines the relational and technical to the deceased rather than its features of demonstrably effective relinquishment. In this interview, clinical interventions. Viewed prominent bereavement theorist constructively, loss challenges the and therapist Robert A. Neimeyer taken-for-granted assumptions of answers questions about the life, and can prompt significant, and upshot of these developments for often salutary revisions in our life therapists who encounter clients stories. Drawing on contemporary in the wake of life-altering loss. models and methods, counselors His humanistic belief in the reality and psychotherapists can make a of resilience notwithstanding, contribution to this outcome. Neimeyer acknowledges the The field of grief therapy is unique complications that can in ferment. Increasingly, time- accompany the death of a loved honored assumptions regarding one, and sketches the role of grieving as a relatively predictable therapeutic presence, process series of emotional stages that and procedure in addressing the proceed largely on an intrapsychic variegated needs brought to stage and that eventuate in clinicians’ offices in the wake of the breaking of bonds to the tragic bereavement. deceased are coming under
Indispensable survival guide for the thinking psychotherapist 7 Features Good Grief
John Soderlund: Bob, the work overstatement; I’ve met very few (e.g., of chronic depression or of Dr. George Bonnano suggests grieving people who wouldn’t give substance abuse), family- and work- that the majority of people who back in a heartbeat any degree of related conflicts, or—of special experience a significant loss personal growth they’ve achieved to interest in the present context—a react with a surprising degree of have their loved one back physically condition known as complicated resilience, to the extent that the in their lives. But at the same time, grief or prolonged grief disorder, grief process can, in the longer resilience is a clear reality for close experienced by about 10% of the term, be a positive experience to half of the bereaved, who manage bereaved. To give your readers a for them. This tends to counter to weather the storm of mourning quick orientation to this significant a prevailing, if rather archaic, surprisingly quickly, finding their clinical problem, I’ll include a view that counseling is routinely footing in the world once again “clinician’s toolbox” to help them a valuable process to help people within a matter of a few months, identify its key diagnostic features deal with bereavement. With this even if they continue to miss their (see Table 1). We can explore this in mind, can you reflect on what loved ones keenly. For many others, condition a little more thoroughly variables therapists ought to bear the loss more profoundly disrupts with a focus on its assessment and in mind when first encountering their mood and functioning for treatment later in this interview. I somebody who has been referred several months, but they too guess the point I’d like to make at to them on account of a recent ultimately grieve adaptively, the outset is that grieving can lead bereavement? integrate the loss into their lives, to surprisingly different outcomes, and return to their emotional only a minority of which are likely Bob Neimeyer: Well, to say that baseline while revising their life to benefit from psychotherapy. Of the death of one’s child, partner, routines and goals accordingly. course, that minority is enough sibling, parent or friend could in the Another 25%, however, tend to fare to keep us busy for the rest of our long run be considered a “positive worse, experiencing exacerbations professional lives! experience” may be a bit of an of previously problematic patterns
Table 1. Diagnostic Features of Complicated Grief
1. Duration of bereavement of at least 6 months
2. Marked and persistent separation distress, reflected in intense feelings of loneliness, yearning for or preoccupation with the person who has died
3. At least 5 of the following 9 symptoms experienced nearly daily to a disabling degree: • Diminished sense of self (e.g., as if a part of oneself has died) • Difficultly accepting the loss on emotional as well as intellectual levels • Avoidance of reminders of the reality of the loss • Inability to trust others or to feel that others understand • Bitterness or anger over the death • Difficulty “moving on,” or embracing new friends and interests • Numbness or inability to feel • Sensing that life or the future is without purpose or meaning • Feeling stunned, dazed, or shocked by the death
4. Significant impairment in social, occupational, or family functioning
Adapted from (Prigerson et al., 2009) and (Shear et al., 2011)
8 New Therapist March/April 2014 Features Good Grief
Before shifting to more discussion most accessible when the distress of Bob: Well, truth be told, the DSM of complicated grief trajectories, bereavement is sufficiently intense 5 probably isn’t the best source to however, I’d like to loop back to to challenge life as usual, but go by! What I mean by that is that your earlier implication about the not so overwhelming as to make it seems to me to fail in at least upside of grief. Beyond resilience constructive change impossible. three ways. First, many people, per se, which refers essentially to a Figure 1 depicts the sort of including major advocacy groups for rapid return to baseline following curvilinear relationship between the the bereaved themselves, argue that a significant stressful event, a intensity of grief and the degree of it risks pathologizing normal grief surprising number of people also personal growth that we’ve observed as “major depression,” diagnosable report substantial post-traumatic in our research. by its criteria within two weeks growth (PTG) in the long-term following the loss. Whether or wake of loss. As defined by John: Some of what you were not this is scientifically legitimate Calhoun and Tedeschi, PTG refers saying about the different on the basis of the consistency to a cluster of developments in the trajectories of bereavement reminds of depressive symptomatology wake of a “seismic” life transition, me that many medically inclined following the loss of a loved one or which include a greater sense of mental health professionals another major stressor, it is likely strength and maturity, deepening tend to roll grief into their list to open the door to widespread of relationships and compassion of pathological processes if the prescription of antidepressants to for the suffering of others, keener attendant emotions persist beyond mourners, even if specialized forms appreciation for life, greater a "reasonable" period. If the of psychotherapy have a stronger readiness to embrace possibilities, latest edition of DSM is anything track record of efficacy when grief and often a renewal of spiritual and to go by, what is considered a is, in fact, complicated. Second, philosophical frameworks for living. reasonable period of grieving is it fails to recognize that grief as a Nothing about this is inevitable, of being steadily reduced. What, in form of separation distress has more course, and our own research and your opinion, should be considered in common phenomenologically and that of others suggests that PTG is pathological in the grieving process even neurologically with anxiety typically a hard-won outcome of a and what should be considered than with depression as such, and good deal of painful reflection and normal variations in the process of therefore often calls for different meaning-making, which is probably grieving? treatment. And finally, even though
Figure 1. The nonlinear association between prolonged or complicated grief and posttraumatic growth.
70
65
60
55
50
45
40
35
30 -35 -15 -5 -25 -45 -65 -85 Prolonged Grief Symptoms (Centered)
Adapted with permission from Currier, Holland & Neimeyer (2012).
Indispensable survival guide for the thinking psychotherapist 9 Features Good Grief
the DSM-5 includes “Persistent John: Okay. So what should we read between the lines of what Complex Bereavement Disorder”— a practicing therapist know clients tell themselves about the apparently an awkward attempt to about intervention when grief is loss to discern the conjunction of combine the commonly used terms complicated or prolonged? For their current need and readiness “complicated grief” and “prolonged example, much is made of the that identifies specific points of grief disorder” into a single mouth- practice of "presence" in grief intervention. For me, grounding filling moniker—it classes it as a counseling. Can you unpack what in process implies a lively alertness “condition for further study,” even this means and why its so crucial to to our clients’ subtle and obvious though the evidence base for it is this kind of counseling? displays of emotion—a slight considerably stronger than that for break in speech, a welling up of many of the conditions included in Bob: Certainly. When I think about sudden tears, a slowing down the manual. Moreover, it defines grief therapy, or any responsive into reflective processing of an the condition with a hodge-podge psychotherapy for that matter, I emerging awareness. By extension, of paraphrased and conjectural think in terms of three dimensions: it implies equal attention to verbal, diagnostic features, rather than the presence, process and procedure. co-verbal and nonverbal channels scientifically established criteria By presence, I mean the capacity to of communication, not only to what summarized in Table 1. Thus, at offer full availability and attention is said and how it is said, but also minimum, the DSM-5 missed the to the client’s concerns, undistracted to the bodily movements or facial opportunity to recognize what was by our own agendas. It is more expressions that accompany it. This uniquely difficult about complicated about being than doing, allowing leads naturally to a “bottom-up” grief, while blurring its distinction ourselves to “indwell” our clients’ approach to therapy that is more from garden-variety depression. narratives of loss, to feel ourselves experiential than psychoeducational, Far more useful, in my view, into their stories, to be moved by in a sense leading a client from is the approach to diagnosis of their love for the deceased and one step behind toward clearer touched by their brokenness. At encounters with his or her emotions, prolonged grief disorder (PGD) the same time, this authentic and relationships and possibilities, rather that appears to be moving forward unflinching willingness to stand than directing therapy in a “top in the current revision of the World in the pain rather than merely down” manner to speak the language Health Organization’s International rush to mitigate it provides a safe of the therapist’s preferred theory, Classification of Disease (ICD- “container” for the client’s own and be trained in our preferred 11), which classes PGD with other exploration of his experience, techniques. But more broadly, “stress related disorders,” identified ameliorating the sense of being responsiveness to process is essential by symptoms that conform closely alone in a silent story of nameless even to more directive therapeutic to those listed in Table 1. This anguish. In this intersubjective field approaches or strategies, as it tells us means that common experiences of vivid presence, characterized by when a client is specifically primed of crying, missing a loved one, the time-honored practice of client- to process the event story of a suicide and so on in the aftermath of a centered listening and reflection, or accidental death, for example, or death are regarded as normal and we in a sense take up residence when they are needing to revisit the expectable reactions, whereas in our clients’ meaning systems, previously unexpressed problems others like pervasive separation understanding experientially the or unrealized potential in the distress, profound disconnection deep wellsprings of their grief, relationship to the deceased. In this from others, and sensing that the alongside their resources for sense, presence and process provide future is bleached of purpose a living with and learning from a container for not only the client’s year or more after the loss, in the it. Like Martin Buber’s concept exploration of emotional meanings context of marked deterioration in of the I-Thou relationship, it is a of the loss, but also for the therapist’s the client’s social or occupational fundamentally respectful stance that utilization of specific procedures. functioning, would be a cause for accords full humanity to our clients, clinical concern. Alongside other prior to any preoccupation with their John: What are some of those possibly comorbid conditions such diagnosis or case conceptualization. procedures? And have any of them as depression, generalized anxiety or Within this relational frame, actually been researched in the post-traumatic reactions (especially therapists then attend like delicately sense of having an evidence base in the aftermath of sudden, violent attuned instruments to the process that supports their use with clients or untimely death), this could call of therapy, that speaking-turn-by- suffering from complicated grief? for clinical intervention. speaking-turn interaction in which
10 New Therapist March/April 2014 Features Good Grief
Bob: Well, the answer to that it portends for their lives going abiding life philosophies—of a question would be a book in itself, forward. On the other hand, they profound rupture in their life and indeed I can recommend a frequently need to access the “back stories, as well as to re-write the few of them! (See Recommended story” of their relationship with the terms of their attachment to the Readings below.) Basically, as deceased, not only to sort out their deceased. It’s a tall order for many, a constructivist therapist, I view “unfinished business” of conflicts particularly when the death was clients in acute grief as struggling or regrets in the relationship, but traumatic, intentional, sudden or with two key narrative processes also to reconstruct their attachment untimely, and when the relationship in their attempts to make meaning bond with their loved one into a was complicated or eclipsed by of the experience. On the one form that is sustainable now. In the narrative of a violent death or hand, clients often feel the need to other words, clients need to make a grimly progressive illness that process the “event story” of the loss sense—viscerally in their bodies, threatens to overshadow the living itself, to in some way wrap their experientially in their emotions, image of the person we knew and hearts and minds around what has conversationally in their families, loved. happened, what it means, and what and spiritually in terms of their
Table 2. Techniques for Facilitating Meaning Reconstruction in Bereavement Processing and Integrating the Event Story of the Death
Retelling the Narrative of the Death Slow-motion review of the loss story to promote mastery
Chapters of Our Lives Situating the current loss in the landscape of previous experience
Virtual Dream Stories Creative writing about loss themes to facilitate their exploration
Playing with Playlists Tracing the trajectory of love and loss in musical memoir on iPod Figurative Sand Tray Therapy Constructing symbolic stories using figurines in sand world Analogical Listening Focusing on bodily felt sense of grief and giving it expression
The Body of Trust Depicting impact of the death story in mixed media on body image
Directed Journaling Diary work to consolidate sense-making and benefit-finding
Loss Characterization Narrating overall impact of loss on one’s sense of self
Overt Statements Voicing deep meanings that make chronic grief necessary
Rituals of Transition Symbolically validating life changes occasioned by loss
Accessing and Reconstructing the Back Story of the Relationship to the Deceased
Introducing the Deceased Reclaiming the deceased as a participant in one’s ongoing life
Imaginal Conversations Visualizing the deceased while addressing unfinished business Correspondence with the Deceased Inviting an “exchange” of letters to renegotiate the relationship Chair Work Choreographing deeply authentic conversation with the deceased Life Imprint Tracing the impact of the deceased on one’s values and decisions Reviewing the Photo Album Consolidating memories with the therapist as a witness
Prescriptive Photomontage Constructing creative composite image of deceased’s role in life
Memory Books and Boxes Organizing mementos and messages that honor legacy of the lost Rituals of Connection Symbolically validating continuing bonds
Indispensable survival guide for the thinking psychotherapist 11 Features Good Grief
case studies of their use. Grief therapy often entails an interplay Finally, in response to your question about the evidence base between two different kinds of for such practices, I am pleased interventions, one centered on the to say that a growing literature event story of the death and its larger is documenting the specific efficacy of retelling, exposure, implications for the client’s life, and the imaginal conversations, directed other focused on the lost relationship journaling, expressive arts and other interventions in addressing the unique challenges of complicated grief. There is more to learn, of Viewed in these terms, grief therapy story of the illness or death itself, course, but the documentation of a often entails an interplay between particularly when it was violent,’ wide range of creative procedures two different kinds of interventions, unanticipated, and involved holds promise that we can offer one centered on the event story of complicated human intention (as in something of relevance to a diverse the death and its larger implications suicide or homicide) or inattention community of clients grieving a for the client’s life, and the other (as in a fatal accident or medical wide variety of losses. focused on the lost relationship malpractice). In such cases I join (see Table 2). I allow myself to be my client in restorative retelling, John: All right, let me finish with ‘led by the client to what he or she essentially a prolonged, fearless a big question suitable for this most needs and stands ready to recounting of the circumstances of big topic. Various psychoanalytic address, as explicitly requested or the death in slow-motion detail, writers, from Freud onwards, have more commonly implicitly revealed giving voice to the horror of what paid considerable attention to how by his or her presentation. For the client witnessed or imagined, we think about, relate to and make example, I may begin by inviting while helping him or her contain sense of our mortality. This interest a widow to tell me how I can be it, breathe through it, master it and in death and how we negotiate useful to her, which tends to lead modulate the associated emotions. the finite nature of our existence to an abbreviated account of the Like the prolonged exposure appears to have been driven from loss and her subsequent yearning therapies to which it is akin, this the prominent position it has held for her husband or her sense of form of deliberative processing can historically in many philosophical feeling lost without him. Alerted to help a client integrate a difficult traditions. Do you think that the significance of the interrupted experience, imagine the more we as a species are increasingly relationship, I might then invite empowered stance that he or she avoiding the issue? Do we have a the client to introduce me to the would have taken in comforting the pathological inclination to deny our deceased, by sharing more about loved one at the time of dying if this own mortality and that of our most the character of their relationship had been possible, and take steps important others? If so, what are or their family experience. This to place the loss into the ongoing the implications of this? might naturally lead to evocative sequence of chapters of their lives, correspondence with the deceased or rather than view it as the end of Bob: Pathology, I suppose, is in chair work to affirm their continuing the story. Alternatively, we can the eye of the beholder. Is it more bond or to address unfinished encourage our clients to engage in pathological for humans, like the business in the relationship, or directed journaling, prompted by other sentient beings who share simply to memorializing the loved questions about the sense made of our small planet, to orient our one in a photo album or meaningful the loss or the unsought benefits or limited conscious resources toward ritual that preserves a sense of learning that might be found in it, engaging and problem solving continuity and connection between or to make use of any of a number of the events of our lives, or toward the living and dead. All of these metaphoric or creative practices to anticipating the eventuality of our interventions and many others bear help them express and explore their deaths? Freud famously argued that on the back story of the relationship, grief to give it voice and validation. “the unconscious cannot conceive opening it to fresh readings in the All of these procedures and a of its own death,” but it is clear that present. hundred others are described clearly as partially conscious creatures, At other times, however, the and succinctly in the recommended we can indeed do so, if only with client clearly needs to revisit the readings, and illustrated with actual some degree of effort and normative
12 New Therapist March/April 2014 Features Good Grief anxiety. Existentialists would go their frequency.] so far as to say that we only live Neimeyer, R. A. (Ed.) (2012). Techniques authentically to the extent that in grief therapy: Creative practices for we courageously contemplate our counseling the bereaved. New York: ultimate nonbeing, and then return Routledge. [Handbook of 96 methods from peering into this “abyss” with of grief therapy, with instructions for each and a case study illustrating its a clarified will to live fully in the application.] light of our highest values. Because we are soft bodies in a hard world, Neimeyer, R. A. (2009). Constructivist we also can appreciate more keenly psychotherapy. New York and London: Routledge. [Practical and readable our collective vulnerability to illness, presentation of meaning-oriented injury and extinction, and live more approach to psychotherapy with numerous prudently and compassionately as a discussions of strategies and case studies result. focused on bereavement.] Finally, with respect to bereavement, Neimeyer, R. A., Harris, D., Winokeur, we are forced to acknowledge H. & Thornton, G. (Eds.) (2011). Grief another existential truth: we are and bereavement in contemporary society: wired for attachment in a world Bridging research and practice. New York: of impermanence. Even if more Routledge. [Comprehensive handbook on new conceptualizations of grief, with narrowly “medical” approaches to focus on different types of loss, special therapy ignore the fact, ultimately, populations and therapeutic issues and every person, every place, every methods; each chapter is coauthored by About the interviewee project and every possession to prominent researchers and practitioners which we are attached we will to thoroughly integrate scholarship and Robert Neimeyer is Professor in the one day lose, at least in an earthly practice.] Department of Psychology, University of Memphis, where he also maintains sense. And so learning how to live Prigerson, H. G., Horowitz, M. J., Jacobs, an active clinical practice. Since S. C., Parkes, C. M., Aslan, M., Goodkin, with this looming reality, learning completing his doctoral training at the literally from loss, shapes who we K., Raphael, B., Maciejewski, P. K. (2009). University of Nebraska in 1982, he become as individuals, families, Prolonged grief disorder: Psychometric has published 27 books, including validation of criteria proposed for DSM-V communities and cultures… just Techniques of Grief Therapy: Creative and ICD-11. PLoS Medicine, 6(8), 1-12. Practices for Counseling the as it can shape how we practice [Review of the development of criteria for Bereaved and Grief and Bereavement psychotherapy. complicated grief/PGD and a field trial in Contemporary Society: Bridging demonstrating their validity.] Research and Practice (both with Recommended Readings Routledge), and serves as Editor of Shear, M. K., Simon, N., Wall, M., the journal Death Studies. The author Zisook, S., Neimeyer, R., & al., et. of over 400 articles and book Currier, J. M., Holland, J. M. & Neimeyer, (2011). Complicated grief and related chapters, he is currently working to R. A. (2012). Prolonged grief symptoms bereavement issues for DSM-5. Depression advance a more adequate theory of and growth in the first two years of and Anxiety, 28(2), 103-117. doi: 10.1002/ grieving as a meaning-making bereavement: Evidence for a non-linear da.20780 [Review of conceptualization process, both in his published work association, Traumatology, 18, 65-71. of complicated grief and implications for and through his frequent professional [Study of posttraumatic growth as a treatment, with emphasis on an attachment workshops for national and international audiences. Neimeyer function of level of grief experienced.] theory framework.] served as President of the Currier, J. M., Neimeyer, R. A. & Thompson, B. E. & Neimeyer, R. A. Association for Death Education and Berman, J. S. (2008). The effectiveness (Eds.) (2014). Grief and the expressive Counseling (ADEC), and Chair of the of psychotherapeutic interventions for the arts: Practices for creating meaning. New International Work Group for Death, Dying, & Bereavement. In recognition bereaved: A comprehensive quantitative York: Routledge. [Comprehensive of his scholarly contributions, he has review. Psychological Bulletin, 134, handbook detailing dozens of grief therapy 648-661. [Systematic review of outcome been granted the Eminent Faculty techniques using visual arts, music therapy, Award by the University of Memphis, literature on grief therapy.] dance and movement, creative writing and made a Fellow of the Clinical theatre and performance, giving explicit Galatzer-Levy, & Bonanno, G. A. Psychology Division of the American instructions and case examples to illustrate (2012). Beyond normality in the study of Psychological Association, and been each.] bereavement: Heterogeneity in depression recognized as an Honored Associate of the Viktor Frankl Association, as outcomes following loss in older adults. well as a recipient of the Phoenix Social Science & Medicine, 74, 1987-1994. Award: Rising to the Service of 10.1016/j.socscimed.2012.02.022 [Analysis Humanity by the MISS of different trajectories of grieving and Foundation.
Indispensable survival guide for the thinking psychotherapist 13 Features A fate less than death
A fate less than death
Supporting clients through non-death loss and grief
By Darcy Harris
14 New Therapist March/April 2014 Features A fate less than death
Introduction
fter I had been in clinical practice for several Ayears, I was asked to provide support to patients who were involved in treatment for infertility by a local center. As I began working with these clients, I became aware that many of them had endured months, sometimes years, of ongoing treatment, hoping for a baby and then having those hopes dashed when the treatments didn’t work. I noted that thelanguage they used to describe their experience spoke of profound feelings of loss and grief. But, I also wondered, if they were grieving, who had died? After I devoted time and research to this topic, I came to the conclusion that their grief wasn’t related to who had died as much as what had been lost. As clinicians, it is important to recognize grief in all of its forms and to understand how to facilitate the grieving process in our clients. In contrast to psychological disorders and disturbances, grief is basically an adaptive (albeit painful) process that allows us to heal after significant losses cause a tear in the fabric of our lives. Because of its adaptive function, the grieving process requires a different clinical approach than disorders that warrant therapeutic intervention.
Indispensable survival guide for the thinking psychotherapist 15 Features A fate less than death
we navigate in the world around us (Janoff-Bulman, 1992; Rando, 2002). These same assumptions Recent research has demonstrated can be shattered by life experiences that bereaved individuals often that do not fit into our view of ourselves and the world around maintain an ongoing, continuing us. Neimeyer et al. (2008) discuss bond with their deceased loved events that “disrupt the significance ones after their death. of the coherence of one’s life narrative,” (p.30) and the potential for erosion of the individual’s life story and sense of self that may occur after such events. What is ’ apparent is that the experience of a Evolution of world. Essentially, the assumptive significant life event that does not understandings about world encompasses beliefs about the fit into one’s beliefs can launch that grief following: individual into a state of significant disequilibrium. This discrepancy 1. How the world should work. ‘Initially, research in bereavement between how the world should work For example, most people focused on Bowlby’s (1969) and the reality that it isn’t working with relatively unremarkable in the way that was expected description of the attachment childhoods in Western cultures system and the ethological/ creates the need for some form of tend to believe that the world is accommodation. Attig (1996) refers instinctual basis for grief. Grief mostly benevolent, that there is was seen as a form of separation to this process as re-learning the more good than bad, and that world. distress that resulted from a broken people are generally trustworthy. attachment bond after the death All significant loss experiences, 2. How people explain events that of a loved one. However, recent death or non-death related, have the occur. This category emphasizes research has demonstrated that potential for an assault upon one’s the ideas of justice and cause- bereaved individuals often maintain assumptions about the world, and and-effect relationships in an ongoing, continuing bond with the process of adjusting to a world certain aspects of life. This their deceased loved ones after that is different from what had been assumption often implies that their death (Klass, Silverman, thought or believed will involve we can directly control what & Nickman, 1996; Rubin & a great expenditure of energy. happens to us through our own Schechter, 1997). It has become This process of adjustment and behavior. For example, it is apparent that the grief response is accommodation is what we would common for people to assume more complex than simply a form of refer to as grief (Harris, 2010). that being a good person will separation distress. afford protection from negative At a basic level, one’s Consider the following case: events, and the idea that you “get expectations about how the world what you deserve”. works begin to be formed from Margaret, a 78-year-old woman, was birth, through the development of 3. How we view ourselves and others. diagnosed with dementia after her the attachment relationships of the Typically, we are taught that grown children noticed that she was infant and young child. Bowlby human beings have intrinsic becoming forgetful and confused. (1969, 1973) posited that early- value and worth. We also They realized that she was unable to continue to care for herself at home life attachment experiences lead learn about power dynamics in due to her forgetfulness and episodic individuals to form working models relationships and society, and confusion. Her family arranged for of the self and of the world. Parkes our place within various social her to have assistance within her (1971) used the term assumptive systems. home, with meals being delivered world to describe the combination to her daily, a housekeeper, and a of these expectations and internal These fundamental assumptions personal care worker who would models. about oneself, others, and how/ help her to bathe and do laundry Janoff-Bulmann (1992) described why things happen allows for a three times a week. Margaret was feeling of safety and consistency as three categories of the assumptive able to cope with this assistance for
16 New Therapist March/April 2014 Features A fate less than death a while, but she became suspicious of control and into a ditch. One of a person is physically present, but of the helpers, accusing them of Angela’s legs was broken in several psychologically absent, as in the stealing things when she couldn’t places. Angela went through surgery scenario with Margaret. Ambiguous find them. After two episodes where to repair the broken bones in her losses leave individuals with a sense she wandered out of her house leg. However, there was permanent of being “in limbo” as they struggle at night and got lost, the family nerve damage. She experienced to live with the ambiguity and decided that she needed a more chronic pain from the injury and uncertainty. supervised living arrangement, and she could no longer skate. Despite Bruce and Schultz (2002) chose she moved into a secured retirement extensive rehabilitation and physical the term non-finite loss to describe residence. therapy, she never regained full a loss that retains a physical and/ Margaret continued to decline. Once function of her lower leg. Angela’s or psychological presence with an a very fastidious woman, she lost life completely changed from that individual in an ongoing manner. the ability to control her bowels and point forward. Despite support and The scenario with Angela fits the bladder. She would sometimes have encouragement from her family and description of a non-finite loss. excrement on her clothing when friends, she knew that she would Angela’s future is now completely she walked around the hallway, and never be the same, and she felt lost different from what she had she often looked unkempt. She because her life had centered upon planned, and her life will never be would sometimes recognize her her skating abilities and potential. the same as before. She will spend children and grandchildren and at the rest of her life accommodating other times she would not. Once Many of the non-death losses that her injured leg and secondary life very social and outgoing, Margaret are experienced by individuals are choices. Roos (2002) explored became reclusive and quiet. She very difficult to name, describe, the concept of chronic sorrow as a died three years after the dementia or validate because there is no response to losses that are ongoing diagnosis was made. The family felt identifiable “death.” For many in nature. In chronic sorrow, sadness when she died, but most individuals, it may be unclear the grief is ongoing because the felt that they had “lost” her a long exactly what has been lost. The loss loss itself (along with continuous time before she actually died. They may or may not involve a person accommodation to the loss) is also realized that they had been grieving and there may not be a defining ongoing. This is an important throughout the past three years experience to denote where the loss distinction from descriptions for the loss of their mom, who was actually originates. of prolonged grief disorder or physically alive, but emotionally In her development and complicated grief. and cognitively absent from them. exploration of loss experiences At the funeral, one of the daughters where there was significant Discussion remarked, “I don’t know exactly ambiguity, Boss (1999) first used when we lost Mom, but it wasn’t just the term, ambiguous loss. Ambiguous Significant losses, death or non- last week when she died. I’ve been loss occurs when either a person is grieving her loss for a long time.” death, involve the shattering or perceived as physically absent, but crumbling of one’s assumptions is psychologically present, or when And this one:
Angela was a competitive figure skater. She was told by her coach that she was a “gifted” skater and that she was destined for the Olympics. Angela’s life revolved Ambiguous loss occurs when around skating. She got up at 5 either a person is perceived A.M. every morning to go to the arena to skate and she had training as physically absent, but is sessions with her coach 5 days a psychologically present, or when week. One evening, on the way home from a movie, Angela’s a person is physically present, but boyfriend (the driver of the car) hit psychologically absent. a patch of ice on the road and lost control of the car. The car spun out Indispensable‘ survival guide for the thinking psychotherapist ’17 Features A fate less than death
and to try to understand them (even if they initially seem beyond At the core of all significant one’s ability to comprehend) is losses is the potential to lose our a key part of the human drive assumptive world, and there is for understanding and meaning. Learning how to “be with” is much support to suggest that this loss more productive here than trying is the main overarching trigger to “do” something to intervene too for the grief response. early in a client’s process. Be aware of the unique implications for certain types of losses about the world, causing us to Clinical implications’ feel deeply vulnerable and unsafe. There are obvious differences The world that we once knew, Name, acknowledge, and between death-related and non- the people upon whom we relied, validate the experience death-related losses, evident and the previously held images in Boss’(1999) descriptions of and perceptions of ourselves and Doka’s (1989; 2002) concept of ambiguous loss and Roos’ (2002) others are no longer relevant in disenfranchised grief is highly elaboration of the concept of light of what we have experienced. applicable to the exploration of chronic sorrow. In situations of ‘Certainly, the death of a loved one grief after non-death losses, as the ambiguous or non-finite loss, there has great potential to cause such a tendency to not recognize these are seldom socially accepted rituals disruption. However, other types losses leads to a propensity to deny that provide acknowledgement of losses that may not involve death their potential significance, or to or credence to the experience of can also have the same outcome, not recognize the degree to which an individual in the way a funeral with the need to re-build and these losses can affect an individual. might provide for a bereaved re-learn one’s assumptive world A social overtone of dismissiveness individual. The absence of a body in a way that preserves a sense of is common, and this lack of social does not mean the absence of coherence and safety. At the core of support can stunt the adaptive grief; however, without an overt all significant losses is the potential to aspects of the process. Loss, change, or outward manifestation of the lose our assumptive world, and there and transition are universal, but loss, the level of social recognition is support to suggest that this loss is the also very subjective experiences. and support is often minimal or main overarching trigger for the grief Not everyone will perceive the same absent. Thus, finding rituals for response. experience in the same way, so it is honoring these losses, normalizing It is important to recognize the important to listen to the client’s the ongoing nature of grief when it significance of these experiences, interpretation and descriptions. accompanies losses that are ongoing and to keep in mind the adaptive The ability to name and describe in nature, and supporting clients aspect of grief that facilitates an experience fully provides the as they search for meaning in these accommodation in the majority opportunity to reflect and consider experiences should be the priority of of individuals. In general, grief its implications for future choices the therapist (Boss, Roos, & Harris, is not something that requires and daily living. 2011). treatment or intervention; rather, facilitation, support, and permission Learn how to offer presence to Cultivate awareness of your own are more appropriate approaches. grieving clients before jumping in loss experiences Too many clinicians assume that to intervene emotional distress means that they Many of us have experienced must intervene or treat the distress Clinicians need to be able to learn significant losses that have shaped without realizing that doing so in to bear witness to the grieving who we are and, perhaps, the career this scenario may actually block the process and give permission for the path we have chosen. While the process and prevent the necessary process to unfold before attempting concept of the wounded healer is adaptation from occurring. to intervene. The need to grapple valid in any profession where the with life-altering loss experiences therapeutic use of self is integral to the work, we are not immune
18 New Therapist March/April 2014 Features A fate less than death to social pressure to conform to a Doka, K. J. (2002). Disenfranchised “norm” that isn’t always realistic grief: New directions, challenges, and strategies for practice. Champaign, IL: or healthy. It will be challenging Research Press. to facilitate the grieving process wholeheartedly in our clients if Harris, D.L. (2010). Counting our losses: we have difficulties recognizing Reflecting on change, loss, and transition in everyday life. New York: Routledge. and honoring its presence in ourselves. Cultivating a practice of Janoff-Bulman, R. (1992). Shattered compassionately attending to our assumptions: Towards a new psychology of trauma. New York: Free Press. own loss experiences and struggles allows us to more deeply appreciate Klass, D., Silverman, P., & Nickman, and honor the grieving process in S. (1996). Continuing bonds: New our clients. understandings of grief. New York: Taylor and Francis. Conclusion Neimeyer, R. A., Laurie, A., Mehta, T., Hardison, H., & Currier, J. M. (2008). Lessons of loss: Meaning- Grieving individuals often have making in bereaved college students. In to struggle for validation and H. Servaty-Seib and D.Taub (Eds.), understanding of their experiences, Assisting bereaved college students (pp. and therapists need to adopt an 27-39). San Francisco: Jossey-Bass. inclusive and validating approach Parkes, C. M. (1971). Psycho-social for clients with a broad range of transitions: A field for study. Social grief responses. We serve our clients Science & Medicine, 5, 101-115. best if we can facilitate the process Rando, T. A. (2002). The “curse” of too of meaning-making and rebuilding good a childhood. In In J. Kauffman with clients whose loss experiences (Ed.), Loss of the assumptive world of all types have disrupted their (pp.171-192). New York: Brunner- Routlege. assumptive world. Roos, S. (2002). Chronic sorrow: References A living loss. New York: Brunner- Routledge.
Attig, T. (1996). How we grieve: Rubin, S.S., & Schechter, N. (1997). Re-learning the world. New York: Oxford. Exploring the social construction of bereavement: Perceptions Boss, P. (1999). Ambiguous loss. Cambridge, of Adjustment and Recovery in MA: Harvard University Press. Bereaved Men. American Journal of Boss, P., Roos, S,. & Harris, D. (2011). Orthopsychiatry, 67: 279–289. Grief in the midst of ambiguity and uncertainty: An exploration of ambiguous loss and chronic sorrow. In R.A. Neiemeyer, D.L. Harris, H. R. Winokuer, & G.F. Thornton (Eds.). Grief and bereavement in contemporary society: Bridging research and practice. (pp. 163-176) New York: Routledge.
Bowlby, J. (1969). Attachment and loss: Attachment (Vol 1). London: Hogarth.
Bowlby, J. (1973). Attachment and loss: Separation (Vol 2). New York: Basic Books. Darcy L. Harris, Ph.D., FT, is an Associate Professor and Thanatology Coordinator Bruce, E.J., & Schultz, C. L. (2001). at King’s University College at Western Nonfinite loss and grief: A psychoeducational University in London, Ontario, Canada. In approach. Baltimore: Brooks. addition to her academic work, Dr. Harris has a private therapy practice and she is Doka, K. J. (1989). Disenfranchised grief: a presenter and an author on topics Recognizing hidden sorrow. Lexington, related to grief and loss. MA: Lexington Books.
Indispensable survival guide for the thinking psychotherapist 19 Features Dreaming the reality
Coming to grief
What you need to know about grief in DSM-5
By Phyllis Kosminsky 20 New Therapist March/April 2014 Features Coming to Grief
fter fourteen years of deliberation: heated debate, the first concerning consensus, conflict and continuing the creation of a formal diagnosis debate, the latest version of The for problematic grief, “Persistent Diagnostic and Statistical Manual Complex Bereavement Disorder” of Mental Disorders (DSM) has and the second, elimination of the Afinally been released into the world, “bereavement exclusion” according to and with it, a Pandora’s Box worth which neither adjustment disorders of controversy. Changes regarding nor depression was to be diagnosed grief-related diagnoses have been the in the immediate aftermath of a source of some of the most heated significant death. The committee disagreement, with extensive media ultimately decided not to add a attention given to the ongoing debate diagnosis for problematic grief at about what constitutes normal grief, this time, although they did elect how grief differs from depression and to include the proposed criteria as other issues relating to diagnosis and an appendix in the DSM for future treatment. consideration. They did, however, Anyone who has experienced grief, eliminate the bereavement exclusion personally or professionally, knows from the descriptions of depression that people who are grieving are and adjustment disorders, a change often extremely sad, weepy, confused, that has been met with responses exhausted and otherwise distressed. ranging from enthusiastic approval to These behavioral manifestations of vehement opposition. (Pies, 2013). deep emotional pain are present, to one Critics of the change warn that degree or another, in most of the people removal of the bereavement exclusion we see in treatment. As difficult as grief will result in an increase in the can be to bear, for many of our clients frequency of diagnoses of of depression the acute pain of loss will subside, among people who are bereaved, and with a little help, the bereaved with an accompanying increase in individual will gradually integrate the the use of anti-depressant medication loss and be able to re-engage with life. in this population. Advocates of But what about the people for whom the change argue that it reflects an this is not the case? What about the acknowledgement that bereavement is client whose behavior falls outside the a “severe psychosocial stressor that can norm of grief? How do we identify precipitate a major depressive disorder people whose grief has gone off course, in a vulnerable individual” and that and how do we help them? in these cases delaying treatment Deliberation concerning how to “adds an additional risk for suffering address grief in the DSM 5 (APA, feelings of worthlessness, suicidal 2013) revolved around this group, ideation, poorer somatic health, worse the estimated 10 to 15 percent of interpersonal and work functioning, grievers whose grief is problematic, in and an increased risk for persistent terms of duration, intensity, or both. complex bereavement disorder“ Two issues generated substantive and (APA, 2013b, p. 5). Thus, although
Indispensable survival guide for the thinking psychotherapist 21 Features Coming to Grief
in a timely manner. Symptoms include relational problems The point of the change is not (“Bitternness or anger related to the to increase the diagnosis of loss[b]”, p.790); cognitive issues (“Maladaptive appraisals about depression, but to encourage oneself in relation to the deceased or clinicians to consider the the death, e.g., self blame”, p. 790); possibility that a bereaved person disruption of identity (“Difficulty or reluctance to pursue interests since may be clinically depressed. the loss or to plan for the future”, p.790). There is also a suggested specifier for traumatic bereavement, the committee did not adopt a the inadvisability of prescribing characterized by “persistent, diagnosis for problematic grief, they medication for everyone who’ is frequent distressing thoughts, acknowledge that grief can become grieving after two months, it would images or feelings related to the chronic and disabling. The point of also be a mistake to assume that traumatic features of the death” (p. the change, in other words, is not to medication is never indicated. 790). Clinicians are encouraged to increase the diagnosis of depression, Whether, in the clinician’s take note of the proposed criteria, but to encourage clinicians to judgement, a recently bereaved which constitute a thoughtful and consider the possibility that a person is exhibiting signs of grief, well- conceived set of principles for bereaved person may be clinically depression, or both, in cases where the treatment of problematic grief. ‘depressed. In these cases, delaying the severity of the client’s symptoms treatment may result in significant raises concerns about the possibility Intervening with complications and prolonged of self -harm, or where functioning complicated grief impairment of functioning. is significantly impaired, medication So what does the DSM offer by can be considered, and the While many people who are way of guidance for clinicians who potential benefits discussed with bereaved want to know how long it provide counseling to the bereaved? the client. Again, the important takes to heal from a loss, or whether point here is that the decision as the extent of their emotional pain Implications for practice to whether or not to suggest a is “normal,” these are not easy referral for evaluation of the need questions to answer. The experience Although much has been made for medication should be made of losing a loved one cannot be of the changes in the DSM-5, the based on the severity of the client’s reduced to a set of parameters, nor impact of these changes remains distress, regardless of whether or can its course be predicted with to be seen. The elimination of not that distress can be definitively certainty for a single person or the bereavement exclusion allows diagnosed. for bereaved people on the whole. clinicians to make a diagnosis That being said, clinicians need to of major depression even when Recognizing complicated be able to identify the significant someone has suffered a loss, but grief number of bereaved whose grief, by this may or may not make much of virtue of its severity, persistence, or a practical difference. Experienced Although the new DSM (APA some combination of both, appears clinicians know that two months 2013) does not include a diagnosis to fall outside the range of what is is only the beginning of grief for for complicated or problematic considered normative. many mourners; they also know grief, it does incorporate, in the Many bereaved people question better than to think that all of these appendix, criteria proposed by the their ability to go on with their lives people should be diagnosed with working committee regarding such in the wake of a significant loss, yet depression. On the other hand, a diagnosis. These criteria define a we know from experience that most some people who are bereaved may range of problems that can arise in do. But for some people, the passing also be depressed. They may have response to significant loss, and that weeks and months bring no relief, been depressed for some time prior can cause the mourner persistent no change in how they feel. The to the loss, or the loss may have and significant emotional distress, longer they remain in this state, the triggered a depressive episode. as well as impaired social and work- more likely it is that their sadness While there is no question about related functioning if not addressed will be compounded by frustration
22 New Therapist March/April 2014 Features Coming to Grief and a sense of personal failure. encouraging someone who has The survivor of a family member’s That frustration, and the emotional become socially isolated to begin to suicide may not be able to accept drain imposed by prolonged reconnect with friends. the person’s decision to take his/ grief, can easily lead to a sense of The Two Track model posits that her own life. In all of these cases, hopelessness. Thus, an important grief presents the mourner with two the bereavement therapist’s role part of the bereavement therapist’s distinct and complex sets of tasks, is to help the client identify the role is to identify these clients, and the first having to do with their unrecognized or unacceptable truth, to intervene before hopelessness sets biopsychosocial functioning (Track and to come to whatever resolution in. I) and the second having to do with is possible, so that emotional energy A number of explanations have the nature of their relationship can be redirected from suppression been offered for the complications with the deceased (Track II). What or denial to engagement and that interfere with resolution of distinguishes the two track model restoration (Rando, 1993). grief. It is generally recognized from earlier characterizations of that traumatic loss is predictive grief and loss is that it combines the Early attachment, affect of problematic grief ( Stroebe, psychodynamic and interpersonal regulation and Schut, Boelen, and van den Bout, view of loss, which emphasizes the 2012) and that certain features of loss of the relationship with the adjustment to loss personality or attachment style living person, with an appreciation are evident in many people who of the potential impact of loss on With regard to our understanding struggle after a loss ( Burke and biological, behavioral, cognitive of complicated grief, we note that Neimeyer, 2013). There are likewise and emotional processes (Rubin, there is increasing recognition of the a multitude of approaches and Malkinson and Witzum, 2011). role of early trauma and lesser forms techniques for addressing problems In this model, the isolation of the of problematic early attachment in healing from loss. Two relatively person mentioned above would be in the etiology of a range of new models, The Dual Process seen as a biopsychosocial factor psychological problems, including Model developed by Stroebe and impeding resolution of grief. As problems in bereavement (Lanius, Schut, and Rubin’s Two Track this example suggests, although the Vermetten and Pain, 2010). Fifty Model, take a broad view of the focus of this model is different, the years ago, Bowlby identified the causes of problematic grief and clinical implications in many cases instinctive need of human beings, of how to help move a bereaved will be the same. at every stage of life, to establish person forward. Stroebe and Schut’s Therese Rando argues that and sustain connection with other model emphasizes that normal grief when mourning is not progressing humans, and their propensity to is characterized by an oscillation it is almost always because of the experience distress when significant between a loss orientation and a mourner’s inability to accept some connections are lost (Bowlby, 1969). restoration orientation. In this view, truth relating to the relationship or Bowlby believed that the quality healing requires that a bereaved the death A son may be unable of early attachment had a direct person be able to move flexibly to accept the truth that he was effect on how well such disruptions between an awareness of the loss never able earn his father’s love. were tolerated, an idea that was and the feelings associated with A wife may not be able to accept successfully tested by American it, and a continuing involvement the truth that her marriage was psychologist Mary Ainsworth. with the people, activities and roles not what she dreamed it would be. Based on her observations, that are still part of their lives. Problems arise when there is a lack of oscillation, as when a person is unable or unwilling to recognize It is generally recognized that and work through feelings, or traumatic loss is predictive of alternatively, when feelings become problematic grief and that certain a quicksand from which no escape or respite is possible. The role of features of personality or attachment the bereavement therapist in these style are evident in many people who cases is to help the client engage struggle after a loss. in whichever part of the process appears to be missing, for example, Indispensable‘ survival guide for the thinking psychotherapist ’23 Features Coming to Grief
Ainsworth extended Bowlby’s with people who are at the juncture 20, 2013 from http://psychcentral.com/blog/ model to address the impact of between who they were before archives/2013/05/31. abuse or neglect on attachment and who they will be in the future Prigerson, H.G., Vanderwerker, L.C., security, and identified a group brings light into our professional & Maciejewski,P.K. (2008). A case for of infants who became extremely lives and a clarity of purpose that inclusion of Prolonged Grief Disorder in dysregulated or shut down in encourages us, as well as our clients, DSM-V. In M. Stroebe, R. Hansson, H. Schut, and W. Stroebe (Eds.). Handbook of response to separation from their to carry on. bereavement research and practice: Advances caregiver (Ainsworth, 1978). in theory and intervention(pp. 165-186). Ainsworth attributed the response References Washington DC: APA. of these infants to the unpredictable Rando, T. (1993). Treatment of complicated and non-contingent behavior of Ainsworth, M.D.S., Blehar, M. C., mourning. Champaign, IL.: Research their mothers, a high percentage Waters, E., & Wall, S. (1978). Patterns Press. of whom were found to have been of attachment: A psychological study of the strange situation. Hillsdale, N.J.: Erlbaum. Rubin, S., Malkinson, R., and Witzum, E. abused or neglected as children. (2011). The two track model of bereavement. Subsequent investigations have American Psychiatric Association (2013). In R. Neimeyer, D. Harris, H. Winokuer, validated the lasting impact of early Diagnostic and statistical manual of mental H., & G. Thornton, (eds.), Grief and disorders, 5th edition. Author: Washington, bereavement in contemporary society: Bridging maternal care and the persistence of DC. regulatory deficits in children and research and practice (pp. 47-56). New York: Routledge. adults who do not receive adequate American Psychiatric Association (2013b). caregiving (Schore and Schore, Highlights of Changes from DSM IV-R to Schore, A., and Schore, J. (2012). Modern DSM V. Author: Washington, DC. 2012). Thus, it is not surprising to attachment theory: The central role of affect regulation in development and treatment. Bowlby, J. (1969). Attachment and loss, Vol. find that insecure attachment is In: A. Schore (ed.) The science of the art of 1: Attachment. New York: Basic Books. associated with complicated grief psychotherapy (pp. 27-51). New York: W.W. (Lobb, et. al., 2010) and that early Bowlby, J. (1988). A secure base: Clinical Norton. mistreatment is reported by many applications of attachment theory. New York: Stroebe, M., Schut, H., Boelen, P. & van Routledge. of our clients who struggle with den Bout, J. (Eds).(2012). Complicated bereavement. Burke, L, and Neimeyer, R. (2012). grief: Scientific Foundations for health care Treatment of bereaved clients Prospective risk factors for complicated grief: professionals. New York: Routledge. who have problems relating to early A review of the literature. In: M. Stroebe, attachment, including difficulty H. Schut, and J. van den Bout (Eds.) Complicated grief: Scientific in tolerating strong emotion, foundations for health care professionals (pp. requires particular sensitivity 190-203). New York: Routledge. on the part of the bereavement therapist, who in effect functions Greenberg, Gary (2012). Not diseases, but categories of suffering. The New York Times, as a transitional attachment figure. Jan. 9, 2012. Special consideration must be given to the difficulties inherent Lanius, R., Vermetten, E., and Pain, C. in working at the edge of what the (Eds.) (2010). The impact of early life trauma on health and disease: The hidden epidemic. client can tolerate with regard to New York: Cambridge University Press. emotion in order to avoid treatment failure or premature termination Lobb,E., Kristjanson,L.,Aoun,S., Monterosso, L.Halkett,K. and Davies, A. of treatment. While the challenges (2010). Predictors of complicated grief: of establishing a strong therapeutic A systematic review of empirical studies. bond with clients who have a Death Studies 34 (8) pp.673-698. history of abuse or neglect are not Mikulincer, M.,and Shaver, P. (2008). An insubstantial, the potential rewards, attachment perspective on bereavement. In: for the therapist as well as the M. Stroebe, R.Hanson, H. Schut., and W. Phyllis Kosminsky, PhD is a clinician in client, are considerable. For these Stroebe. (Eds.). Handbook of bereavement private practice and at the Center for clients, the loss of a loved one may research and practice: 21st century perspectives Hope in Darien, Connecticut. A Fellow in (pp. 87-112). Washington DC: American Thanatology, she is the author of Getting be the catalyst that moves them to Psychological Association. Back to Life When Grief Won’t Heal, and embrace a deeper and ultimately with John Jordan, and she is currently more satisfying emotional life. The Pies, R.(2013). How the DSM-V got grief, writing a book about attachment opportunity to do this kind of work bereavement right. Retrieved on December and bereavement.
24 New Therapist March/April 2014 Features Getting Grief Working
Getting grief working:
A guide for the new grief therapist
By Dale Larson
Indispensable survival guide for the thinking psychotherapist 25 Features Getting Grief Working
ruce, a Silicon Valley is to accelerate or unblock this they would normally turn to for engineer, confronts the natural healing process—to get support in times of stress. This sense unimaginable: the loss grief working—particularly if this of aloneness can also result from a of his beloved 7-year old son to process is moving more slowly widening gap between their inner B than expected or if the reaction a cerebral hemorrhage. Mary, a experience and others’ expectations, mother of two, struggles with the to a loss is severe or protracted. e.g., “Isn’t it time to move on?” If we loss of her 30-year old husband to Given this central goal for grief can be fully present as companions an aggressive adult leukemia. These counseling, what therapeutic style, to clients when they feel most alone, are my clients. Is there something understandings, and interventions grief begins to work, and distress different from my everyday are most likely to achieve this over separation and loss lessens. approach to psychotherapy that I outcome? Finally, grievers’ naturally need to know and do so that I can occurring support systems are be optimally helpful to them? My Offer a Supportive often quickly exhausted or lack a answer is a resounding yes. Therapeutic Relationship nonjudgmental listener unafraid Although my everyday approach to be present with the intense to psychotherapy has served well for A deeply empathic, caring, and and often unsettling emotions, the many loss-related experiences inviting therapeutic relationship thoughts and changes in identity my clients present with, whether a may be the fundamental criterion that accompany grief. In-depth disappointment at work, a midlife for effective grief counseling discussions of the impact of crisis, a failed relationship, or the (Larson, 2013). The healing power losing your child are not, as I like absence of an empathic caregiver of the therapeutic relationship, a to say to my graduate students, during childhood, I have learned significant mechanism of change Starbucks conversations. It is also that counseling for the loss of a in all psychotherapy, takes on even well documented that powerful loved one asks more of me both more significance in work with social constraints (Lepore, Silver, personally and professionally, grieving clients. Wortman, & Wayment, 1996) emotionally and technically. In Why is this so? First, grieving make disclosure of loss and trauma this brief article I try to capture persons are often dealing with in one’s social world both risky some of this learning in quick and trauma, ruptured attachments, and unlikely—another reason a rather bold advice outlining some and shattered assumptions about therapeutic relationship can be core principles—some do’s and the world being a predictable and such an invaluable resource for the don’ts—that guide my personal orderly place. The therapeutic bereaved. approach to grief counseling. relationship provides a secure base My approach to grief counseling or holding environment that enables Practice balanced is shaped by my basic understanding clients to confront, integrate, and empathy of grief as a natural condition— transform trauma and loss as they the human reaction to loss—that move forward in their changed lives As a grief counselor, you must can generally be expected to and worlds. find a way to achieve a balanced abate over time and, frequently, Second, grieving persons can feel empathic stance toward intense to lead to psychological growth. painfully alone in their loss. They emotional experience. Not The role of grief counseling, then, often no longer have the very person doing so leaves you vulnerable to compassion fatigue and burnout. From a Buddhist perspective, this balanced stance can be described The role of grief counseling, then, is as a mindful, nonattached, yet to accelerate or unblock this natural fully engaged witnessing of the healing process—to get grief working— client’s experiencing (Gehart & McCollum, 2007). Others term it particularly if this process is moving “exquisite empathy” (Harrison & more slowly than expected or if the Westwood, 2009), but I prefer Carl reaction to a loss is severe or protracted. Rogers’s (1957, p. 99) description: "To sense the client's private world as if it were your own, but without ’ ever losing the as-if quality—this 26‘ New Therapist March/April 2014 Features Getting Grief Working is empathy." Losing the “as-if” quality leaves us more vulnerable to vicarious traumatization, countertransferential reactions, and Accurate empathy, in contrast, gets personal distress that derails our grief working: Clients are able to accept therapeutic focus and pulls us into and make sense of their loss experience, what I call the Helper’s Pit (Larson, allow the emotions of grief to guide their 1993). Lacking this balanced adjustment to loss, clarify and integrate stance, repeated confrontations with death and grief can push perhaps new experiences of self, and discover our most powerful emotional button new meanings in the painful events. —fear of our own mortality—and cause us to distance ourselves from our clients. to loss, clarify and integrate new grief (Stroebe, Schut, & van den’ Don’t scratch where it experiences of self, and discover Bout, 2013), posttraumatic growth doesn’t itch new meanings in the painful events. (Tedeschi & Calhoun, 1995), They begin to convert what is anticipatory mourning (Rando, Our empathy must not only be often termed “pathological” grief 2000), the interaction of trauma and balanced, it must be accurate. (grief not working) into normal grief (Fleming, 2012), grief across Two common errors in empathy grief (grief working), and establish the life span (Walter & McCoyd, are overresponding and continuing bonds with their lost 2009), retelling of violent death underresponding to our clients’ loved‘ ones that are not maintained (Rynearson, 2012), gender and distress. As recent research tells when they are struggling with the mourning styles (Doka & Martin, us (Bonanno & Kaltman, 2001), pain of loss. For therapists, accurate 2010), the role of rituals in grief many bereaved persons do much empathy leads to an expanded and mourning (Imber-Black, 2004), better earlier on than we might concept of the variability of normal grief in an online world (Sofka, anticipate. If we probe the depths of grief, and also prevents taking a Cupit, & Gilbert, 2012), and these persons’ psyches for existential one-size-fits-all approach. cultural factors (Rosenblatt, 2008). anguish, or aggressively recruit them for our counseling services, we Do your homework Use grief-facilitating are scratching where it doesn’t itch. microskills and Your work with grieving persons interventions Don’t trivialize distress will be considerably enhanced and more rewarding if you dedicate Finding ways to communicate Many bereaved persons, however, time to exposing yourself to recent your empathy that get or keep grief are doing less well than we might developments in the field. Become working for your clients is a creative expect. It is not uncommon for thoroughly acquainted with current challenge because grieving clients friends, family members, coworkers, grief models, especially Worden’s take diverse pathways. I find that and even trained psychotherapists, task model (2009), Stroebe and a more person-centered style is to not recognize this and to instead Schut’s (2010) dual-process model, best—fewer questions, less advice, emphasize the positive side of and Neimeyer’s constructivist and more (elegant and evocative) things, thus trivializing their approach (Neimeyer, Burke, reflections of feeling and meaning distress. When encouraged to Mackay, & van Dyke Stringer, (Larson, 2013). Use of metaphors be “more resilient” or on “grief’s 2010). In addition, an extensive can also be helpful (“It’s like being journey” clients may conceal their and fascinating literature on in an earthquake”); however, the distress because they see it as a sign grief-related constructs and issues test for any intervention is whether of their failure to cope. deserves your attention, including it assists your client to discover his Accurate empathy, in contrast, work on continuing bonds (Klass, or her personal pathway through gets grief working: Clients are able Silverman, & Nickman, 1996), grief. to accept and make sense of their disenfranchised grief (Doka, 2008), Interventions I find helpful loss experience, allow the emotions differing grief trajectories (Bonanno include displaying a photo of the of grief to guide their adjustment & Kaltman, 2001), complicated
Indispensable survival guide for the thinking psychotherapist 27 Features Getting Grief Working
who answer yes to the following two questions: “Are you having As a grief therapist, you must find trouble dealing with the death?” a way to maintain your compassion and “Are you interested in seeing a and emotional involvement while grief counselor to help with that?” courageously assisting clients to Conclusion live with hope in a world in which loss is inescapable. Describing the qualities of the therapeutic relationship necessary for deeper therapeutic work, Diana Fosha reflects that “the emotional ’ atmosphere should be one in deceased during sessions, meeting When difficult clinical interactions which the patient feels safe and the with family members, referring to create self-doubt or personal therapist brave” (2000, p. 213). As local bereavement support groups, distress, don’t conceal these a grief therapist, you must find a and listening for and supporting experiences and do allow them to way to maintain your compassion the establishment of new goals that become stress-enhancing helper and emotional involvement while restore meaning to life. In addition, secrets (Larson, 1993). Instead, find courageously assisting clients to I typically use the empty chair or a confidant who understands the live with hope in a world in which ‘imaginal conversation technique, work and its vicissitudes and can loss is inescapable. This challenge an intervention endorsed by grief offer you quality social support. is best met in an authentic and therapists of all persuasions. caring helping relationship between Get grief counseling to all a therapist who believes in the Be multiculturally who need it and desire it client’s healing capacities and a attuned client who is motivated to engage these capacities, get grief working, In the past decade, a pessimistic As Paul Rosenblatt says, culture and move into the future without view of grief counseling has relinquishing the past. shapes grieving (2008, p. 79). emerged, with claims that it is Cultural background makes an ineffective or possibly harmful with References important contribution to individual normally bereaved clients. Don’t differences in the grieving process. let these claims keep you from These cultural considerations Bonanno, G. A., & Kaltman, S. (2001). providing grief counseling to all The varieties of grief experience. Clinical become even more paramount when those who need and seek it. The Psychology Review, 21(5), 705-734. doi: theory is translated into practice claim of harmful effects, based on a 10.1016/s0272-7358(00)00062-3 and we strive to match the type and single unpublished dissertation, has level of intervention to the needs of Doka, K. J. (2008). Disenfranchised been shown to be invalid (Larson & grief in historical and cultural perspective. a particular client. Hoyt, 2007), and no other evidence In M. S. Stroebe, R. O. Hansson, H. of a pattern for harmful effects has Schut & W. Stroebe (Eds.), Handbook Take self-care seriously appeared (Stroebe, Hansson, Schut, of bereavement research and practice: Advances in theory and intervention. (pp. & Stroebe, 2008, p. 598). Grief 223-240). Washington, DC US: American Find what works for you and do counseling, like other therapeutic Psychological Association. more of that, whether it is exercise, interventions, tends to be effective Doka, K. J., & Martin, T. L. (2010). meditation, a good consultation for those who seek it out (Hoyt group, your faith, or your friends. Grieving beyond gender: Understanding the & Larson, 2010; Larson & Hoyt, ways men and women mourn (rev. ed.). New The to-do list here could quite 2009). York, NY US: Routledge/Taylor & Francis lengthy, but self-care most Who should receive grief Group. importantly requires taking the counseling? Gamino and his Fleming, S. (2012). Complicated grief time and making the commitment colleagues (Gamino, Sewell, and trauma: What to treat first? In R. to doing it. Ongoing exposure to Hogan, & Mason, 2009-2010) offer A. Neimeyer (Ed.), Techniques of grief grief, loss, and trauma requires probably the best answer when they therapy: Creative practices for counseling the finding a balance between giving to bereaved. (pp. 83-85). New York, NY US: conclude that grief counseling is Routledge/Taylor & Francis Group. your clients and giving to yourself. appropriate for all bereaved persons
28 New Therapist March/April 2014 Features Getting Grief Working
Fosha, D. (2000). The transforming power Grief therapy and the reconstruction of of affect: A model for accelerated change. New meaning: From principles to practice. York, NY US: Basic Books. Journal of Contemporary Psychotherapy, 40(2), 73-83. doi: 10.1007/s10879-009- Gamino, L. A., Sewell, K. W., Hogan, 9135-3 N. S., & Mason, S. L. (2009-2010). Who needs grief counseling? A report from the Rando, T. A. (Ed.). (2000). Clinical Scott & White grief study. Omega, 60(3), dimensions of anticipatory mourning: Theory 199-223. and practice in working with the dying, their loved ones, and their caregivers. Champaign, Gehart, D. R., & McCollum, E. E. IL: Research Press. (2007). Engaging suffering: Towards a mindful re-visioning of family Rogers, C. R. (1957). The necessary therapy practice. Journal of Marital and and sufficient conditions of therapeutic Family Therapy, 33(2), 214-226. doi: personality change. Journal of Consulting 10.1111/j.1752-0606.2007.00017.x Psychology, 21, 95-103.
Harrison, R. L., & Westwood, M. J. Rosenblatt, P. C. (2008). Grief across (2009). Preventing vicarious traumatization cultures: A review and research agenda. In M. of mental health therapists: Identifying S. Stroebe, R. O. Hansson, H. Schut & W. protective practices. Psychotherapy: Theory, Stroebe (Eds.), Handbook of bereavement Research, Practice, Training, 46(2), 203-219. research and practice: Advances in theory and doi: 10.1037/a0016081 intervention. (pp. 207-222). Washington, DC US: American Psychological Hoyt, W. T., & Larson, D. G. (2010). Association. What have we learned from research on grief counselling? Response to Schut and Rynearson, E. K. (2012). The narrative Neimeyer. Bereavement Care, 29, 10-13. dynamics of grief after homicide. Omega: Journal of Death and Dying, 65(3), 239-249. Imber-Black, E. (2004). Rituals and doi: 10.2190/OM.65.3.f the Healing Process. In F. Walsh & M. McGoldrick (Eds.), Living beyond loss: Sofka, C. J., Cupit, I. N., & Gilbert, K. R. Death in the family (2nd ed.). (pp. 340-357). (2012). Dying, death, and grief in an online New York, NY US: W W Norton & Co. universe: For counselors and educators. New York, NY US: Springer Publishing Co. Klass, D., Silverman, P. R., & Nickman, S. L. (1996). Continuing bonds: New Stroebe, M., Hansson, R. O., Schut, understandings of grief. Philadelphia, PA H., & Stroebe, W. (2008). Bereavement US: Taylor & Francis. research: 21st-century prospects In M. S. Stroebe, R. O. Hansson & W. Stroebe Larson, D. G. (1993). The helper's journey: (Eds.), Handbook of bereavement research and Working with people facing grief, loss, and practice: Advances in theory and intervention life-threatening illness. Champaign, IL: (pp. 577-603). Washington, DC: American Research Press. Psychological Association.
Larson, D. G. (2013). A person-centred Stroebe, M., & Schut, H. (2010). The dual approach to grief counselling. In M. Cooper, process model of coping with bereavement: M. O'Hara, P. F. Schmid & A. C. Bohart A decade on. Omega, 61(4), 273-289. (Eds.), The handbook of person-centred psychotherapy and counselling (2nd ed., Stroebe, M., Schut, H., & van den Bout, pp. 313-326). New York, NY: Palgrave- J. (2013). Complicated grief: Scientific Macmillan. foundations for health care professionals. New York, NY US: Routledge/Taylor & Francis Larson, D. G., & Hoyt, W. T. (2009). Group. Grief counselling efficacy: What have we learned? Bereavement Care, 28(3), 14-19. Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and transformation: Growing in Dale G. Larson, Ph.D., is Professor of Lepore, S. J., Silver, R. C., Wortman, the aftermath of suffering. Thousand Oaks, Counseling Psychology at Santa Clara C. B., & Wayment, H. A. (1996). Social CA: Sage. constraints, intrusive thoughts, and University where he directs graduate depressive symptoms among bereaved Walter, C. A., & McCoyd, J. L. M. studies in health psychology. A mothers. Journal of Personality and (2009). Grief and loss across the lifespan: A Fulbright Scholar and a Fellow in the Social Psychology, 70(2), 271-282. doi: biopsychosocial perspective. New York, NY American Psychological Association, 10.1037/0022-3514.70.2.271 US: Springer Publishing Co. he is the author of The Helper's Journey: Working with People Facing Neimeyer, R. A., Burke, L. A., Mackay, Worden, J. W. (2009). Grief counseling and Grief, Loss, and Life-Threatening M. M., & van Dyke Stringer, J. G. (2010). grief therapy (4th ed.). New York: Springer. Illness.
Indispensable survival guide for the thinking psychotherapist 29 Book reviews
t is not often that an author anticipates that their book is not going to be well received, and especially not an author with IChristopher Bollas’s illustrious publishing record. This is not a false modesty on his part, but rather a concern that his approach with analysands who are about to have a breakdown will be seen as not conforming to what is usually understood as psychoanalytic practice. He remarks that in formal presentations to groups of psychoanalysts over the years he has been accused of “violating the frame”, of being “seductive and gratifying to the analysand”, and that his approach amounted to “an enactment within the transference and countertransference that goes unanalysed” (p 7). His concern about the novelty, or transgressive radicality, of his approach with pre-breakdown analysands, is evident in his interview discussion with Sacha Bollas in the final chapter, when he (Christopher) says that he has been using this method with patients for over 30 years, and is only writing about it now: “To have remained silent in the face of what I have discovered might have been convenient—I hardly expect this text to serve me well with my colleagues—but I think I have no choice but to get it out there, and let others see what is to be made of it in time.” (p 116). It is somewhat Title: Catch them before they fall: The of an indictment about the conservatism and psychoanalysis of breakdown punitive boundary-monitoring that characterises psychoanalysis, that such an eminent and Author: Christopher Bollas respected analyst such as Bollas only felt able Publisher: Routledge to publish these views on his practice now, and Year of publication: 2013 even so, hesitantly! Reviewed by Grahame Hayes Bollas has a number of important things to say about how he understands the psychology of breakdown. For instance, he says that “for
30 New Therapist March/April 2014 Book reviews those who understand breakdown as a profoundly human experience, He emphasises this point regarding distracting a self from the meanings of their frailty produces loss by suggesting that if a a particular new form of loss” breakdown is not transformed into (p 2). He emphasises this point a potential breakthrough, then regarding loss by suggesting that people become what he terms if a breakdown is not transformed into a potential breakthrough, “broken selves”. then people become what he terms “broken selves”. Coming from his work with seriously disturbed individuals he wants to affirm the an abandoning of psychoanalysis, ’ generative and positive aspects but in fact following psychoanalytic in the contexts within which of working psychoanalytically principles precisely. He says that we work in South Africa, and with someone about to have a his commitment to psychoanalysis arguing that his approach is in breakdown. as the treatment of choice for principle problematic, or that In adopting this approach the someone having a breakdown is ultimate putdown: whatever it first thing to do of course is to why he offers them more (all-day is, it isn’t psychoanalysis! Even if assess that the person is in fact sessions),‘ not less, psychoanalysis. psychotherapists aren’t going to about to have a breakdown, and has Bollas is advocating “an alteration follow Bollas’s method there are become too fragile to cope with the in the analytic frame, but not the still some very fascinating and ordinariness of their everyday lives. process. The new structure is set in challenging ideas in his brief book. Bollas would at this point assess place temporarily, in order to help It is also one of his more personal whether the person just needed the analysand through a crisis and books as it is the writing of a some extra sessions during the then allow a return to the reliability working and thinking therapist week, or whether all-day sessions of the ordinary contract.” (p 103). with a focus on the practicalities of were required. At this point Bollas However, while Bollas says that therapy. There are three fascinating makes a whole range of practical what he is doing is just offering chapters devoted to the case studies arrangements. He agrees to see the more psychoanalysis, there are of analysands (Emily, Anna, person for full-day sessions, for as some interesting features that and Mark) that he has worked long as it takes. Full days means particularly characterise these with in this way. While focused starting at 9.00, having a break for all-day sessions. For instance, he on the therapeutic process and lunch, and ending around 6.00 if notes that the silences are much case studies, it is by no means he feels that the person is able to longer than in ordinary one-hour an un-theoretical book as Bollas go home on their own. Remarkably sessions, and sometimes there also discusses the psychological he tells us that in all his years can be a silence of a few hours. processes of breakdown, and what of working this way it is been His theoretical argument about the psychoanalysis of breakdown extremely rare that the full-day this is that the person needs time amounts to. sessions have exceeded three days! and quietude to process their He also arranges for a GP that emotional experience (chapter For those interested there is an he works with, or the analysand’s 9), and to feel contained by the audio interview with Bollas by psychiatrist if they have one, to be holding environment of these Tracy Morgan on his book: http:// on standby should his three days or all-days sessions. Bollas is not newbooksinpsychoanalysis. so of intensive work not be enough suggesting that the therapist should com/2013/03/26/christopher-bollas- catch-them-before-they-fall-the- and the person requires medication not interpret, but that too much psychoanalysis-of-breakdown- or hospitalisation. He also arranges interpretation will interfere with routledge-2013/ for social services to assist the how the analysand reflects on, and person with any domestic issues, makes sense of the “unthought like meals, transport, and so on. known”. Bollas’s argument throughout There is a difference between his book is that his approach is not how we might struggle to put into practice Bollas’s approach
Indispensable survival guide for the thinking psychotherapist 31 From the therapist's chair
Lost and found
The evolution and eventual reversal of borderline dynamics as demonstrated in one patient’s life narrative
By Robert Waska
Abstract internalization and identification processes. The point of this that either helped to balance the ongoing column is to highlight the ontinuing the ongoing more persecutory perspective or therapeutic nature of allowing the story of a long term added an element of idealization. In patient to tell his story and to have patient in psychoanalytic illustrating these points, the author an unique chance to hear from the Ctreatment, the author highlights shows how the Kleinian approach patient their own view of their life, points in this patient’s development considers the ongoing relationship the evolution of their pathology, and where the borderline or paranoid- between external and internal and the way external life imprints upon schizoid experience seemed to have how the intra-psychic elements internal life just as internal phantasy solidified. At the same time, there of attachment and phantasy are shapes the experience of external were critical moments of shaped by projective identification life.
32 New Therapist March/April 2014 From the therapist's chair
oing on with his story I was at Sunny Acres. Only now, that my liver was now damaged by about his new roommate I realized the owner was a cocaine very high enzyme levels. This was, situation, John told me addict and an alcoholic. I was part in the doctor’s words, a classic sign Gthat he continued his sad ride into of his drama of divorcing his wife of severe alcoholism. I was drinking oblivion “with drinking all the time and co-owner of the store after his at least a six-pack of beer a day but and drugs whenever I could get affair with another girl working when I had the money it was always them. I fancied myself as a nature there and his descent into alcoholic more. A typical day when I had lover so I would take long walks in oblivion. I would wake up in the enough money was more like six the hills behind our house. I would back room of the pet store, after shots of whiskey, 6-10 beers, lots of smoke as much pot as possible we had spent the night drinking pot, and any cocaine I could find or and bring a six-pack of beer with and snorting cocaine. Without a afford. me. Then, I would just wonder shower or a change of clothes, we After we could not afford to around in the woods looking at the would slug down another beer and pay the rent anymore, this band of trees and feeling free and easy. A open the doors for the customers roommates broke up and I found mellow nature lover was an easier who asked us questions about bird several other misfits to move in with identity to take on than to admit to food and wanted to buy tropical in another town in Marin. At this myself I was a lonely loser with a fish. Again, my other more healthy place, I ended up with a girlfriend drinking problem. My roommates side was struggling along for the who was twenty years my senior. grew to not respect me as I would ride. I was actually very interested She was a 40-year-old alcoholic have black outs and say or do in the pets and through reading on disability for mental health things that offended them. They all the books the pet store had, I problems. She was prone to fits grew to see me as the kids in high was very knowledgeable about any of rage and violence when drunk. school did, a drug addict out to get species of tropical fish we sold and But, we loved to have sex and drink high at everyone’s expense. I had any underwater plant, goldfish, or together. Eventually, I moved into nothing to give and only wanted flea product you could imagine. I her house when I was kicked out what I wanted. I was not able or liked my job and I was very good of this house but first I had to willing to be social so I seemed very at it although I was probably a very experience my first overdose before withdrawn and selfish. scary person to deal with. My hair making my exit.” During this time, I was with was down to my waist at this point At this point, my patient John a couple of women for a short and I always stunk of booze and told me a detailed story about one period of time. One example was cigarettes. Yet, the customers always of the many scary, emotionally a prostitute I picked up when she asked for me because they knew I torn moments in his past that and her eight year old daughter cared and was honestly trying to showed him to again be frantically where hitchhiking. They were help them. Again, my giving nature struggling for life among his death- homeless and poor and I invited was trying to stay afloat throughout seeking behaviours. John told me, them to stay at my place. Another my selfish destructive spiral “Imagine my delight when I talked time, there was a sweet younger girl downhill. my drug dealer into fronting me down the street who was smitten It was while living at this $500 of cocaine. In 1985, this by me but after I kept having sex roommate situation that I ended was quite a haul. I told him I had with her without pursuing the up with hepatitis. I managed to “an eager customer” to sell to and deeper relationship she obviously meet up with one of my old heroin promised to pay him within 48 wanted, she took her sister’s advice buddies and we shared a needle hours. I felt guilty lying since he to stay away from me. There were while doing some of the drug. I was one of my only friends plus it numerous women I brought home remember feeling extremely ill the seemed crazy that he would trust from the bar after we both had next week or two and having a stiff me given that I was one of his best closed it down. This was always neck along with the worst possible customers. followed by the awkward morning flu like symptoms. But, it wasn’t This period of time was part ritual of trying to figure out who until some ten years later that I of a 13-year low. I was moving they were and what their name was. found out from a blood test that I through life without ever thinking, I was back at college barely had Hep C. What I did find out just grabbing and digesting all the keeping up with my undergraduate during this time from blood tests at drugs and alcohol I could find. I courses and working part time at a physical exam prompted by dizzy was anxious and depressed, to the the pet store I used to work at when spells and an ache in my side was point of being suicidal and did
Indispensable survival guide for the thinking psychotherapist 33 From the therapist's chair
my best to blot those feelings out. famous 60’s band that hadn’t really Berkley beat poet and now living Nevertheless, I was aware enough done much in twenty years. He with the rock star. The other part of my chaotic reality to end up lived in a house bought back when of me realized that this would feeling like I was watching myself he had money and fame. It looked probably get back to my drug careen through a sad series of events like a quaint cottage at night when dealer/rock star, ruining my chances without brakes or steering wheel. I went to pick up my goodies but in for any more bundles of blow on Like watching a scary movie, you the light of day, it was a rundown credit. want to yell at the character to dump with a sagging roof and a But, the sober little man that “watch out for the monster around rusted washing machine sitting in lived in the back of my head the corner” but you know they won’t the front yard. He hadn’t recorded was whispering in my ear. I was hear you. anything in over a decade and painfully aware that here on the My drug dealer was a really nice only practiced occasionally in side of the road was a washed up, guy, a noted musician “back in the order to jam at the local dive bar aging woman who lived with a drug day”, whom I would sit around with once a month. He still knew other dealer and looked like a bunch of and chat for hours, fairly easy when luminaries from the 60’s music dried flowers, a faded remnant of you both are high on a stimulant. I scene so when they came to buy what used to be vibrant and alive. was at his house so often I felt like drugs I got to meet people I had Chatting her up was a terribly family. seen in Rolling Stone magazine. But, confused drug addict completely He and his girlfriend were most of them were still making adrift and desperate for love and interested in my college endeavors. records and were buying cocaine comfort. So, I said goodbye and First I was enrolled in a nursing for recreation, not dealing it for made my way to the liquor store program but now I was studying a living. When I saw my dealer’s for my nightly six-pack and half psychology. On the surface it five year old daughter watching pint, with the hope of ignoring the seemed we were having nice him prepare the scales to weigh empty void that was tunneling into scholarly discussions about academic out the cocaine, I knew something my soul. matters although I never let on was terribly wrong. But, that is the that my life was completely out of painful life of a drug addict. You control and I was barely passing know you are living ugly but you my classes. In school, I was usually don’t walk away, you hang in there hung over, trying to stop a drug- over and over, becoming part of a induced nosebleed as the teacher sick distortion. called on me to answer something My dealer’s girlfriend was a I had no idea about, since I had quiet woman who looked like the chosen to go to a the bar instead stereotype of a California flower of the library. The quizzes might child, now a bit wilted. She seemed well have been written in another to be drawn to me and over time we language, they seemed so foreign. developed an unspoken attraction I felt ashamed to be sitting there, for each other. It was clear that if smelling like stale beer and her boyfriend wasn’t in the picture, pretending to take a test that that I we would have become involved. didn’t know anything about. One day, when driving around So, on one level, I felt cool to town, I saw her walking along by be hanging out discussing my herself. I stopped and we talked for psychology program with my a while. friend the famous rock musician, I had two distinct feelings. I his beautiful hippie girlfriend, and wanted to ask her to come home their cute five-year-old daughter. with me. She would have said yes, Robert Waska MFT, PhD is a 1999 graduate But, my mind was still hanging on we would have gotten high, had sex, of the Institute for Psychoanalytic to enough bits of reality to painfully and had a great time. I envisioned Studies, an International Psychoanalytical notice the other side of this study in the union of two hipsters, me the Association affiliate organization.He denial. bright college student and her the conducts a fulltime private psychoanalytic In fact, my friend/drug dealer sophisticated older woman who practice for individuals and couples in San Francisco and Marin County, was the former drummer for a used to be married to a famous California.
34 New Therapist March/April 2014 I'm a cake, you're a cake
time is available and emergency responses are not required, a simmering approach allows more of the individual essence to emerge for a fuller, more flavorful effect. Clients of a more delicate nature I'm a cake, often respond to a style that attends you're a cake to the work gently and slowly, while clients of a tougher disposition also benefit from the simmering style, which facilitates increased elasticity with hardened lifestyle habits. Key issues, childhood events and personality patterns are stewed down to a simpler, more concentrated form in the therapeutic relationship. As in the Crock Pot simmering process, which allows the fat from the cooked protein to Simmering to float to the top to be skimmed off easily, rather than stirred back in, slow therapy allows more of the Satisfaction unnecessary to come forward and be released, rather than repeated. By Sandra Wartski There are also lovely surprises associated with the use if a slow- cooker style. The slow approach allows for a satisfying blend of listening and reflection, acceptance and change, positive and negative, past and future. The flavors may immering is an efficient food steady temperature in the 79–93 be stronger and more pungent at preparation technique in °C (175–200 °F) range, with the times, but this method ultimately which foods are cooked in lid being essential to prevent provides more clarity, meaning and hotS liquids kept at or just below vapors from escaping and to allow power. The final product looks quite the boiling point. Simmering flavors to be circulated. The low different from the way it appeared provides generally gentler treatment temperature of slow-cooking at the start, but there is adaptive than boiling as it prevents food makes it almost impossible to burn value in looking back to remember from toughening or breaking up. food, though some types of meat the place from which one has Simmering can be used to cook or vegetable can be over-cooked. come. The healing nature of time proteins (such as poultry and meats), There is also the bonus of using and patience is always reinforced. often in the form of poaching just a single pot, as clean up time is And much of the work may occur (cooking in enough liquid to cover significantly reduced. between sessions, unattended by the the food) and braising (cooking in a Just as simmering foods allows clinician, as it gently percolates in small amount of liquid). them to become moist and fork- the adaptive heat of the psyche. A slow cooker, also known tender over time, the process of by its trademark name of Crock traditional psychotherapy allows About the author Pot, is a countertop electrical clients to warm up slowly and to cooking appliance that is used for allow issues to be exposed gently. Sandra Wartski, Psy.D. is a psychologist in simmering. This terrific invention Unlike some of the short-term Raleigh, North Carolina, USA. She is also allows unattended cooking of or “shock therapy” approaches, a mom who has special interest in feeding certain dishes at a relatively low a simmering style can be her family nutritiously and efficiently. temperature for hours. The heating therapeutically effective with certain element heats the contents to a presenting problems. When more
Indispensable survival guide for the thinking psychotherapist 35 I'm a cake, you're a cake
Savory and Hearty Beef Barley Stew
Ingredients:
2 cups baby carrots 10 ounces fresh mushrooms, sliced 1 1/2 pounds boneless beef chuck steak, cut into 1-inch cubes 2 teaspoons minced onion 1 teaspoon onion powder 1 teaspoon salt 29 ounces beef broth 14-1/2 ounces diced tomatoes, undrained 2 cups water 3/4 cup uncooked pearled barley 1 cup frozen green peas 1/4 teaspoon black pepper
Directions
1. In a slow cooker, layer carrots, mushrooms and beef. 2. In a medium bowl, mix the onion, onion powder, salt, tomatoes, water and barley. Pour mixture over beef. 3. Cook, covered, on low 8 to 10 hours or until beef is tender. 4. Stir in peas and cook, covered, for a further 5 minutes, or until heated through. Season with ground black pepper and serve.
Recipe adapted from www.momswhothink.com
36 New Therapist March/April 2014