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Grief Issues in the
Psychotherapeutic Process

Barry Greenwald, Ph.D.

Issues of loss are certainly not uncommon topics in psychotherapy. Whether it is a break-up in a relationship, a separation caused by a geographical move, a life story that includes abandonment, or a history in which the death of a significant other plays a prominent role, therapists are used to hearing and dealing with their patient's reactions to these events.

Because the topic of death was, for so long, a "taboo," both patients and therapists are often less familiar with the intricacies of the adjustment process required to deal with this event. Dealing with the psychological responses of the dying patient called upon therapist's to become comfortable with their own mortality--or at least conversant with it. It became abundantly clear that while therapist's were well trained to deal with a great variety of life issues, death had been placed in an entirely separate category, and the anxieties and fears that were aroused in the therapist often precluded an effective therapeutic interaction. Therapists were simply unprepared for their own emotional responses when they began to deal with the dying patient. Patients facing the imminent end of their life had a way of crashing through their therapist's defense system leaving the therapist feeling as helpless and vulnerable as the patient he or she was treating.

In truth, this was really not a big problem. Most therapists didn't treat the dying and those that did realized the need for some rigorous soul searching and coming to terms with their own fears and anxieties in order to truly be available to their clients. The luxury of a limited practice that can avoid immediate "death issues" is no longer tenable. The AIDS epidemic is bringing more and more people in search of support and help from the mental health community. While dealing with death may not have been part of the original therapeutic contract, it can certainly enter the process if a terminal illness is diagnosed. AIDS or not, there is probably no safe place a therapist can hide from dying and death. It requires rethinking, retraining, and reviewing the life process in order to help the terminally ill deal with the end of their lives.

Grieving
As the body requires time to heal from a physical injury, one's emotional life needs time to recover from loss. Grief is the natural process that follows upon death. It is the period when a person:

This is not an exhaustive list nor does the order imply a step by step progression followed by the bereaved. Mostly, it serves to highlight the tasks of the morning process--what needs to be accomplished in order for the person to move successfully beyond the death experience. It also alerts us to the many places that trouble can occur if the tasks are not negotiated. Unresolved bereavement is remarkably fertile ground for the growth of eventual psychopathology. As therapists, we are often confronted with patients who have somehow side-stepped the mourning process or were not allowed or helped to get through their grief at some earlier time in life. If there is one axiom that resonates through the entire field of death and dying, it is that grief and mourning are inescapable. It may be postponed, side-stepped, avoided, or denied, Eventually, however, it seeks expression and influences behavior. The longer denied and avoided, the more difficult to deal with. Mourning will have its "day."

Within the Therapeutic Relationship
Issues of dying, death, and grief can enter the therapeutic process in a variety of ways. Whatever else may be going on in the therapy, whatever other issues have been prominent, it is very likely that these issues will take prominence and supersede these other issues until they are adequately resolved. At the very least, they will remain lively and impact the therapeutic process coloring and influencing everything else that is happening.

A Few Examples:
  1. A patient either comes to therapy with an already diagnosed terminal illness.
  2. A patient in treatment is diagnosed with a serious or terminal illness.
  3. A patient is in a relationship with a significant other (parent, spouse, sibling, child, lover, friend) who is dying and the patient is dealing with the stress and emotional upheaval inherent in that situation.
  4. A patient seeks out therapy for any of a variety of reasons but eventually it becomes clear that the underlying issue is a recent or remote death.
The first three examples deal with death and grief in current time. A life is about to be cut short and the patient is faced with a reality that has most probably been denied. It is a frightening reality not only for the patient, but for the therapist as well. There are several pitfalls to be avoided from the therapist's point of view.

Denial becomes a very attractive and understandable defense for both the patient and/or the therapist. Patients who become involved in unending searches for second opinions, hoping that finally one physician will say "It isn't so" are often firmly wrapped in the denial process. It is the excessive nature of this search that signals the denial process. It also represents where the patient is in the process and defines the nature of the "hope" that is held. Hope means the prolongation of life and a removal of the death sentence.

There is neither kindness nor therapeutic efficacy in crashing through the denial. Making the patient face the reality of the end of his or her life before he or she is ready is contraindicated. As often as not, it is born of the therapist's needs and not the patient's. Knowledgeable as we are these days of the Stages of Dying, therapists can feel an imperative to move the patient through these stages so that "acceptance" is reached before death occurs. It is necessary to remember that some patients never move from denial and that is acceptable.

It becomes important to ask and answer the question: "Whose denial is this?" A dying patient becomes very astute in assessing the reactions of those around him or her. People are frightened by death in general. This reaction is exacerbated when someone they love is dying. Frightened of being abandoned and alone, the dying person may shy away from overt, frank discussions of his/her situation and the fears that attend it so as to not put those around under increased stress. It may appear that the patient is entrenched in denial. In truth, the patient is struggling valiantly to contain his/her emotions so as not to frighten others away and fulfill his/her worst fear: abandonment. In like manner, the therapist's difficulty in dealing with the patient's death may also be transmitted and the patient may respond by taking care of therapist by not approaching the dreaded issues. It is an obligation of the therapist to check this out within him/herself. It takes readiness on the part of both individuals. A simple "When you're ready to talk about it, I'm ready to listen" may be all it takes to facilitate the process.

Being angry is part of dying and a part of grieving. It is often one of the most difficult parts for the patient. It can be equally so for the therapist, particularly if the therapist has his/her own problems with these kinds of feelings.

The patient who is dying needs to be helped with the anger that is felt. For some, anger has always been verboten; dying doesn't change that. These are the patients who need help in coming in contact with their anger and finding ways to give it expression. Again, it cannot be forced. The dying do not give up their personality style of a lifetime simply because death is imminent. The gentle, steady, neutrality of the therapist in this as in all other issues is required.

Other patients may begin to spill anger everywhere and on everyone. They are angry at all the healthy people in their world for whom life will go on. Despite the fact that they are dying, they become difficult people with whom to live and to treat. The patient's rage and anger effectively pushes others away. The therapist may be no exception. Often the therapist feels misused and abused, especially if special accommodations have been made to deal with the patient's declining health. It is helpful to keep in mind how any of us might feel in the same situation and just how angry we would be. Therapeutically, all that is required is to sit quietly and to accept the anger. It requires little comment; just an atmosphere of acceptance. While the anger may never totally dissipate; its intensity is likely to lessen if it finds a place where it can be heard and accepted without judgment.

Bargaining is also a stage that the dying move through. They will accept their own impending death but they set terms or conditions on it. "If I can just live to see my grandchildren," or "If I can just once again see the place where I was born" become the bargain they strike in order to deal with death. It is important to note that the bargain, even when it is kept, is not something the dying remain consistent about. Once one bargain is made and realized, another may take its place. These are coping mechanisms designed to forestall the inevitable. It is still a means towards prolonging life rather than dealing with its end. Again, it is probably non-therapeutic to try and dissuade the person from these attempts. Rather, it is more important to understand the enormity of the task with which the dying are coping: The ultimate end to their own existance.

It is important to keep in mind that dying people are treated differently by the world. As soon as people discover that your patient is terminally ill, they vest your patient differently. Friends who used to turn to the person for advice, stop asking for help. In general, the dying get treated as if they are already dead. They will complain that people no longer see them as having anything to offer. This type of treatment fuels both anger and despair and isolates the patient from what were meaningful and contributing relationships. As the patient's physical condition declines, it is likely that she or he will feel less and less in charge of life. Therapeutically, it can be important to help the patient find ways that enhance a sense of "in chargeness" throughout the process. Equally important is not taking over things for the patient out of sense of caring or an exaggerated sense of the patient's vulnerability. Treating the patient as capable, competent, and someone who has something to contribute goes a long way therapeutically.

Inevitably, the dying person comes to face the loss of everyone and everything that he or she loves. The impact of that realization is hard to imagine. The therapist, too, comes to face the fact that the client will die--she or he will be lost. There is no way to avoid the sadness. This is real sorrow and it is a source of real pain. To be able to speak about this is certainly the patient's right. Therapists will differ as to how much of their own feelings they might wish to share with their patients. The Psychoanalytically inclined may well maintain their blank screen posture throughout the entire therapy. The Humanistic may spend more time in sharing and exposing their own feelings to their dying patient. Somewhere along this continuum, is a place that feels correct, congruent, and genuine to your own therapeutic style. And if may differ from patient to patient. Be assured, however, that you will mourn your patient and for a period of time the death will effect your life in a significant way.

Silence may become a very large part of the therapeutic process. Tolerating it is essential. It represents hard work being done on the part of your patient. The patient is pulling back, coming to terms with the losses that are imminent. It does not mean that she or he wants you to go away. In fact, your presence is as critical as it ever was. Sitting silently with a dying patient who may no longer be able to talk is among the more heroic acts we can perform. It is also the time when our own inclinations are to pull back to soften our own sense of loss. Be alert to the excellent reasons you begin to offer for not seeing the patient and then dismiss them. If you can be--and we all have limits--be present.

In the third example offered above, your patient is not the person who is dying. The person, however, is part of the immediate and significant circle who are involved with someone who is facing imminent death. The psychological process parallels that of the dying and the stages are very much the same. It is important to emphasize over and over again that although we have identified stages, it does not mean that everyone moves through all of them. They do not necessarily occur sequentially in some right order. Not everyone reaches acceptance. Not everyone bargains. And if anything can be used as a Rule of Thumb, it is that the dying and those who surround them are likely to move back and forth through any and all the stages throughout the process.

In particular, the therapist should be alert to one of the most powerful emotional issues that is likely to assert itself during this kind of treatment. Those who care for the dying are faced with an extraordinary sense of helplessness. As the reality of death takes on sharper focus, it becomes clearer that efforts to prolong life are simply not going to work. Nothing can be done to stop the inevitable. This is a danger point particularly for physicians who have exhausted the resources of scientific technology. The inclination is to pull back and to abandon the patient for whom nothing else can be done medically. Research has shown that patients near to death are often placed in rooms furthest from the nursing station, they wait longer when they push the call button, professional staff enter their rooms less frequently, and physician's visits become briefer. Medicine defines heroic attempts to save a person's life in terms of high technology interventions. If you have ever witnessed the kind of mobilization that hospital personnel undertake when a patient undergoes a cardiac arrest, you know something about heroic measures. From a psychological point of view, it seems that heroic measures may better be defined as an ability to stay with the patient when all other resources--except the presence of another human being--have been exhausted. It is at those moments when we face our own helplessness not as some abstract concept, but as a palpating pain and insecurity within ourselves. No one likes it and most of us live lives attempting to deny it by trying to exercise more and more control over everything. Death has a way of destroying the illusion of control and we are unlikely to be grateful for the seemingly destructive and ofttimes paralyzing lesson.

Helping your client to look at, feel, and integrate helplessness as a part of the human condition can be an enormously worthwhile therapeutic endeavor. In essence, it is what death can teach us about life. To be able to accept one's own limits, to endure one's own helplessness in certain life situations without having it diminish our sense of worth and self-esteem has the potential for making us better able to deal with all aspects of life. We have worth and value simply because we are. To learn that our value is not determined solely by what we do, what we produce, or the number of our accomplishments is psychologically freeing. As all therapists know, it is an issue we continually deal with in all forms of therapy regardless of the presenting complaint. Death simply plays out these issues in much bolder relief.

The last example deals with issues of unresolved bereavement and how it can manifest itself in a variety of symptoms later in life. Depending upon when in the developmental cycle the loss is experienced, the evolving personality will be affected in differing ways. For the child still dominated by magical thinking, the death of a parent may reinforce an exaggerated sense of the power of aggression. Wishing can actually make someone die leading the child to become fearful of his or her own aggressive wishes and making anger an absolutely taboo emotion. For the child emmeshed in competitive rivalry with a parent, the death of that parent may result in the unconscious stifling of assertiveness, competitiveness, and a desire to achieve. The death of a parent when a child is involved in the struggles associated with adolescence may thwart the normal development of autonomy and independence. It is certainly not unusual for a child to experience a great deal of guilt over the death of someone who is near and dear. Often a child blames him/herself for some action (usually a misdeed) that is interpreted as the cause for the death. Or, equally possible, the child feels that there is something that he or she could have done to prevent the death from happening. Either interpretation leaves enormous guilt associated with unaswered questions. If there is no avenue to express these concerns, doubts, and questions, they may move underground influencing and distorting the evolution of the structures of personality.

This is fertile ground for the development of later pathology. Because the adults surrounding the child are also experiencing their own profound reactions to the loss, it is very likely that they are emotionally unable to be as sensitive and responsive to the child's turmoil as they might be at other times. The stress of grief can impair even a highly effective family system. A conspiracy of silence which disallows the expression of feelings and questions can effectively drive the seeds of conflict underground. At some later time, when the child, now a young adult, attempts to form attachments beyond the boundaries of the family, symptoms may emerge requiring therapeutic intervention.

The impact of a death in a family should never be underestimated regardless of how it is presented by the client in treatment. The seemingly sealed over event may still be exercising a strong influence on the present personality organization. Separated by time and elaborate repressive barriers, the client may be totally unaware of how the death has impacted him or her and how it is now being played out in current functioning and relationships. Careful therapeutic work requires attention to and a willingness to explore this event in order to bring about a more complete resolution of the core, conflicted feelings.

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