Lost a Small Child

Dear Dr. Neimeyer,

I’m a therapist in general practice who was just referred a couple who had lost a small child.  The mother called to make the appointment and emphasized that her husband was willing to accompany her, but she also said they seemed to be “on different pages” in dealing with their loss.  We arranged for a joint session to assess their needs, but from that point on the format for therapy is an open question.

So my question is, would you try to work with them in a conjoint therapy, or recommend individual therapy for each, if they have different issues with the death?  And if your response is the latter, would you refer one of them to another therapist?

Charlene K., LCSW

Dear Charlene,

It sounds like your referred case reflects a common reality in bereaved couples and families:  just because people have had the same loss doesn’t mean that they  have the same grief.  Teasing out these differences—which of course reflect different personal and relational styles as well as gender and family roles—respecting them, and promoting empathic bridging between mourners is typically a first crucial step in working with grieving partners.  Let me then suggest some practical considerations as you attempt to do so.

1.  Choose your format.  In couples with a history of high, unresolved conflict, intimate partner violence, or an active affair, consider the safety of individual sessions.  In most other cases, consider joint sessions.  Even with the caveats noted below, an overarching goal of therapy for bereaved parents is to build trust and understanding through compassionate communication at well chosen times.  Obviously, this is best facilitated when both partners are present.  However, also consider your own competencies and theoretical orientation, recognizing that skilled and ethical therapists will differ in the therapeutic format with which they are comfortable.  If you are a couples or family therapist, you will likely be well practiced at forming an alliance with two partners who stand in some tension with one another, and helping them bridge their differences.  If you were trained to practice individual therapy, dealing with the death of a child probably isn’t the best circumstance for trying out conjoint therapy.  Instead, refer to someone familiar with the subtlety of couples work in the presence of intense pain, meet with one partner at a time, or collaborate with another therapist who might see the other partner, and then assist with joint work when both clients are ready for that.

2.  Shift your focus within sessions.  If you see the couple together, consider the advantage of interviewing first one, and then the other, in the presence of the partner.  Explaining that your goal is to get a clear sense of the meaning of the loss for each of them, begin by asking the partner who seems to be in most visible distress if you could speak directly with her or him for a few minutes, while the partner quietly looks on from the sidelines, about what is uniquely hard about this loss from his or her position.  Obtaining this permission, check to see if this is also alright with the partner, who will have a chance to share comments and questions when the two of you have finished.  Then, possibly shifting the seating to encourage direct eye contact between you and the partner to be interviewed, and positioning the listening partner to one side, conduct an empathic, emotion-focused interview into the first parent’s emotional reality in the wake of a horrific loss.  Concentrate on her or his first-person experience of grief, how it feels psychologically and physically, and what he or she desperately needs to move through this impossible experience.  Very likely, the interview will bring tears, which you can support without rushing toward problem solving.  After 10 minutes, ask the interviewed person’s permission to invite the comments of the parter, which you will receive with equal empathy.  Then reverse their and seats, repeating the procedure with the other partner.  This will usually bring to light a far deeper understanding of what is unique, what is shared, and what is needed for each partner, from their mate and from others in their life.

3.  Talk about talking.  Having gone some distance toward constructing more mutual compassion and understanding in this fashion, use the remainder of the session to consider how, and even whether, to talk about the loss between sessions.  What are the pros and cons of doing so?  The goal in this is not to push toward conversation, on the naive assumption that more communication is always a good thing; in bereaved couples, the audible pain of the other often can trigger a spiral of escalating pain that only reinforces the perceived danger of closeness.  Instead, discuss with the couple how they can also engage in self-care (as through exercise, music, spending time with other friends), coming back together with no immediate compulsion to speak of their grief.  As physical presence to the other becomes safer in this way, working out mutual ground rules for conversational connections will become more feasible.

Dr. Neimeyer

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