Therapist question about a mother who lost a son and is now experiencing complicated grief.

Dear Dr. Neimeyer,

I’m a family therapist who has been working with a couple who have lost a young adult son in a drowning accident in a distant country, and in which the mother has remained in a deep, unshakeable grief for over three years, for two of which I have been working with her and her husband in therapy.  At this point I feel like I’ve tried everything with her, grounding our work in deep compassion, making a safe place for the expression and exploration of her feelings, nudging her to take small steps toward something that could bring her pleasure, pointing out the irrationality of her self-blame, and trying to foster greater closeness to her husband.  Nothing has made a dent in her grief or her guilt, though her relationship to her son was a good one and she had no hand in his trip or his death.  Nor will she accept my referral to a physician who could evaluate her for antidepressant medication, which she probably needs, or do anything more with her husband than ruminate about the loss, as she pushes away his efforts to reach out to her in a consoling way.  We’ve reviewed the story of the death, though it doesn’t feel like she is dealing with trauma, per se, and we’ve also tried to explore her relationship to her son, with little effect.  In short, I feel quite stuck, even though she seems committed to seeing me weekly, and says she feels more desperate on weeks that we are not able to meet.  My client says that she will never be happy again, even though her other children and grandchildren try to involve her in their lives.  At this point, I am beginning to believe her, though I have tried to remain supportive.

Is there something more I could be doing to help her?

Harriet

Dear Harriet,

I can hear your clear frustration with the impasse in this case, as your earnest efforts to make a difference seem continually to be rebuffed or seem to be drawn down into the quicksand of your client’s grief.  Compassionate attunement is surely the place to begin, and validation and exploration of her feelings and great pain surely are a big part of what most bereaved people need.  But it sounds like in this case this often necessary foundation for intervention is clearly insufficient.  So here are a few quick suggestions that occur to me, with no omnipotent conviction that any of them will be a magic key that opens a door out of the prison of her grief.  These are simply some things I might try.

  1. When what you are doing isn’t working, do something different. Rational disputation and emotional expression and exploration haven’t made much difference so far, so I would tend to let them go.  Releasing these approaches could make way for something else.
  2. Shift the context. Your office seems to have become a safe haven for this mother, as suggested by her missing it when you skip a session, but also seems to have become a confessional for her unwavering grief.  So consider a change up:  Greet her at the door, and take a walk.  Stroll to a nearby park or green space as you talk, with only occasional eye contact as you both necessarily focus on the changing landscape.  In my experience this has sometimes injected movement and outward attention for clients stuck in ruminative constriction, allowing a conversation that varies naturally from observations about the world around you (“What a beautiful flower!”  “Do you recognize the call of that bird?”) to reflective probes that are lightly metaphoric (“Where would you like to see your path heading as you move into summer?  What do you imagine the next step might be?”).  If nothing else, the walk may be more enjoyable and stimulating for you personally, and could contribute to to her wellness at a physical level.  More optimistically, making a practice of this could begin to build a sense of mastery, self-care or more regular exercise for her, in a way that has been demonstrated to be useful in the treatment of depression, and it might even prompt movement in her foreclosed psychological world as well.
  3. Interview the resistance. There is ample evidence in this case for what my colleague Bruce Ecker would call “pro-symptom positions” (PSPs), deeply entrenched and largely unconscious meanings of suffering and thriving that make this particular form of grief more important to have than not to have, despite the genuinely life-vitiating pain associated with it.  For example, preserving a conviction of her own responsibility for her son’s death might prove less anguishing despite her terrible guilt than reckoning with her own maternal powerlessness to protect her child, or her intense grief might stand as an accusation to God or the universe that the death was cruelly unjust, and leaves a permanent wound that will not heal.  Pursuing such hidden meanings is not an intellectual guessing game, however, as it requires special methods for indirectly inviting and encountering these entrenched beliefs that make her suffering in just this way necessary.  If getting to the roots of these PSPs is a direction you’d like to pursue, you might like to check out “coherence therapy” and Ecker’s work on the internet, as it offers a clear alternative to pushing harder for change, and instead provides a methodology for encountering and dialoguing with the resistance, with no overt effort to change (and for this very reason it often provokes profound and rapid transformation).  Coherence work greatly informs my own practice, and is a mainstay in my work with complicated grief cases.
  4. Go social. Therapy can become its own little world, especially when a client has cut off from (or been cut off by) many others.  As a counterbalance to this, secure your client’s commitment to engage in some form of regular social activity, whether it is a weekly “meet up” group announced on the internet, a knitting circle, a tennis class, a book club or a gourmet club. In keeping with the Dual Process Model of grief, which emphasize both the need to process the loss but also to restore life, the goal would be to venture weekly into restoration, just as she ventures regularly into loss oriented work with you.  Make time for both, and push her gently to reconnect with a world in which grief is not the singular focus.
  5. Use the grief, instead of trying to lose it. Suffering can be borne nobly, rather than merely wasted in rumination and self-indulgent anguish.  Seek ways to draw on her pain in order to engage a deeply broken world, filled with loss and suffering.  Meeting others in compassion, whether in a self-help group, by volunteering for an organization promoting social justice, tending to rescued animals or doing good work with suffering communities, could be a way of reaching out from her own broken heart to embrace others who know their own form of pain and loneliness.  Performing such acts of kindness in her son’s name also honors him, and extends his impact beyond the grave.

Best of success with this.  But also humbly recognize that we do not save all lost souls; sometimes we just make their purgatory a little less hellish.

Dr. Neimeyer

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