Dear Dr. Neimeyer,
I am currently working with a woman who lost her adult son to sudden death when he was residing in a foreign country 5 years ago. Since then she has been absorbed in a deep and isolating grief, though she has two other adult children and a husband who remain quite concerned about her. I have seen her with her husband in therapy for 12 sessions, but her grief remains intense and unremitting, to a point that she seems to have cut off from all other relationships with friends and family, and although not actively suicidal, clearly wants to die. Her psychiatrist has been unable to alleviate her anguish with several adjustments in antidepressants, and my best efforts to empathize with her suffering only seem to reinforce it. She presents with a deep feeling of being all alone, and she even looks this way, leaning away from her husband on opposite ends of the sofa in my office and sending few signals of feeling connected to me as well. I feel very stuck in this therapy, but am reluctant to “abandon” her by suggesting that she consult another therapist, as this client describes vividly the pain caused by a childhood experience of being “unwanted,” and even felt abandoned by her son when he left to live in another country. What could I do to help restore momentum to the therapy, and help this woman find the hope and meaning that seems to have died with her son?
Beverly
Dear Beverly,
As central as empathy and compassion are in attending to those in deep grief, there are times when they are not enough, and this appears to be one of them. We ourselves can ultimately be drawn into their hopelessness, as the therapeutic options seem to narrow to the point of trying “more of the same,” only harder! In the service of opening up some options, let me therefore brainstorm a few alternatives, each with a brief explanation. I’ll start with a few easy-to-implement suggestions, and then work up to more complex interventions.
- Shift the proxemics: If part of your client’s problem is a sense of isolation from others, move your chairs closer together by one foot when part way through a session. Then continue as before, and after a few minutes, process with the client whether she noticed a difference, and if so, which felt more comfortable and why. Likewise, invite her to sit closer to her husband, or him to her, in a separate experiment with physical closeness. If the closeness is welcome, ask in what other ways she would like to invite more of it in her life. If it is uncomfortable, ask to talk with that part of her that prefers distance about what makes that necessary, despite her loneliness.
- Take a walk: If the problem is “no movement,” literally mobilize her by conducting your session as you stroll together through the neighborhood of a nearby park, speaking therapeutically about how it feels to be in motion, as you literally walk alongside her going forward. In addition to helping promote psychological movement, the exercise can itself be a form of behavioral activation, self-esteem, and self-care. It can also set the stage for walking with friends or family as homework.
- Investigate motherhood: Interview her about the best part of being a mother, during those special years she had with all three of her kids. Ask “What did Stephen represent to you?” Consider how she can still be a good mother to her living (and grieving) children, and what Stephen–and his death–meant to each of them.
- Open the photo album: Stimulate the stories of her family and their interrelationships over time, considering what endures in each even following this hard mutual loss.
- Talk to Stephen, not just about him: Use chair work to encourage her to express to her son symbolically in an empty chair where she is in her grief, what she feels and what she needs. Then change chairs, loan Stephen her voice, and have him “respond” to mom, offering advice, counsel, and–almost surely–love and appreciation.
- Go to the source: In this variation, consider chair work with her mom about the abandonment your client felt as a child, and what she needs and is seeking as a result.
- Family meeting: Invite the other adult children into therapy with mom and dad to talk with them about their perception of who is hurting most, next most, and least, and what each needs from the others to feel or adapt better. Help them plan a shared ritual that honors Stephen to reduce their individual isolation.
- Ground the client: When she is overwhelmed by emotion, move her back into head by discussing problem solving strategies or coaching in diaphragmatic breathing to modulate and tolerate the affect.
Note that most of these approaches can be used in tandem rather than as stand-alone interventions, but beware of overloading her by implementing too many at one time.
–Bob Neimeyer
Thoughts from another therapist. The first thing that stood out for me was your wanting to restore momentum to the therapy. What does that mean? I am disconcerted to think of therapy as a thing apart from the people. That might be appropriate with a different person or problem, such as someone leaving prison. But grief may or may not have rhythms. If a client seems stuck, that is not a problem. Many places in grief are a kind of stuckness. No matter what we do, the loved one is still dead, not coming back. Being present for someone who is stuck takes a lot of grit. It is hard to face the emptiness and pain and lack of joy in grief. But that is our job.
I try to sit still and be with them. Be there with their pain. Do not deny it, as that is hurtful to the bereaved. Try to let your spirit meet with theirs. Call upon your own angels, your own ways of coping with the unendurable. You know that there is relief down the road for your client. You just don’t know how long that may be. When I re-read my journals from painful losses, I am reminded that I have survived the pain of that time. In some cases I may still carry the pain more closely than I would wish, but then I remember that we do, indeed, come out of that darkness. Grace really does happen.