A Therapy for the Griever

For thirteen years, I worked as a hospice chaplain, where grief was hardly an unexpected development. People were dying, families were losing someone they loved, and the suffering that followed was not evidence that something had gone terribly wrong with their mental health. Yet bereavement could become considerably more complicated than the circumstances of the death might suggest. A family might spend months preparing for the inevitable, say their goodbyes, and understand the medical condition with remarkable clarity, only to discover that nothing about their preparation had made the loss easier to live with. Another family might experience a sudden death and gradually find their way through the experience without the same enduring complications. It became difficult to explain these differences merely by considering the circumstances of the death. Within hospice and the broader field of thanatology, there has long been considerable resistance to pathologizing grief, while the mental health community has increasingly sought to distinguish ordinary bereavement from prolonged and debilitating forms of suffering. The recognition of prolonged grief disorder has intensified the debate over whether grief should be treated or supported. I have considerable sympathy for both positions, having spent much of my professional life within the practices that gave rise to them. To make an illness of ordinary mourning risks placing grievers under expectations of recovery that have little to do with their actual experience. But to insist that grief is natural and therefore requires no treatment can become another way of deciding what the griever needs before we have understood the person who is asking for help. The argument becomes particularly troublesome when we consider what diagnosis is being asked to accomplish. A diagnosis can describe the duration, intensity, and consequences of psychological suffering. It can establish the need for assessment, identify impairment, and help clinicians consider appropriate interventions. Within the arrangements of insurance reimbursement, however, the diagnosis must also help justify the necessity of treatment. The clinician identifies the symptoms, establishes measurable goals, and describes how treatment will address them. This is a reasonable expectation of a system responsible for determining which services it will cover. The difficulty emerges when the description begins to prescribe the work itself. The person cannot sleep, so treatment addresses sleep. They have withdrawn from ordinary activities, so treatment addresses their return to those activities. Their feelings have become overwhelming, so treatment seeks to regulate them. There is nothing inherently mistaken about any of this. Someone whose suffering has become disabling may benefit enormously from interventions that make ordinary life possible again. But what has been treated when the person begins sleeping, working, or feeling better? The question is not intended to diminish those accomplishments. It introduces the possibility that relief and understanding, while often related, are not necessarily the same thing. We may know something about what the person is suffering without yet knowing very much about how they have come to suffer in this particular way.

This difficulty becomes more apparent when we consider how many people might benefit from therapy without ever seeking it. A drinking problem may become the familiar way of getting through the evening. An eating disorder may be understood as a disciplined concern with food and appearance. Years of disappointing relationships may confirm the conviction that other people cannot be trusted. Sexual difficulties, chronic resentment, and even destructive patterns of aggression may become so familiar that the individual no longer considers whether life might be organized differently. None of this necessarily announces itself through an unbearable feeling. Indeed, some of the most consequential difficulties in a person's life may be accompanied by an extraordinary certainty that the problem belongs to someone else. This complicates our tendency to understand mental health through the presence or absence of distress. Painful feelings do not necessarily indicate psychological illness, any more than feeling reasonably comfortable establishes that someone has no need of psychotherapy. Then someone dies. Grief occupies an unusual place in our culture because bereavement provides a recognizable reason to ask for help. A person may be unwilling to seek treatment for drinking, a troubled marriage, or familiar patterns of dissatisfaction, but the death of a spouse, parent, or child may finally make the possibility of therapy seem reasonable. The loss becomes the occasion for a conversation that might have been needed long before the death occurred. Someone may enter treatment because they cannot stop crying after losing a parent and gradually begin speaking about a relationship to food and body image that began decades earlier. Another may seek help with insomnia following the death of a spouse and discover how much of their adult life has been organized around alcohol. A griever may arrive troubled by loneliness and begin recognizing familiar patterns of dependence, resentment, or sexual dissatisfaction that have accompanied several relationships. This does not mean that grief conceals a more important disorder waiting to be discovered, or that the therapist ought to be suspicious of the reason someone has come. The loss may be devastating in its own right. But the person who enters treatment has a mind that existed long before the loss, already organized through relationships, identifications, defenses, wishes, and conflicts. The death enters this organization, disturbing some of its arrangements while making others increasingly necessary. The person may come hoping to understand why they cannot stop grieving and discover that their suffering has become involved in questions they had never previously considered. The circumstances of the death remain important, though they cannot tell us how the individual has come to contain the loss. The description of symptoms may justify treatment, while the experience of treatment begins opening onto something that the initial description could not have anticipated.

Alan Wolfelt's Understanding Your Grief has been enormously influential in bereavement care, particularly through its insistence that grief is not an illness requiring correction. His philosophy of companioning offers a different understanding of what it means to help someone who is grieving. Rather than approaching the bereaved as patients whose suffering must be relieved, Wolfelt emphasizes presence, mourning, reconciliation, and the importance of allowing the individual to encounter the loss without being hurried toward an expected resolution. I found this particularly helpful during my years in hospice, when the temptation to say something useful could become an obstacle to remaining present with someone whose pain could not simply be taken away. Robert Neimeyer's work on meaning reconstruction approaches the experience from another direction. A loss may disturb the assumptions, stories, and relationships through which a person has come to understand their life. The griever may need more than companionship because something about the world they inhabited has become impossible to recognize. Neimeyer's therapeutic work provides opportunities for the individual to encounter these disruptions through narrative, memory, and the reconstruction of meaning. The differences between these approaches are substantial, yet both have something important to preserve. Companioning recognizes that the presence of suffering does not necessarily establish a problem requiring correction. Meaning reconstruction recognizes that suffering may involve more than an emotion requiring expression or comfort. The difficulty begins when either understanding becomes sufficiently familiar that we already know what the griever needs. The companion may become committed to the idea that what the person requires is presence rather than treatment, while the therapist may become invested in helping the person reconstruct meaning when meaning itself is not what has become troublesome. Wolfelt's six needs of mourning and Neimeyer's therapeutic practices can become useful ways of recognizing what is happening, though their usefulness does not settle what these activities mean for the particular individual. A person may express grief openly while remaining unable to recognize the resentment that was inseparable from their love. Another may reconstruct an elaborate account of a relationship while preserving the very image of themselves that has become involved in their suffering. It is entirely possible to remember someone accurately while misunderstanding something about one's own place in the relationship. We encounter this difficulty in the familiar expression that grief is the other side of love. The sentiment is comforting, though it becomes less convincing when we consider what intimacy actually involves. Grief is not synonymous with sadness, and love has never been especially successful at keeping hatred outside the relationship. A spouse may deeply miss the person whose demands had become unbearable. A daughter may discover relief after the death of a parent whose approval she spent decades seeking. Someone may grieve a relationship that never became what they had hoped it would be. Freud's account of ambivalence makes room for love and hatred as inextricable features of an intimate bond, while Donnel Stern's understanding of unformulated experience helps us consider how something may have been lived without becoming available for thought. A person can know that someone has died while remaining unable to encounter the significance of what has been lost. The experience may be spoken about endlessly without its most troubling associations becoming recognizable. Here the distinction between treatment and support begins to develop another meaning. Someone may need the companionship that allows an experience to be borne in the presence of another, while the encounter may also make possible the discovery of something about the experience that had never been available before. The difference cannot be established simply by deciding whether grief itself requires treatment. It concerns what becomes possible within the relationship, including what neither person could have known at its beginning.

The difficulty for the griever is that therapy can become another place where someone is eager to explain what has happened. We may spend considerable time understanding the loss, identifying its emotional consequences, and helping the person recognize experiences that are common to mourning, while remaining less curious about how the griever has arrived at their own understanding of what happened. Their account of the loss has already been organized through a mind with a history, a character, and familiar ways of making sense of relationships. To become interested in that mind requires the analytic listener to sit a little further back, taking up the position of a learner and listener rather than a teacher of grief stages, familiar emotions, techniques for expression, or even the comforting words that have helped so many others. There is nothing particularly wrong with any of these offerings. The difficulty comes when the analytic listener becomes so occupied with being helpful that the griever has little opportunity to discover something about themselves that neither person had anticipated. Some grievers may find self-reflection difficult, especially when the loss has disturbed their ordinary capacity to think, work, sleep, or feel secure. Before there can be much consideration of what the loss means, the person may need help finding some continuity in a life that no longer feels recognizable. This is where support becomes particularly important. Support may involve the presence of someone who can bear witness to their suffering, assistance with practical responsibilities, or help reconnecting with family, friends, and community resources upon whom the griever can depend. It may involve guidance without requiring that the person accept an explanation of their experience. The griever may need someone to help them hold together the ordinary arrangements of living until they can begin doing so themselves. There is already something therapeutic in this kind of support, even when no formal psychotherapy takes place. It can restore a measure of safety, security, and constancy without requiring that the griever make some further discovery about themselves. Yet the restoration of these supports does not necessarily resolve the suffering, and the person may continue to struggle even when the practical demands of bereavement have become manageable. This is where treatment can introduce another possibility. The question begins to concern not only what has happened to the person, but how the person has come to understand what happened and what the loss has done to their sense of themselves. Even severe or traumatic loss does not produce the same consequences for everyone. Some people experience profound disruption, while others may report few recognizable symptoms or have little conscious association between an event and their present difficulties. We cannot assume that an absence of symptoms conceals a repressed trauma any more than we can assume that the presence of symptoms explains what the loss has meant. It takes time to discover how a person thinks about their own life and what the event has done to their sense of themselves. A sense of oneself is a peculiar thing, involving thoughts and feelings that are seldom so easily separated. One may know who one is without having given it much thought, because the relationships and familiar arrangements of living have provided enough continuity for that knowledge to remain relatively undisturbed. Support can help sustain this continuity, while treatment may begin to explore the conditions through which it has been established and what happens when those conditions can no longer be maintained. Freud approaches something of this difficulty in Mourning and Melancholia, where he distinguishes the world that has become impoverished through mourning from the ego that has become impoverished in melancholia. The griever may begin to speak as though the loss has emptied something within themselves. We can almost hear the reproach in such a statement. It may not be that there is nothing left within the person, but that there is nothing good left. Something of the goodness they recognized in themselves had been bound to the person they loved, to the recognition they received, or to the image of themselves that became possible within the relationship. The loss now troubles their ability to recognize that goodness as their own. What had been found in the other, and reflected back as something belonging to the self, no longer seems available. The person may continue describing the absence of someone they loved while gradually discovering that they have also lost something of the person they believed themselves to be. This is where the work of therapy begins to take on another significance. The griever has come because someone is missing, but through their associations they may begin to discover how much of themselves had been held within the relationship, including what they have come to believe is no longer there.