Dear Dr. Neimeyer,
I am a marriage and family therapist with a 55 year old female client who is the only surviving member of her family Her mother died suddenly and unexpectedly last year and she’s given up all her many interests. She is full of anxiety and fear–seems agoraphobic–having panic attacks and hot flashes have recurred although menopause has long passed. Any intervention suggestions? I am a cognitive behavioral therapist with a strong belief in choice theory.
The sharp constriction of your client’s once full life is indeed cause for concern, especially as her retreat from the broader world seems to be motivated by a generalized state of anxiety and physiological arousal. Here let me offer a few thoughts along the lines of case conceptualization, each with some practical implications. In this, your own theoretical base in Glasser’s choice theory and your working familiarity with cognitive behavioral methods could prove good allies, especially when supplemented with evidence-informed contemporary theories of prolonged or complicated grief.
First, as you know, one foundation of choice theory is its conceptualization of four basic human needs centered on (1) belonging, (2) significance, (3) freedom and (4) learning. This dovetails closely with an understanding of bereavement as a challenge (1) our attachment bond to the deceased, as we (2) seek to make sense of the loss and our lives in its wake, by exercising our (3) irreducible freedom to chose our attitude toward our suffering, and ultimately (4) relearn or rebuild a world of meaning that has been challenged by loss. This broad orientation to bereavement draws on the work of Bowlby, Frankl, Attig, and others, including myself, to view grieving as an active process which, although unchosen, turns out to be rich in choice. The very fact that your client chose to seek therapy rather than languish further at home is a step, and one that can be extended in the work you do together.
Second, as you also recognize, Glasser famously contended that all problems that persist are relational problems. In the context of complicated grief this is clearly the case, although the self-isolation of the mourner might mask this fact, leading us toward diagnoses like depression that tell at best only part of the story. At the heart of complicated grief is a pervasive and preoccupying yearning for what eternity will not return–namely, the deceased loved one, who commonly was a or even “the” source of attachment security in life. The loss of a mother at any age can deprive the mourner of the critical person who represented a “secure base” for sailing out into life, and a “safe haven” from the inevitable storms that threaten to capsize us. This could help makes sense of the terrible anxiety and fearfulness that contributes to your client’s withdrawal and shutting down, and could further imply that in a transitional sense you might partly serve this safe haven function until your client begins to develop or access other caring attachments that can meet her needs.
So, what to do in therapy? One fundamental task is to provide some of the nonjudgmental presence and empathy that her mother might ideally have done, without pushing her beyond her window of tolerance for anxiety by requiring immediate or dramatic behavior change. Gradually, however, you could draw on your skills as a behavior therapist to help her gradually expose herself to fearful things or circumstances, which may range from painful reminders of her mother’s absence to engagement in once valued activities and relationships that she has avoided since the death. Just as Glaser would recognize, choice would play a central role in this progressive enlargement of her world, allowing her to choose, or to collaborative with you, to discover some small, do-able action (looking through a family album with you in session; going to a place she once frequented with mom) that would push back against her fear, but in a feasible way. Think of this in terms of systematic desensitization, constructing a fear hierarchy of progressively larger steps back into the world. But keep these modest, as success will build motivation to undertake more steps, whereas failure will fuel further retreat.
However, remember that change will only be sought and sustained by the client if it moves her in the direction of greater meaning; few people undertake the hard work of pushing back against strong emotions to engage in challenging actions just because we tell them they should. For most people with complicated grief this means that they need to see these steps as helping secure a greater sense of connection to their deceased, as by doing things their loved one would be proud of, by undertaking a legacy project that honors her, or that fosters a closer continuing bond (as in writing an AfterTalk letter to her). Alternating between exploration of significant emotions, discussion of problematic or hopeful interpretations of circumstances, and brave attempts to perform life differently can make a great difference over time, alongside appropriate medical evaluation of persistent symptoms of depression or potential hormonal problems that could compound your client’s grieving.
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I am surprised to see that Dr. Neimeyer failed to mention that you might want to explore the use of a short-term focused approach that has been efficacy tested. Our highly effective complicated grief treatment is structured and based upon basic principles of attachment relationships and adaptation to loss and uses strategies to enhance self-determination and emotion regulation. You can contact the Center for Complicated Grief at Columbia University School of Social Work if you are interested in learning more. We have a library of materials available as well as an extensive training program and have now trained more than 1000 therapists.
I hope this is helpful.