A paper on grief, loss and therapy. Grief is presented as a spiritual opportunity - a rare moment of truth when significant changes are possible. Two levels of adjustment to loss are defined, specific and universal, each requiring or imparting a different kind of wisdom.
INTRODUCTION
There is a sense in which all the problems which are presented to the therapist are problems in coping with actual or anticipated loss since all psychological problems are to do with coping with the way our lives change or fail to change. We suffer when we are separated from the things we are attached to. Some of these things are concrete, some abstract. They include possessions, relationships, circumstances and states of mind. In this sense it is possible to conceptualize all human suffering as related to grief. Grief is what happens when our world is severed. Healing is what happens when it becomes whole. The on-going dialectic between these processes of severance and closure creates all the agony and ecstacy of our existence. Clearly whether our world appears to us as severed or whole is a function of both external and noetic (=in the mind) factors. Perception plays a major part. Hence we cannot really understand grief or its healing without appreciating the phenomenology of loss.
All suffering is loss in some sense. Sometimes this is overtly and immediately the case, as when a client is grieving for a deceased loved one. This is the prototypical situation which we must look into most deeply. Sometimes loss comes to light over time, as when one discovers that what impedes a person in coming to terms with life is a reservoir of unshed tears for a loss experienced many years before. Sometimes we are confronting the loss of a person; sometimes a change of circumstance; sometimes a change within our own personality. Sometimes it is the loss of status or purpose in life. Sometimes it is the loss of an ideal or the loss of innocence which a person has difficulty accepting. Sometimes even changes which are generally classified as good fortune can be a cause of difficulty.
Coping with change is usually stressful. Up to a point, this stress is pleasing. We like to be challenged. Beyond that point, stress becomes distress. We have difficulty coping with more than a certain degree of change and some changes are less welcome than others. When change becomes too hectic or threatening, we may close down. Then we devise strategies for warding life off, the so-called "defense mechanisms". In practice, most of us, most of the time, are warding off a good deal of what is really happening. That which in phenomenology is called "the natural attitude" consists to a large degree of the conventions a society has devised for helping its members to avoid the day to day discomforts which a more raw "confrontation with reality" would involve.
All therapists, therefore, need to know a good deal about the processes involved in coping with change: the physiology, as it were, of the human response to loss and stress. In this paper, however, we would like to offer a more general perspective on the subject. There has been a good deal written about grief and loss and probably even more about stress. We will refer to this material but there is little point in reiterating what is well known and readily accessible. The aim here, rather, will be, on the one hand to consider the fundamental meaning of loss and, on the other to explore some of the implications this analysis has for the actual practice of therapy.
DENIAL
The central argument of this paper is that grief, the pain of loss, is a consequence of the way we habitually perceive our world; a way which, although it has practical advantages and brings us some comforts, does so at the cost of denying some of the most important characteristics of existence. It will be argued that the very structure of the perceptual process, as it functions for virtually everyone, involves a large degree of denial and that grief, far from being a disease or abnormality in anything but a statistical sense, is, in fact, the experience of a rare moment of truth which penetrates to the core of our being as few other events do. Grief, then, is here portrayed as a spiritual opportunity.
Making such an assertion seems risky: "But who shall speak the unspeakable? Who may break the taboo and still go unharmed?" (Gersie 1992, p.15). Grief and loss is always a subject around which there grow up taboos and denials. It remains unspeakable not just because it is so painful in itself, but because to speak of it threatens the false security of everyone else. We live as though it is not going to happen. When it happens to somebody else, we would rather not know. This is the common mentality. The function of therapy may often be simply to hear what nobody else is willing to listen to. To really be able to do so the therapist needs to be rooted in a deep "inner" security, based upon acceptance rather than denial.
It seems important, at this point, to enter a word of caution against judgementalism. To examine the subject of grief we have to look at the issue of avoidance and denial. The fact that people avoid the subject and deny many aspects of reality is not, however, really to be wondered at. Grief is terrible. It is only human that people defend themselves against it. The client who is struggling with such feelings may be very ambivalent about going into them. The relatives may be quite understandably cautious about talking about the subject. The therapist too may feel rattled from time to time. It may be as much a part of the therapist's role to understand deeply, patiently and compassionately why people are not facing the subject as it is to help them to do so.
CHANGE
When I put sticks on the fire, they burn and disappear. In fact, however, although they have disappeared, they have not ceased to exist. They now exist as ash and smoke and heat. I take the ash out and put it on the garden. After a few days it has gone. Yet, again, the ash has not really ceased. It has now become part of the soil. Should I lament the sticks or celebrate the enriching of the garden? Perhaps, one day, a tree will grow in this soil and the ash will have become sticks once again. Or, more likely, it will follow some other path. All will depend upon the conditions which prevail. I cannot know where the ashes of my life will be blown.
In this universe nothing is ever lost but everything changes. Loss is really transformation. Things seem to disappear, like the sticks in the fire, but "sticks" is actually just a concept in our minds for a particular stage in the evolution of earth becoming plant becoming branches becoming firewood becoming ash becoming earth. We designate a particular stage in this on-going process "sticks" for our own convenience. Because of this there arises the illusion of a world full of "things" when what really confronts us is a world made up of processes - flow. It is for this reason that virtually all funerary rite in different cultures include references to renewal and growth (Bloch & Parry 1982).
We may say, then, that really all we ever lose are our illusions. This, however, should not be considered a reproach since these illusions are deeply embedded in the way our perception of the world occurs. In this respect, ontology (how things are) and phenomenology (how we perceive them) diverge. Loosening the hold which the "illusion" of loss has upon us is not easy and, for most of us, is never fully achieved. It is open to us to become relatively wiser in this respect and a few may achieve profound insights into the nature of existence by contemplating the universality of change as it manifests in all the seemingly concrete things around us. For the most part, we live in a world of seemingly enduring objects and spaces even though the world itself is not like that from its own side. Our world of objects (including people) gives rise to the experience of gains and losses, pleasures and griefs. Seeing the world in this way, although it is a distortion, has a number of practical advantages for us. On the other hand, our involuntary response to loss can be the most acute suffering we ever experience.
It is a basic characteristic of perception that it is a process whereby the mind attempts to extract a sense of stability and permanence from the flux of impressions which bombard our senses. Marris (1974) calls this "the conservative impulse": "the construction of meaningful perceptions is cumulative" and "the impulses of conservatism... are all means to defend our ability to make sense of our world" (p.11).
We tend to assume that we see what is there, but, in fact, perception is more a matter of constructing meanings which have some degree of constancy about them out of a flux of incomplete impressions. Even if the object we are looking at changes its colour totally as the evening light changes, we still tend to think we see it the same as before. We try to hold our vision of our world steady. Perception itself resists change. When we can no longer resist the evidence of change we experience a shock.
The experience of grief is acute because we experience loss as an event, something which happens relatively abruptly, and the more abrupt it is the more we seem to suffer. Grieving is lessened when a loss is anticipated because in such a case perception has diverged less from reality. In all cases, change is continuous and we cannot really ever count on things staying the same. This, however, is exactly what we do do. Grief is the result. Things are not what they seem.
We walk in the countryside. We admire the trees. They are covered in green leaves which offer a distinctive outline. The tree seems solid enough and it has a distinctive overall shape, characteristic of the particular kind of tree, yet modified by its particular circumstances. If we take the same walk a number of times the tree becomes familiar to us. We recognise it. It becomes one of the comfortingly familiar features of our world.
If we stop and look more closely, of course, we immediately see that the outline of the tree is not actually at all how we generally envisage it. Looking closer, we see that most of what makes up the "boundary" of what seems like a "solid mass" from a distance is actually empty space, gaps between leaves. And even those leaves are moving with the breeze. The notion of solidity is an illusion.
We also realise that there is continuous change going on within the leaves and branches themselves. Our senses are not equipped to see this directly, but we know that it is so. Sap moves about. Cells grow and decay. There is constant movement of substances which themselves are being repeatedly transformed. We might say that new bits of tree are constantly being born and other bits are dying but even this implies discrete events of change whereas, in reality, there is a seamless process. The tree is a continuous flow of change. The actual material substances that make up the tree at any one time were, for the most part, not part of the tree in the past and will leave it again soon. We think of the tree as a material object but virtually all the material of which it is composed is just passing through.
This continuous change is not, however, what we tend to perceive. We tend, rather, to perceive the tree as a solid, enduring feature of the landscape. When we come for our walk in the autumn, we say: "Oh look, the leaves have all turned brown." But we did not see them turning. The change seems to us as a sudden one. The leaves fall to the ground. We are impressed by the actual moment when a stalk finally breaks and the leaf begins its descent, though even this is something we rarely actually witness. The moments immediately before, however, were just as much a part of the process of dying. It would always be arbitrary to say at what point a particular leaf actually did die. Its death was inherent in its original coming into being, in all its growth and change throughout the summer. Nor does death end the process of transformation. The leaf is now on its way to returning to the earth to feed other plants.
So change is happening all the time. This is true not just of the tree but of everything. It is true even of the mountain upon which the tree stands and of the planet itself. It is true of us, ourselves. It is true of all those who live with us. They are all changing, which is to say "dying", all the time. If you are reading this in a room with other people, pause a moment and reflect upon the fact that the person near you is dying now. We do not know when this process of dying will become manifest as what we call a corpse, but we do know that it is already underway. We do not usually perceive people or things this way, of course. We only perceive their death at a particular point when the conditions which support vital functions cease to operate, or when we are told that this is going to happen soon. Then we grieve.
How well we grieve depends upon how we have perceived the person or object prior to the loss and upon how we regard the world from which they are now seemingly absent. In fact, we do not really grieve the loss of an individual person or object so much as the loss of the whole world of things which existed for us when they were in it, the world as our mind constructed it. It is our frame of reference which has been ruptured. The psychological adjustment which grief involves, if all goes well, moves us toward acceptance of a "new" world, a world from which the lost one is absent. Presence and absence, however, are largely constructions. The point at which a person "dies" for another may be only loosely related to the time of clinical death. Many clients do not actually say goodbye to the deceased until many years later. Some, on the other hand, have mentally written the person off long before they actually die.
Worden, in an excellent manual on grief counselling and therapy, writes, therefore, of "the four tasks of mourning" which he designates as: (1) To accept the reality of the loss; (2) To experience the pain of grief; (3) To adjust to an environment in which the deceased is missing; and (4) To withdraw emotional energy and reinvest it in another relationship (Worden 1982). The approach advocated by Worden is very practical, showing how a therapist may help a person let go of the past and eventually reinvest in the future. We would like to suggest in addition, however, that there is something more at stake.
Grief may not actually be something that one should "get over". Grief may actually be a door which opens onto a reality which can hardly otherwise be reached. Rather than being a disruptive interlude after which normal service can be resumed, mourning may also move us toward an acceptance of the existential reality of change: a completely different way of viewing life. "You never get over it," a client said to me: you become a different person. A "healthy" encounter with loss may make us more accepting of the world as it is, more able to flow with it. An "unhealthy" one may make us become more rigid, more determined to hang onto whatever constancies seem to remain. This latter state is "unhealthy" simply in the fact that it actually renders us even more vulnerable in the future. It is commonly the case that each loss a person experiences exacerbates the pain of other losses. Grief becomes cumulative. This does not have to be so, however. The manner of the therapist's contact with the client may sometimes be enough to make the difference between these two different kinds of outcome.
We can see then that the therapy of grief can occur at a number of different levels. There is a global level and a specific level. The global level has to do with appreciating the insight which loss thrusts upon us: a reexamination of the way we set ourselves up to suffer by failing to appreciate the facts of our existential situation in a deep enough way. The specific level is concerned with how we do or do not heal and integrate particular wounds and the vicissitudes which the process of grief may take. Western psychology has, for the most part, concerned itself with the latter, eastern psychology with the former. The two levels cannot, however, be readily separated since the way we respond to a particular loss will be substantially determined by our outlook on life as a whole and our experience of particular losses will render us more or less wise in our regard for the totality of things. Sufferings can make or break us.
If we were able to perceive the process of change more completely, we would be less afflicted by specific griefs since the points of loss would no longer seem discrete and acute. On the other hand we would experience a more generalized grief, a "great grief", since we would become aware of how every loss, not just those close to us, does affect us at some level. We would be connected. We would deeply understand the words of the poet Donne who bid us not send to know for whom the bell tolls since, in every case, it tolls for us.
There is a famous story in which a sage is asked to give a definition of happiness in the form of an inscription and the sage writes: "Grand parents die; parents die; children die." When someone asks how this catalogue of losses can be a definition of happiness, the sage explains that if things happen in this natural order, this is best. If children die before their parents we see it as unnatural and feel it as a great shock but if people live to a good age and die peacefully, there is much greater acceptance.
Similarly, when a person has been ill for a long time and then dies, the relatives may not grieve as much. When asked about this they are likely to say: "I think I did the grieving before they died," or: "Well, it was natural." The adjustment will have been more gradual, the acceptance greater.
NON-SEPARATENESS
To summarize the argument so far: change is continuous but is perceived by us as a series of abrupt changes. The more abrupt these transformations seem, the more stressful the adjustment we have to make. The role of therapy may be both that of helping a person to integrate the experience of a particular loss and also that of helping the person profit from the experience by moving toward a more universal acceptance, an enlarged eigenwelt, rather than becoming further handicapped by closing down into a narrower vision.
These same facts can be also be usefully restated a different way. This way is in terms of connectedness. We have already explored one divergence between how things are and how we tend to perceive them. Now we need to examine another.
In reality, nothing in this world exists in isolation. This is true at both the material and the psychological level. There is constant inter-change between ourselves and our "environment", ourselves and those we love or hate, ourselves and our society, ourselves and the material world. In fact, this is so much the case that the term "environment" is somewhat inaccurate. It implies that there are two things, us on the one hand and our surroundings on the other. In reality, we are part of our surroundings. As we perceive it, however, we tend to see ourselves as discrete and distinct. We have a lot of difficulty really perceiving the total extent to which "we" are simply a function of "that" and "that" is a function of "us".
When I lift my arm, I have a sense that my body is all of a piece. The arm rises because my shoulder muscles contract, and the muscles contract because of an intention that arose in my brain. The field of this activity, however, really extends well beyond my body. The intention arose in my brain, perhaps, because my eyes saw the cup of tea arrive. Is the cup of tea, then, part of me too? I think not. However, soon I will drink the tea. At what point will I start to consider that the tea is now part of me? Is it me while it passes down my throat? While it lies in my stomach, mingling with other juices secreted by my glands? When?
Really there is no point at which I stop and the environment begins. The same is true psychologically. If we talk together, when is a thought or piece of information or image yours and when is it mine? These impulses pass through us both like waves passing through the sea. If I am inclined to disagree with you and you say "yes", I will think "no". But was that really me? If you had said "no", I might have thought "yes". Which of us really thought "my" thought? Are we really separate?
Now, grief is about separation. The more separate we feel, the more grief there will be. The more that the feeling of separation becomes established in us, the more vulnerable to the pain of grief we become. There is ample evidence that losses early in life predispose us to later depression (Brown & Harris 1978). Similarly, it is those who feel most psychologically isolated that are most at risk of suicide. Ostracism is one of the most powerful punishments. Losses impinge upon us so strongly because they reinforce our sense of separation and damage our perception of our involvement in existence.
This is one of the reasons why people who are grieving often gain solace from walking in the country. Walking slowly and peacefully, allowing a sense of communion with one's surroundings to grow, is wonderfully restorative. It enables a person to regain an experience of connection with the elements. Even though the human world may seem barren after a bereavement, the wind and the flowers, the rivers and the clouds, may still speak to us. Perhaps grief counselling should be conducted while walking gently in the open air. Similarly, great comfort can sometimes be obtained by those who are grieving from contact with animals. The pet makes few demands, yet is there close at hand, appreciative of the connection made by rubbing against one's leg, by being fed or stroked.
The importance in the healing process of restoring the sense of connection can hardly be over stated. Often enough, however, people attempt to avoid the inevitable pain of grief, actual or anticipated, by separating themselves further. It is not uncommon, for instance, to talk to clients who have themselves ended satisfying relationships prematurely because they could not bear the thought that the relationship might one day end. We may even have done something similar ourselves. It can seem better to "get it over with" now, even though, in extreme cases, this may have meant giving up the only good thing in the person's life.
Not infrequently, the prime task for the therapist is simply to be there in an open way, a way which permits the client to weave themselves back into a relationship with another living being, a relationship which is loving and acceptant yet not clinging or restrictive. The grief process can be a doorway to a new freedom. It is probably much more common for the therapist to damage the therapy process by doing too much than by doing too little, provided that this acceptant climate can be established. Therapists can easily spoil their work by falling prey to impatience. We like to feel that we are doing something when, often enough, the most important thing to do is simply to be fully acceptant and appreciative of things as they are: nature will do the rest.
It is a fallacy to think that we can avoid grief by uninvolvement. By making our world narrower and narrower we only make our grief more all pervading. A good deal of confusion is caused in this respect by some of the writing about "detachment" in books of spiritual guidance. The enlightened person is not one who has become small minded and uninvolved in life but rather one who has become so large hearted and involved with every moment and drop of life that they cannot be capsized any more by ephemeral events (Suzuki 1970).
THE UNAVOIDABILITY OF SUFFERING
While we are looking at the ways in which our perception of the world affects our ability to cope with loss, we need to examine our attitude to suffering in general. All of us are going to suffer illnesses and injuries, changes and losses in our lives. There is hardly ever a time when the body is not subject to some degree of discomfort. As I sit here writing, if I stop to think about it, I am aware of minor discomforts in several parts of my body. This is normal.
It is in the nature of things that they "go wrong" (Brazier 1990). The implication of the term "go wrong", however, is that such things should not happen. This is the third important area of common self-deception which complicates our response to loss and change. There is, in our mentality, a strongly established notion that things should not go wrong, that suffering should not occur. Yet, in reality, things go wrong all the time and suffering is, in varying degrees, encountered everywhere.
In grief, in particular, we suffer greatly enough simply from the natural process even when all goes as it should. For many, however, the suffering is needlessly exascerbated by the fact that it brings with it a reproach, a sense that something is wrong. One of the most useful things which a therapist does with a person who is grieving is to convey, by their manner primarily, that the pain of grief is perfectly natural. If one has been attached to something or someone and then that thing or person is lost, one goes through a process of grief. This grief is not something which needs to be hidden or rejected. It is the only way back to stability and peace of mind. Many people, however, attempt to suppress the grief, regarding it as one would a disease, taking drugs to suppress it or simply keeping themselves endlessly occupied so that there is no room for feelings.
Paradoxically, the way to freedom from the pain of grief lies in fully accepting it and going through it, accepting each new stage of the process - shock, rage, sadness, regret, withdrawl, re-engagement - as it comes. It can seem as though there is a certain quantity of pain which a person simply has to pass through. If one does not do the grieving at the time, one may simply have to do it later. It is not uncommon for people to refuse to enter the grieving process at the time and, as a consequence, to become, in some respects, frozen up inside. Such a person may come into therapy many years later suffering from something which seems quite unrelated and yet find, as they explore the subject, that it is the hidden grief which lies at the root of their problems and that even after this great delay of time, the grieving process is still waiting to start.
Sometimes delays of this kind have occurred by dint of circumstance. A young person who is the eldest child of a family in which a parent dies, may feel constrained to get on and look after younger brothers and sisters and give no time to their own grief over the loss. Later, this same person may reach a more secure stage of life and then find a need for therapy. Coming to the therapist, perhaps decades after the loss, this person may say, "I cannot understand what is happening to me. I had a difficult time as a child because my mother died when I was thirteen but I coped with all that really well. Now I am adult and have a loving spouse and a secure income and suddenly I find I am crying for no reason and feeling unable to cope." We can understand this as the grief surfacing now that it is safe enough for it to do so.
Suffering is an inevitable part of life. Life is full of suffering, yet it is also full of wonders. If we suppress the one, we generally suppress the other at the same time. Suppressing realistic pain only makes matters worse, or, at least, puts off the inevitable. Sometimes it is the only practical course for a person and we should not blame a person for not facing their pain, but it may well be our task to help them find a way to do so and, in this, there has to come some acceptance that such suffering is not "wrong".
To achieve the kind of large heartedness which enables a person to be a source of strength to another when that other is passing through a period of grief requires that we do much work upon ourselves and upon our way of perceiving our world: "As our pain for the world is rooted in our interconnectedness with all life, so surely is our power" (Macy 1983, p.30).
THE DEATH OF A PERSON
Let us here make a short resume of the points made so far as they apply to the death of a person. We tend to think that we are, somehow, a completely separate category from the rest of the universe, but, in fact, just the same laws apply to us as to everything else.
Just as the sticks are consumed in the fire, so my life is gradually used up. Just as the sticks turn into ash and smoke and heat, so my life gradually turns into other things. A human life has many aspects: body, feelings, perceptions, all the many factors which make up a personality, consciousness itself.
The body changes all the time. As we get older we become progressively more aware of all our "little deaths" - the knee that no longer bends as it did, the hip that gives pain in certain positions, the teeth becoming fewer in number, the thining hair. These things embarrass us because we do not really accept that we are part of a process of change; that our being is a function of many factors completely beyond our control; that suffering and decay are an inevitable part of existence.
Not only the body is already dying: as we grow older our mental lives are also consumed. We give love to our children and they grow up and leave. We still love them but they no longer need us in the same way. We put our energy into other things, the projects of our lives. In time, these too will be out of fashion, will have passed. Our thoughts and feelings and inspiration have not ceased to exist. They have simply slipped out of our grasp, passed into the minds and hearts of others and are functioning elsewhere. Bit by bit we give our lives away. Eventually we die.
GRIEF AS A RETURN TO REALITY
The analysis so far suggests that, in one sense, we grieve because we have, over a period of time, become more and more detached from the existential reality of our situation. We live without awareness of the impermanence, the radical inter-dependence, and the inherence of decay and suffering in our situation. We live in a "fool's paradise" which gradually edges nearer and nearer to the time when its fundamental emptiness will, all of a sudden, become apparent.
Grief is an attempt to return to reality. One client of mine, for whom an important bereavement had been a pivotal point of her life, said to me that in the time immediately after the loss: "I was nose to nose with reality and because I was, I was able to see the reality of other situations too." The time of loss is, if we are willing to look, a time of enlightenment. At such a time we are forced, against all our habitual tendencies to the contrary, to perceive reality in a more naked fashion. This can often lead people to spiritual insights. The language of poetry and spirituality may be the only language which, at such times, seems anywhere near adequate to express what is going on and what, at such a time, one knows with a certainty which eludes us at other times.
Looking back upon a important loss, one client recently wrote:
- Death and what does it mean to me? I never knew and never had cause to wonder until S. died, other than never being afraid of death myself. On the day S. died it would be easy to say it was the worst day of my life, but I actually did not feel a great deal: I was too shocked. It was as if all my worse nightmares were happening in front of me: I couldn't take it in. I was watching from another place. I felt very separated from people as if what had happened had separated me from normal life. People's reactions to me were generally of horror and inability to talk to me. I didn't know then that I was about to experience the worst pain I had ever known and even now I can remember how bad it was. I never told anyone. Close friends found it embarassing, I think, and a lot of people had the attitude that I should "keep busy", that "time would heal", and "I was young enough to start again". I tended to listen and say very little as I knew even then that it was untrue. I found it very strange how clearly I could understand what it meant when someone you love dies, and how much people who should perhaps have had more sense were talking rubbish. I realised quite early that I had a choice: I could either accept S's death and so endure the pain, or I could attempt to run away from it and spend the rest of my life doing just that and probably end up quite ill and taking drugs. I never did tell anyone involved what was happening. However, what I did not appreciate at the time was just how long I would be enduring the agony and pain. It was two years before I felt any better and since then it has been a long slow process of learning to live with S's death and learning what death means to me. The positive side of this story is one that I find difficult to talk about, almost as if there should not be one: would people be shocked if I said as much? I think a lot of people would find it harder to accept than me being ill. By accepting S's death, or at least always trying to, I found I somehow had the strength to do it and it became a point of growth. I was given insights into life that I would otherwise not have had: that life is eternal and that we never cease to exist. This is not something I had ever thought of, despite my Catholic upbringing. But at S's funeral I was acutely aware that not only was S. not there but that he was somewhere else. Not something many people will listen to. Rather they would call me crazy.
The obstacles to profiting from the experience of loss are often embedded in attitudes which give no place for a spiritual dimension to life and no vocabulary for its expression. Yet grief is a profound experience which can lead a person to a completely new level of understanding and compassion: "Perhaps it is only those who understand just how fragile life is who know how precious it is" (Sogyal 1992, p.23)
GRIEF THERAPY
The therapy of grief occurs largely at an unconscious level. Grief is such a primitive feeling that it is touched very little by rational discussion, though caring dialogue may be an important factor in establishing the therapeutic bond with the client which is the basic medium through which the healing takes place.
The loss which concerns us most acutely is commonly the death of a person near to us. This is when we feel grief most painfully. The waves of feeling seem completely out of our control and flow through us, wracking our physical frame with agonies, sometimes filling us with tears or wailing, sometimes bringing images of the lost loved one before our eyes. Yet amid this there are interludes of peace and acceptance. Then the pain starts all over again and we go through another cycle of torment. When we encounter a person in the acute phase of grief, we too will be infected by their pain. Human beings resonnate with one another. In effect, we take a little of the other person's pain upon ourselves. The extent to which we can open ourselves to the other and remain whole is a measure of the extent to which we can help.
The actual medium through which therapy takes place can be very varied. Arts media often permit expression where words fail. Sometimes a person has distanced themselves from the reality of the loss, in which case enactment, perhaps including a death bed scene, may bring the reality back into view in a powerful way. Sometimes the problem is one of under-distancing rather than detachment, in which case it may be important to use media or methods which assist containment and control (Beech 1993; Leijssen 1993).
The following case study will help to clarify this process.
JEAN
When Jean arrived for her first session she looked composed, but sat on the edge of her chair as if a little anxious. She was smartly dressed, and told me she had come straight from work. She ran her own business. Jean told me that she had come because she was having difficulty getting over the death of her brother, Tony, which had occurred two months earlier. She found herself sleeping badly and unable to concentrate properly on her work.
I asked Jean to tell me more about her brother's death. It seemed that he had died suddenly from a heart attack. The day that he had died, his wife, Sarah had phoned Jean to say that he had been taken into hospital with chest pains. Jean was concerned, but had a busy day at work, so did not visit him. She intended to go the following day, but that night Sarah phoned again to tell her that he had died. Jean rushed round straight away to be with Sarah and the three children. She became very involved in helping with arrangements for the funeral. At one point Sarah had asked her if she thought the children should go.
As she told me this, Jean's face, which until now had been remarkably unemotional, became reddened "'Of course they should!' I told her, 'Children should always be allowed to go to funerals!'"
I was quite taken aback by the sudden force in Jean's voice, and commented on this. Tears came into her eyes.
"I really believe children should be involved when there's been a death." She said.
I wondered if this had personal meaning for her and shared these thoughts. Jean looked as if she were about to burst into sobbing, but then regained her controlled look. She told me that when she was twelve her father had died of a heart attack. She had been staying with her grandmother at the time, whilst Tony, who was eight, and their younger sister were at home. Tony and the sister suddenly arrived at their grandmother's house, where they were to stay for a couple of weeks. It was from them that Jean learned about her father's death. When she asked her grandmother what was happening, she was told not to worry, because she would know soon enough.
After their return home, things were very different from how they had been in the past. Her father's death was not talked about and she was never given any indication of what had become of him. Later, as an adult, she discovered that he had been cremated, but she had no idea what had become of his ashes. Her mother was suddenly very weepy, and seemed unable to cope with even the simplest things. Often she would take to her bed, telling Jean that she was ill. Jean was a capable girl and willingly took on many of the jobs her mother had done previously. She would feed the two younger children and make sure that they were clean and tidy for school. She cleaned and shopped for the family, as well as doing her own school work. This pattern continued throughout her teens.
Everyone remarked on how cheerful and able she was, but Jean was not always happy. She would worry about her mother's health, and wonder if her mother too was going to die. These thoughts never lasted for long, however, because Jean would always push them aside and throw herself back into her work.
When she was sixteen, Jean's grandmother died. Jean wondered if she could go to the funeral, but her mother, who was herself inconsolably upset, told her she must look after the younger ones, because, in any case, funerals were not places for young people. Jean accepted this, but began to have worries about her own death. Looking back, Jean realised that her mother must have been mentally ill for many years after her father's death, but at the time she was constantly afraid that her mother's retreats to bed were a sign of serious physical ill health. In fact her mother died ten years later from cancer, after several years of illness. Jean, now married, returned home daily to nurse her.
Jean recounted her story with little overt emotion. I was aware that her eyes would fill with tears at some points in the story, but she would always fight them back and carry on. Sometimes I would repeat a particularly poignant phrase back to her, and then Jean would cry briefly, as if hearing it for the first time. At these moments I was almost unbearably touched by the depth of feeling, but always Jean would regain control and carry on.
At the end of the session Jean left after arranging a second session. I commented on how much grief she had shared with me.
The second week Jean returned looking less composed and told me she had been feeling quite ambivalent about returning for counselling. She had been feeling more upset during the week, and had found herself crying uncontrollably on two occasions. She complained that for the first time in her life she had not been able to leave it all behind. We spent most of the session talking about her fear of being overwhelmed by feelings. She realised that she had grown up thinking that she should not show her feelings, because if she did, her mother became more distressed. She realised that she had always prided herself on being the strong member of the family, the one who coped, but that this had been at the cost of burying her feelings.
In subsequent sessions, Jean talked about the events around the time of her father's death, and the difficult years that followed. She returned to the same events many times, but each time seemed to allow herself to experience more feelings.
After several months the therapy seemed to reach its culmination in which Jean enacted a scene in which she said goodbye to her father and mother. A continuing theme throughout the therapy had been the lack of any place which she could associate with her father. I asked her where she would like to place him and she suggested a garden. We spent some time in building together a mental image of the garden within the therapy room, laying out flower beds, lawns and trees. Jean saw a beautiful silver birch beside the window, and decided that its shade would provide a spot where her parents could be happy together. We imagined her laying the bodies in the soft earth.
"Are there things which you want to say to your parents before we say goodbye?" I asked.
"I just hope they can rest now.... and I want them to know that I love them both" said Jean
"Can you say that to them?"
"I want you to be happy now.. to be at peace.... and I love you Daddy... I love you Mum..."
Jean's eyes filled with tears. She looked at me.
"Are you ready to say goodbye?" I asked
"Yes.. I think so," Jean bent over and touched the ground where we had placed her father. "Goodbye Daddy.." then touching the ground next to this, "Goodbye Mum."
She stood up, her face full of emotion. "They can lie at peace now," she said, moving away, back to her chair at the other side of the room.
"And you can leave them together, knowing that," I said.
Jean had two further sessions after the one in which she said goodbye to her parents. Although she was still very emotional, there seemed something more settled in her manner. She talked about her husband and children, and her plans for developing her business.
I wondered if the therapy was nearing its end, and asked Jean if she felt this. Jean said she had been wondering about finishing. I was wondering how Jean would feel about leaving. The therapy had been an important time for her and we had been through a lot together. It seemed important to make this ending a positive experience. I shared some of these thoughts with Jean.
Jean smiled. "Yes, you're right. I would have just slipped away without saying anything, but that would have just been repeating the same pattern. I hate saying goodbye, but I've got to learn to do it."
She talked about how her feelings had changed over the time we had been meeting. When the end of the session came, she told me that she would not make another appointment for the present. She then reached out and took my hand.
"I want to thank you... I want to say goodbye...." She held my hand warmly. "I don't know if I'll be back sometime, but it is goodbye for now, and that feels important to say."
COMMENTARY
Jean is typical of many clients. Her early experience of the sudden loss of her father plunged her suddenly into a world without the previous safety and adult support, in which she just had to get on and cope as best she could. In many ways she coped very well, and lived a life which apeared to all around her to be successful. She did well at school, became qualified, and set up a career, married and had a family of her own.
Her strategy was one which she learned, probably even before her father's death, from the adults around her. She was not expected to show feelings. She was to protect herself by separating. If she did express feelings, they seemed to threaten others' stability, particularly that of her mother, who was in any case a great source of anxiety to her. She learned to avoid feelings by keeping herself busy. Whenever a feeling started to emerge, she would tell herself that it was a sign of weakness, that she had to be brave. She would then bury herself in some all consuming task. This strategy was one that worked well for her, and it soon became a habit, to the extent that she became unaware that the feelings were there at all.
Of course Jean was not aware that she was doing this. Nor was her way of coping unusual. We all push aside painful feelings to some degree. We watch the news but we rarely weep for the starving people of the third world or the victim of a gunman in Ireland. We distance our reactions and distract ourselves by telling ourselves this is not my child or my husband. We have to do so in order to get on with life.
Jean's feelings, however, were touched when her father died. Although not allowed to grieve, she was not unaffected. There is perhaps more awareness of children's needs now, but in the past many children, like Jean, were left to find their own way of dealing with the pain of loss. It was only many years later that Jean's brother's death, in surprisingly similar circumstances, resurected the feelings that had been burried for so long. As Jean looked at her brother's children, a part of her that was not conscious recognised their plight. In her insistence that they be involved, she revealed her own needs that had been denied years earlier.
Even at this time, Jean was not aware until it was pointed out to her that the difficulties she was having over her brother's death were partly related to her father's death. Indeed, her expectation that, after only two months, she should "be over it" was unrealistic, based on her impatience with her own feelings.
Keeping her grief under control was probably taking a high toll on Jean. It takes a lot of energy to hide so much from oneself. It may well have left Jean with a constant feeling of stress and exhaustion, which she coped with by simply driving herself to work harder. It probably also left her with a feeling of emotional deadness, which she was only to recognise after therapy had put her back in touch with some of her feelings. For some clients unexpressed emotions may emerge in particular symptoms or behaviours. Anxiety attacks or tension related physical illnesses may occur. They may get caught up in a cycle of eating or drinking too much, or fall into other compulsive or addictive patterns of behaviour. Keeping strong feelings controlled often leads to a feeling that chaos is never very far away. Fear is often the uppermost feeling in the person's mind: a fear of chaos and disintegration. It is this fear that keeps the person running from anything that seems to be a feeling.
When the early experience has been of the child's world falling apart, with the death of a parent, one of its cornerstones, this fear of chaos and disintegration will have real as well as imagined echos. It is this person's experience that the world can indeed disintegrate; that life is indeed untrustworthy. For someone like Jean whose experience has been so overwhelming, starting to face the chaos is terrifying. And yet, doing so also helps her to reestablish a deeper contact with reality; not only that of the past but also that of her present.
As Jean began to tell her story, the feelings began to resurface, intensifying the fear of chaos. This fear comes as a complete surprise to Jean, who has effectively kept it within manageable limits for so many years. She dives into therapy, expecting that this is another activity which she can sail through in her capable way. Working with a client who has so many buried feelings is a difficult balance for the therapist to walk, as many clients whose coping strategy has been to be capable and efficient, approach the therapy in the same way, expecting to be able to "deal with all this" in a few sessions and "get it over with". They may then find themselves suddenly aware that the small ice floe hides a huge and uncharted mass of dangerous ice hidden below the surface. At this point the client may well revert to the former pattern and simply try to push the feelings back from where they came. The difficulty is that feelings, like cats, are often hard to get back into the bag! Many clients, nevertheless do leave therapy because of the fear of what further terrors may surface. It is not uncommon for clients who start to glimpse the chaotic feelings which they have been holding down for so long to feel that they are going mad.
Many therapists in this situation would assert that they follow the client's lead, but this is not always straight forward. Often the client reveals to the therapist things of which she is not herself fully aware. Her look may reveal distress at points where she is not conscious of feeling it. Often she says things in a matter of fact way, which, if repeated back to her, will bring up feelings of shock or distress. The therapist will almost certainly be aware of distressing areas of the client's world long before the client is able or willing to recognise their pain. If the therapist reflects back all that she sees immediately, the client will almost certainly feel overwhelmed, and may stop the therapy. If the therapist does not reflect any of the non-verbal clues, the client will stay caught in the pattern of denial. The therapist's skill is in achieving a balance that is managable and appreciating the value of the client's defenses. (After all, this coping strategy has served Jean pretty well over a very difficult time, even if at a cost.) This does not need to be a process in which the therapist takes all the decisions. A therapist may well say to the client:
"I can see this is very difficult for you, and sometimes you feel overwhelmed by it. I can also see that you have so many feelings that you want to look at. I'm wondering how we can best look at them without you feeling completely overwhelmed."
The therapist may also suggest ways of working that offer some containment of the client's chaotic feelings and may suggest things the client can do in between sessions such as keeping a journal or talking with friends, as it is often after the sessions that the full force of feelings become clear (Beech, Leijssen, op.cit.).
As Jean continued with therapy, she was gradually more able to recall the events of the past without feeling completely overwhelmed. Her need at this point was to go over and over the stories. This pattern of continual repetition is like that identified as post traumatic stress disorder, in which the victim of a tragedy needs to repeat over and over the events of the trauma. Freud identified this need for repetition in dealing with traumas (Freud 1920). It is as if we can only take in a little at a time, and need to keep taking another bite in order to de-sensitise ourselves and integrate the experience. Here therapy follows the natural healing process. For Jean, her brother's death, though traumatic in itself, provided in some sense a first repetition. Because, in this instance she was more able to take an active part in events around his funeral, she was also enabled to begin to look at her past.
If we look at the theory of the grieving process as presented by such writers as Colin Murray Parkes (1972), none of the deaths affecting Jean were straight forward. When her father died, Jean was not at home. She was not told anything about what was going on, and was left to learn what she could from her younger brother and sister. Although she picked up that things were very wrong at home, she was left to imagine what might be happening. She had no concrete event or time to which she could pin her anxiety and distress. Her father simply ceased to be there. As Jean was excluded from the rituals of the funerals in both his and her grandmother's case she found it hard to experience the reality of their deaths. Funerals are often an important landmark in the grieving process, as they give public acknowledgement to the bereaved person's grief. They acknowledge what otherwise may remain unspeakable.
In the case of her father, Jean also had no physical place with which she could associate him. There was no grave, he had just disappeared. Even the discovery that he had been cremated did not help her in finding a place which she could associate with him. When someone close has died there is often a strong need to have such a place. It can sometimes seem as if the bereaved person must carry the dead person forever in their thoughts because there is nowhere they can mentally lay them to rest. If there is a grave, then it is possible to gain great comfort from visiting it. There can be a sense of returning to the person's presence, of being close for a while, but also of being able to leave them and return to ordinary life, knowing that the grave can always be returned to. Where a death has occurred but its physicality is not experienced, as when a person is lost at sea, the bereaved person can be left unable to take even the first step in the grieving process: unable to recognise the event as real.
There seem, then, to be two needs which we have in order to start to let go of the lost person. We need to experience the reality of the loss in a way that is psychologically concrete, and we need to be able to mentally place the dead person in some place outside ourselves; a place we can visit, but which we can also leave them in, knowing that they will safely remain there if we wish to return. Several clients whom we have worked with have felt this need for a physical location in which to place their loved one so strongly that they have created such a place for themselves. This might be by creating some kind of monument or shrine, either in a public place or in their own home or garden. It might be simply by endowing a place associated the deceased with a sense of that person's continued presence. Such ritual externalisation of the dead person often happens spontaneously, and seems to be a process we go through naturally. A similar process may be at work in the attachment many of us feel for the posessions of those we have been close to. A book or item of jewelry or piece of clothing may be carried around for years. Such a portable reminder can give constant closeness, which still remaining external.
Jean's mother's death was also complicated for Jean to cope with. Having already a store of unexpressed grief, Jean was vulnerable to a difficult reaction. This death was not sudden. Jean knew her mother was dying, but there is a sense in which most deaths are unexpected. Certainly there was a lot that had never been said between Jean and her mother. Jean still held the shadow of all the years of anxiety and secret resentment during which she had brought up the family. In one sense too, Jean had already grieved for her mother, having feared she was dying for many years. Such anticipation can sometimes help the grieving process, but in Jean's case it made it more difficult since the fact that she had begun expecting her mother's death even before her mother became ill left her with a vague feeling of having almost brought the death about. When her mother actually died, it was in some ways a relief, but Jean could not be certain in her own mind whether this sense of relief was for her mother or for herself. The niggling doubt that it might have been selfish ate away at her. Such complicated and ambivalent feelings left her once more unable to face the reality of her mother's decline and death and its effect on her. She returned to her earlier strategy of distracting herself from the grief.
When Tony died it was as if Jean's well of unexpressed grief began to overflow. She could no longer cope with her feelings by burying them. Jean began to feel her grief, to experience feelings that had been pushed aside for so long. This experiencing, even though it only began to touch the depths of grief which she held, made it possible for Jean to start to see her life in a more real way. She became centrally involved in arranging the funeral. She knew, although she did not know why she knew, how important it was that the children were not left out. Although she had no consciousness of the connection with her own past, her grief put her in touch with this inner wisdom.
In other ways, however, Tony's death had its own difficulties. Jean felt guilty that she had not gone to see him on the day he had died. Although she had told herself at the time that she was too busy, a part of her wondered if this too had been a strategy of denial: that she had not wanted him to be ill or dying, that she had been afraid she could not cope with another death and had some sense that if she stayed away and pretended there was nothing to worry about, she could magically stop it from happening.
The resolution of the therapy came in the enactment of a ritual. Ritual plays an important part in our successful negotiation of life transitions. In psychological terms it provides a focus for our recognition of the loss. It also provides an externalisation of our inner psychological constructions.
Jean needed to find a way to let go. She had carried both her parents unburied for many years in her mind. Part of her need, no doubt, was to reunite them. Her teens had been dominated by her mother's distress at their separation. Jean had carried this sadness within her. Finding a way to bring her parents together, allowed Jean to stop holding her mother's grief alongside her own. Jean chose an imaginary place in which she could leave her parents, but the scene was acted out in a physical way. Although in Jean's case the place was not one to which she could return in reality, this acting out of the scene was sufficient to give Jean a lasting mental image of her parents in a place outside herself; a place to which she could return in her imagination should she wish.
It was important that the scene should be as real as possible to Jean, and that she should herself have a sense of actually being present with her parents. For this reason I encouraged her to address her parents directly rather than talking about what she might say to them. It was also important that she had the opportunity to say whatever she needed to them before she said goodbye. It was probably also important that Jean actually addressed each parent separately and used the names by which she called them in her mind. At the end of the scene, Jean moves away and sits down. She has really let go.
It is not uncommon for clients to repeat such significant scenes several times. Sometimes the scene may be an imagined one, other times it may be a repetition of a death bed or funeral scene. It is crucial that the client is given the opportunity to say what feels right and to let go at her own pace. The therapist needs to be aware of whether the client actually seems to have said goodbye and moved away or whether this has just been a "going through the motions." If the latter is the case, the client is probably not yet ready to let go.
The ending of any therapy is significant, but with grief work, ending therapy can provide an opportunity to experience dealing with loss in a more conscious way. It is important therefore that the end is talked about and acknowledged. When Jean said goodbye at the end of the last session her warmth and her recognition of the importance of the time we had spent together came over to me. I felt that this time she had not hidden her feelings. We had created a new pattern.
My experience of Jean throughout the therapy was of a person who was growing and changing fast. Although the sessions were often extremely painful, there was a newly emerging quality in Jean's presence. She had an energy, and a warmth that became quite special. By the time the therapy ended, I felt that Jean was someone whom I had really known - not in an intellectual or social way, but as someone who was capable of connecting with me in a way that went beyond words. I was aware too that this change was also present in her relationships with others. Sometimes she would talk of her increasing feelings of involvement with her husband and children. She also told me that her circle of friends was changing as she found she no longer felt comfortable with those who she had spent time with before. She wanted something more than her old friends were prepared to give.
Recognising and facing her grief had brought Jean to an engagement with life which she had not experienced before. It is hard to know how Jean might have been had her father not died, but it seemed that by coming to terms with his death, Jean had grown as a person.
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Dh.D.J. Brazier
1994