Dear Dr. Neimeyer,
Thanks for considering my question. I am a grief counselor working providing support to a local community. I am currently working with a woman grieving the loss of her infant son, due to premature birth. She also concurrently has a medical diagnosis of Munchausen’s syndrome. In trying to navigate grief and re-establish meaning, I am considering the use of your narrative re-telling. Are you aware of any contra-indications to the use of this modality? There is very little information regarding grief counseling and Munchausen’s syndrome and so I am feeling a bit in the dark in regards to her clinical plan.
Pat C.
Dear Pat,
As I imagine your work with this challenging case, I can appreciate that the characteristic presentation of physical problems without clear medical basis that typifies Munchausen’s syndrome could mask a more direct acknowledgment of the very great emotional pain that this woman must face in the aftermath of the birth and death of her child. It might help me, were I working with her, to recognize that her tendency to experience as well as express her suffering as medical rather than psychological conditions may well impede her ability to recognize and articulate her grief, rather than representing a form of motivated resistance to a psychological approach, per se. Viewing her seemingly factitious physical syndromes as in part an inarticulate and embodied attempt to communicate and explain her pain, let me offer a few ideas that I hope will enhance your work with her.
First, if she is willing and able to do so, and if you have established a secure therapeutic bond with her, invite her to walk you through the terrible experience of the child’s premature birth and death, from the first sign of trouble in delivery through the child’s funeral service. Use the child’s name, granting him or her personhood, and exploring your client’s hopes for that child in a respectful way, as a backdrop to focusing on the narrative of the death. Then, very, very slowly, encourage a full telling of the events leading up to and following the child’s delivery—not merely the “external narrative,” what happened and when, but also the “internal narrative,” what was happening in her body and heart as these same events were unfolding. Consider questions like, “Who else was there?” “What did the nurse say?” “What did you see in your husband’s eyes when he entered the room?” All of these invite a “think description” of the events, alternating with questions like, “What did you notice in yourself, in your body, in your emotions as you experienced that?” This allows your client to be less alone in the experience, to name and claim her reactions of physical pain, emotional anguish, fear or guilt, all received and contained by a compassionate and nonjudgemental listener. Your role is to listen deeply, validating but not problem solving, during what would typically be a very emotional retelling. Note that this almost certainly will take the majority of a session, saving 15 minutes for stepping out of the retelling and processing it with her, and it might well take multiple sessions, as you retell one “chapter” of the story at a time, as you help her identify and perform appropriate self-care in between. The work of Ted Rynearson and his colleagues in “restorative retelling” could be very helpful here, as could my own coverage of this topic in the original volume of Techniques of Grief Therapy, published by Routledge. The key is to marinate in the experience long enough to discern and identify and make sense of the difficult emotions that need first to be validated before they can be assuaged. This would be especially important in the case of someone presenting with Munchausen’s, for whom the language of psychological distress may be a foreign language to be begin with.
Second, bear in mind that just because this client presents with factitious disorders, this doesn’t mean she might not develop quite real ones. Regardless of her diagnosis, it is important to remember that both premature delivery and bereavement are associated with very real physical illness and injury that can manifest in the aftermath of her tragic stillbirth or perinatal loss. Especially if her Munchausen’s was a pre-existing diagnosis, that is, one that preceded her bereavement, vigilance about subsequent symptoms of a quite real nature is in order. Of course, this in no way diminishes the importance of psychological interventions for grief like analogical listening (also covered in the Techniques book), which could help her find and voice the sense and significance in bodily felt pain or malaise. But it does raise the possibility that collaborating with a compassionate rather then critical physician could be essential in her ongoing treatment.
Dr. Neimeyer