Category: Death and Dying

Encounters with Suicide: A Psychotherapist Remembers Not to Forget

Posted on by Psychotherapy.net Team

Forgetting Begins

Back when phones had cords and I was sixteen, my mother’s friend called our house one afternoon and told me that she had a shotgun across her lap and asked me if I could give her one good reason why she shouldn’t blow her head off with it. I was alone in the house because I had not joined my family that year on our annual summer vacation in Maine. Instead, I was flirting with an eating disorder by trying to live on iceberg lettuce with low-fat blue cheese dressing and getting up each morning at 4:30 to ride my bike two miles to the Holiday Inn just outside town where I was working as a waitress on the breakfast shift. So there I was, all by myself, trying really hard to think of the right good reason. Already I was imagining the explosion roaring through the headset, the result of my inadequate and faulty answer.

I am quite certain that I did not give her one good reason, but I must have said something that furthered the conversation, because I remember her saying, “Do you know what it is like to live with a man who hasn’t touched you in years?”

Well, no.

I think we talked for a while. I tried to imagine what a compassionate adult would say to her, and tried saying it. I offered her my mother’s phone number in Maine. There was not a telephone in the cabin, but the owners could deliver a message. My mother’s friend refused. “Oh no, I couldn’t bother her on vacation.” I was thinking that bothering my mother on vacation was the best possible idea under the circumstances, but clearly it was not going to happen. My mother’s friend told me that she was feeling desperately lonely now that her youngest child had gone to college. She told me her husband of thirty years was having an affair with a woman in her twenties. I did not want to know any of this, at least not first hand.

Gradually she came out of herself and seemed to remember that I was the kid her daughter used to babysit for. “I shouldn’t be saying all this to you,” she said. I couldn’t disagree. I made her promise that she would not shoot herself.

“You don’t need to worry,” she reassured me. “I’ll be fine. It has been a really bad couple of weeks, but I’ll be fine. My neighbor will be home from work soon. I’ll go see her.” I felt a lack of sincerity in this. “It is quite a distance from blowing your head off to visiting a neighbor, and I was quite sure our conversation had not traversed it.” But there was nothing I could do, so I said, “I’ll tell my mother to call you when she gets home.”

“Don’t call her,” she said. “Don’t bother your mother. I’ll be fine.”

I hung up the phone and put this conversation so thoroughly out of my mind that I nearly forgot to mention it to my mother when she returned from vacation, and when I did tell her I found myself experiencing a sort of delicacy and shame that precluded any mention of the shotgun. I suspect I did not even mention the threat of suicide. I can’t quite remember, but I imagine myself saying that her friend seemed unhappy.

Forgetting Returns

I remembered this incident only recently when I was sitting in session with a client who was telling me about how she was going to buy a gun in order to shoot herself. This client, now in midlife, has been suicidal to varying degrees since she was sixteen, so her thoughts were not new, but the method she was proposing was far more likely to be lethal than anything she had considered before. At one level, I was working hard to assess her immediate safety and devise a plan. At another I was aware that I was feeling oddly wooden, disconnected, and ashamed. I knew I was irritated with her, as well as anxious. She is coy, deceitful, challenging—there is a way in which she teases me with the drama of her death, a drama she has been crafting with loving care for decades, a narrative in which her final explosive act of rage sears all of us who know her. It is a story she caresses like a beloved, spoiled pet, but also one that frightens her, and I have found over the years that she is readily diverted by small gestures of empathy on my part, or that she inserts her own delaying tactics, such as the need for a pretty death dress, or her plan to be honest on the permit application for the gun regarding the purpose of her purchase.

What she will not do is explore how this story serves her, what its purposes are in her life, what it helps her to avoid. I struggle to find some way toward this conversation, but as often happens, my own thinking is muddled by anger, anxiety, and that odd sense of shame. The only question I seem to be able to articulate clearly to myself is, “Will she kill herself now?” I believe she would not, and extract a promise to that effect. The promise comes easily, almost too easily, and prompts a new discomfort: I worry she is lying because, after many years of experience, she knows what would happen if she acknowledges an active plan. In the end, we contact her husband together, and afterward I let her leave.

And when she leaves, I forget completely—not about her, but about her thoughts of suicide. At our next session, fortunately before I have a chance to reveal my forgetfulness, she reminds me, but I forget again anyway. Or maybe forgetting is not quite the right word. It just seems to fall out of my mind. I start having defensive little conversations with myself about this forgetfulness. Maybe, I tell myself, it is because I am not really worried. After all, I am as confident as I can be when she leaves that she will not kill herself. She has been doing this for over 30 years. She can’t live in a hospital. But then I worry that I should be more worried. And then it falls out of my mind again, until our next session.

Of course it is hard for all of us who are clinicians to think about suicidal clients. It is frightening. It is a sad, hostile, violent act, in which we stand to lose a great deal at many levels: most importantly our client, but also self-esteem, self-trust, and professional reputation. We fear losing our livelihood if we fail these clients. We fear blame from ourselves and others. We choose not to think about it in many ways, including by resorting immediately to hospitalization as a way of ensuring not only our client’s physical safety but our own emotional safety. We insist on safety contracts before exploring deeply with the client. We find excuses and the means to get rid of them. “We rush to make repairs before we have the courage to examine the injury, slapping bandages on wounds so deep we are afraid to see them.” We increase medications, we loosen boundaries, we are afraid to ask questions, we demand answers we want to hear. With those who make chronic threats, we can become impatient and irritated. Some of these actions are of course sometimes necessary and desirable. But often what we are feeling first and foremost is a need to put a lot of distance between ourselves and the thought of a client’s suicide. These intense feelings and avoidances are common in one way or another at one time or another to all of us as clinicians, and certainly in this case they were part of mine, but I was beginning to suspect that for me, there might be something else coming up as well.

The Roots of Forgetting

On the surface, it seemed obvious. My father’s family worked very hard to forget my grandfather’s suicide. This dramatic issue, however, seemed so far from my direct experience I wasn’t sure if I could legitimately connect it in any way to what I was noticing about my feelings and behavior with my client. On the other hand, it seemed risky to assume my own even indirect personal experience with suicide was irrelevant, so I gave it some thought.

“My grandfather hanged himself when my father was four, and my grandmother did all she could to erase every memory of him.” I know a couple of things about my grandfather that I am pretty sure are true. He was a rumrunner in Pennsylvania during Prohibition, and he brought big bands like the Dorsey brothers to local hotels and night clubs. I have seen only one photograph. He is a broad-shouldered, dark-haired man standing next to a three-year-old version of my father on a merry-go-round horse. Once after my grandmother died I went on a search of her house for evidence of his life. I thought I had hit the jackpot with a pile of photo albums in the closet of an extra bedroom. It turned out that in each of the scalloped-edged photos from the 1930s, every one held carefully in place with little black corner pockets glued to the page, she had ripped out the images of my grandfather, leaving the others standing and laughing and smiling in front of buildings and cars, unaware of the torn edges framing the emptiness where he had been.

My grandmother lied about her husband’s death for more than 30 years, claiming he had died of a variety of unlikely ailments, including back problems. Nonetheless, her feelings of abandonment, rage, and shame were palpable to everyone who knew her. Even once she had admitted the real cause of his death, her explanations were dislocated and strange, and for me, always at least secondhand. In one version my grandfather was in a mental hospital and had what we now call bipolar disorder. In another, less likely but still my preferred version, he was also in a hospital, but possibly hiding from mob associates who murdered him.

There is no one left now who knows what really happened to my grandfather, or who can really even guess why. Like in the children’s game of telephone, the stories I have heard are probably distorted beyond recognition from their original source as they have been whispered down an almost century’s long lane. Even my own memory is confused by odd and inexplicable distortions and images. I remember with crystal clarity, for example, driving with my father and hearing him tell me that my grandfather probably had an affair with one of my grandmother’s many older sisters. I remember seeing the colors out the passenger side window, rural New York in the fall: the fields yellowing, bark darkened with rain, leaves brown and drifting, hints of lavender and red, the steady green of conifers. There was only a little gray in my father’s beard. I remember not just envisioning but knowing, remembering, the dark-haired older sister I never met, more settled than the younger, more beautiful red-haired one my grandfather married. I imagined her specifically. I could see her hanging laundry on a warm day in her flower-patterned dress. I could see the intense sexiness of the seam of her stockings drawn along her slim calves from the fall of her skirt to her square-heeled shoes.

But my father is bewildered by my memory of this conversation and has no recollection of any such affair. Why have I imagined it? Why has he forgotten? I am reminded of another children’s game, where one child draws a head and folds the paper over so the drawing can’t be seen, another draws the arms and folds her part in turn, another the legs, another the feet. Once unfolded, a figure is revealed, a crazy patchwork of imaginings. This is my portrait of my grandfather.

He is for me essentially fictional, his only reality in my life the shadow he cast on those he chose to leave behind. There is no pain in his release of any claim on me, although the long, slow-burning coals of the suppressed rage that were his legacy have in their way come down to me. Yet I think that in these odd moments—with my mother’s friend, with my client—I become aware of something else my grandfather has left with me. He lives with me in my unreasonable, inherited loyalty to my cranky little gnome of a grandmother, who demanded that my father never remember, never even try to remember, his father. He lives with me when my client’s words obediently fall out of my mind. In my father’s family, it is an act of loyalty to erase my memory and bury my anger and fear. Even though he died 20 years before I was born, my own memory of my grandfather is in its way constant and precise: “I remember him by forgetting.”

Awareness and Remembering

As so often happens in therapy, it is hard to be certain that this subtle, internal shift in awareness that I experienced thinking about my inability to hold my client’s suicidality in mind produced a change in my client. The role of therapist self-knowledge and self-awareness in the course of therapy is really immeasurable, in both senses of the word—certainly not readily quantified, but equally certainly a source of lasting, profound growth for ourselves and for our clients. I know it has become easier to get past my anger, fear, and denial when my client is suicidal, and this has created a change in the quality of our conversations about it. We are less focused on management and more focused on meaning. Usually by the time we wrap up with a safety plan it has become unnecessary, more of an addendum than a centerpiece of our conversation. Between sessions, I do not forget how she has been feeling. I know I will feel deeply angry, sad, betrayed and, yes, guilty, if she kills herself one day, but whatever happens, it will not be because I have allowed that possibility to fall out of my mind. She still holds on to her fantasy of killing herself, but for some time now speaks of it not as a plan, but as a feeling. “I am feeling suicidal” for her is no longer a threat of immediate action, but a description of despair. Like partners in a dance, we have both taken steps away from the concrete and into the symbolic, for I have replaced the concrete act of forgetting with engagement and curiosity.
 

Motivational Interviewing in End-of-Life Care

Posted on by rezendevknowfully.com

Betty: A Case Study

When Betty answered the door and welcomed me into her living room, I couldn’t help thinking she looked almost like a different person from the Betty I’d seen just the day before: a neatly dressed, very composed 80-year-old woman. Today, her clothes were messy, her hair was disheveled, and she had bags under her eyes. Her husband, Frank, was resting in their room after his morning nursing visit. He had been diagnosed with prostate cancer a year earlier, and the treatment had been unsuccessful. The hospice team of which I was a member had been called in to assist with the final few days of his life, which is why we had met Betty and Frank the day before.

The nurse, spiritual counselor, and I had visited the couple in their home, as this was where Betty and Frank preferred for him to pass away. During the initial visit, Betty had engaged appropriately, was very pleasant and cooperative, and asked common questions about what to expect in this process. She had hired a caregiver for further support. She seemed to be coping well and had a strong supportive network with her children and neighbors. Frank had been a bit lethargic, but was able to engage with us as we discussed his care over the next few days. The visit had gone smoothly; we hadn’t expected any unusual problems.

But the morning after the initial visit, the nurse called me explaining that she had completed her daily visit and Frank had declined significantly overnight. He had been very lethargic and difficult to arouse during her assessment. Betty had asked the nurse if she could feed her husband, since he had only a few bites of food at dinner the night before and had not had breakfast. The nurse had informed her of the risk of feeding when a patient is closer to death, but felt that Betty was very resistant to this information. The nurse was calling me to ask if I could meet with Betty to address this resistance.

As a social work intern, this would be my first meeting alone with a client. As I was simultaneously enrolled in a graduate course on Motivational Interviewing, I decided to put my beginning skills to use.

Engaging the Client

I began by checking in with how Betty had been feeling since our visit the previous day.

“I feel good,” she said, “but I had a hard night last night with Frank waking up several times. He was moaning and confused, and even tried to climb out of bed. It really scared me, but I was able to call hospice and they walked me through giving him some medication to calm him down. It worked quickly and I was able to get some rest for a few hours.” She paused and touched her forehead absently. “I’m glad to have our caregiver here this afternoon so I can lie down and get more sleep. She was so helpful yesterday.”

I remembered from my MI course that open-ended questions, affirmations, reflections, and summaries (OARS) are key to building rapport and conveying empathy and understanding. When clients feel heard, they are not only more inclined to engage with the practitioner, but they are also more comfortable processing their ambivalence, and eventually reaching a resolution. I knew that Betty had had a fraught conversation with the nurse that morning, and that she must be feeling overwhelmed, so even though we had limited time, both in the session and in terms of Frank’s life, I began slowly.

“Wow,” I said. “It sounds like you had a difficult night caring for him. Caregiving for someone in the dying process is challenging. I’m really impressed that you’ve been doing this, while also recognizing you need some help and have hired a caregiver. I’m glad you called our main line for support, too. We’re always available to help.” The simple reflection and affirmation I used helped us start the visit well. Betty knew I was present and listening to her. I was also able to validate and affirm the challenges of providing caregiving at end-of-life and how well she was doing.

“I understand you met with the nurse this morning,” I continued, now that I saw Betty relaxing a bit in my presence. “How did that go?”

Betty paused and her voiced dropped. “Fine. She told me I should stop feeding my husband, but that’s hard because he could be hungry.” She paused again and then raised her voice. “She said that feeding him could hurt him, though. I’m not going to be the one to kill him!”

I reflected that Betty felt confused about what the nurse had told her about feeding.

Betty raised her voice again and spoke more quickly. “It’s really confusing. And it’s like she doesn’t really understand where I’m coming from.”

“She doesn’t see how much you value feeding Frank,” I nodded.

This exchange confirmed for me that Betty was struggling with understanding and accepting that her husband no longer needed to eat or drink as he was declining quickly. As the nurse had explained to her, feeding him would have likely caused more harm because as his body declined, it would not metabolize food and fluid as well, which could cause increased toxicity, pain, and discomfort.

Given the medical nature of this information, and especially because of the urgency of the situation, with Frank having only a few more days to live, it would have been tempting to believe that Betty’s inability to understand could be solved by intellectual persistence: maybe if someone explained the details to her again, she’d “get it.” But using an MI framework, I saw clearly that Betty needed to be met emotionally in her struggle before she could comprehend the medical problems that continuing to feed her husband would create.

In situations where there is a clear preferred outcome, it is often challenging for counselors and other helping professionals to steer away from what in MI is called the “righting reflex,” the temptation to tell the client what is best for her and what she ought to do. But this technique does not support client autonomy or self-determination, and defies the MI belief that the client is the expert. It also tends to pit the client against the therapist as an adversary or an authority against which to rebel. Telling Betty to stop feeding her husband could have caused her to shut down and damaged any trust she had in me that I understood her situation. Furthermore, the righting reflex may have robbed Betty of the opportunity to process her loss.

Change Talk

 It is important to note that Betty acknowledged that she heard that feeding could be harmful and even said, “I don’t want to be the one to kill him.”

MI emphasizes two concepts called “sustain talk” and “change talk.” Clients engage in sustain talk when they discuss the status quo, or give reasons why they cannot make a change. Betty had been engaging in sustain talk thus far in our conversation, going through her reasons for believing she should continue to feed Frank. Change talk, which is any mention of change as a possibility, marks a client’s willingness and preparedness, however slight or tenuous, for change. A clinician using MI should emphasize and explore a client’s change talk through reflections and open-ended questions. This allows the client to focus on change rather than maintaining the status quo.

Betty’s statement that she didn’t want to be the one to kill her husband identified her ambivalence and was an example of change talk. It let me know that Betty was open to exploring the possibility of refraining from feeding her husband in this final stage of his life, though clearly she had not yet reconciled herself to this option.

Before we examined the change talk, I wanted to reflect Betty’s ambivalence and confusion while stressing how much Betty loved her husband and wanted nothing more than to give him the best care possible. “You’ve really taken on the role of being his caregiver and part of that role is feeding,” I began gently. “The way you see it, just because he’s at the end of his life doesn’t mean you should stop that role now. And as you said, he could be hungry.”

Betty sat forward in her chair. “Exactly!” she exclaimed.

Sensing I had struck a chord with her, I continued. “You also said that you heard the nurse explain that feeding could be harmful.” Here I was able to focus on both sides of the issue: one the one hand, feeding was part of her role as caregiver, and on the other, she was aware that it was risky and could likely cause more harm, which she didn’t want.

“Yes, but I don’t really understand why,” Betty said, her voice heavy now, and she slumped back in her chair a little. “I know if people don’t eat, they die, so I don’t want to have that guilt that I’m not feeding him and he dies. He’s my husband, and I want to do the best job I can.”

Noting that Betty was moving back into sustain talk, I continued with affirmations and reflections to build a sense of alliance. “You have taken excellent care of your husband, and your family, for the sixty-four years you’ve been married. Feeding is not only part of caregiving, but also a way you show your love for him, which is something I definitely understand. It sounds like if you stop feeding him you’re scared that it could hasten his death, which would make you feel guilty, like you’re responsible for him dying.” I was able to use this complex reflection—drawing on Betty’s implied statements and feelings as well as the words she spoke—to assign meaning to the feeding, explore the sadness of her changing role as a wife, and allow her to process the fear of hastening her husband’s death.

“Yes,” said Betty. “I’ve taken care of everything all these years. The cooking, cleaning, laundry, shopping. And he likes that I do those things. I want to take the best care of him all the way until his last breath.”

I affirmed her role by saying, “Something I’ve seen from you in the times we have met is that you are a very dedicated, loving wife, who wants nothing more than to care for your husband, especially at the end of his life.” I began to understand that Betty’s roles as wife and mother were not only central to her relationship with her family, but also to her personal identity. Although cooking and her other activities seem like minute household chores, these activities were how Betty showed her love for her husband and children. If she was no longer feeding, how could she express her love, especially at this most intimate time in life?

As I reflected Betty’s deep desire to provide the best care to her husband in his dying process, she became tearful. “I’ve cared for him for so long,” she said, “and I’m feeling very overwhelmed about this. I just can’t believe he’s dying. We’re high school sweethearts. I can’t remember life without him.”

I could really empathize with Betty in that moment. Although she had been able to understand intellectually that her husband was terminal, the emotional impact of the dying process weighed heavily on her. Thinking about what her life would be without her husband was devastating. “This experience has been really difficult and emotional for you,” I said. “It’s hard to even imagine life without him.”

With tears filling her eyes, all she could say was, “Yes.”

Ambivalence, Not Resistance

 I was sensitive to not push her too far. We still needed to address the feeding, and if she became overwhelmed with grief, it would have been inappropriate to have that conversation. So I continued to affirm her. “I see just from listening to you that you and Frank are so incredibly in love and have been for a long time. You’ve created an incredible life together, have two wonderful children, three beautiful grandchildren, all are an extension of you two and represent your life and your love for each other.”

Reflecting on the lives patients and families have shared is a vital component in helping them experience a peaceful death with dignity. Processing their lives affirms they were special and facilitates closure. Here, affirming Betty’s desire to continue providing loving care helped her to feel understood and acknowledged. My acknowledgment of the specialness of her bond with Frank seemed to calm her down a bit.

I decided this moment was the opportunity to provide some education about Frank’s state, but first I needed to ask permission. Asking permission is essential in MI because it gives the client control of the session. In a careful tone I said, “Maybe if we could clear up some confusion about the feeding, then that could help you feel a little better and assured that you are taking the best care of Frank. Would it be okay if I shared some information with you about feeding at end-of-life?”

“Yes, I’d be okay with that,” said Betty. “The nurse just didn’t explain it to me well.”

“I can understand,” I said. “Sometimes we think it’s clear because we have this discussion often, but the family needs a little more education and I’m happy to provide that.”

“Yes. I just cannot understand how eating could be harmful.” She had become quite agitated again, her shoulders tense and limbs tense.

Maintaining a gentle tone, I explained, “It seems very unclear because when the body is healthy, it needs nutrients from food. As a person gets closer to death, the body doesn’t need the same amount of nourishment as it did when it was healthy. The body slows down and its metabolism slows down, so the food cannot be broken down at the same speed as when the body was healthy. Now that Frank’s body is slowing down, he can’t digest food in the same way, so the food and liquid gets kind of stuck in the body, causing more harm than good. I know that sounds strange, but does that make sense?”

She seemed puzzled. “So he can’t break down the food?”

“Exactly,” I told her.

I was becoming hopeful that Betty was beginning to understand the risks of feeding and we were about to make a break in resolving her ambivalence. But then she responded, “Well, what if I just give him less food?”

I suppressed a twinge of impatience. That question made me see that she was still unsure and possibly resistant to stopping the feeding. But although resistance can sometimes be frustrating for practitioners, an MI practitioner always rolls with the resistance and should avoid the righting reflex in times of client ambivalence. Betty’s question was simply her way of expressing that she was still unsure what was right.

Resisting the urge to use the righting reflex, I calmly said, “Well, sometimes that can be okay, but if the food is not soft and thick, there is a risk that it could go into his lungs and he would aspirate. That could cause an infection and actually hasten his death.”

My hopes that this education would help move discussion along were quickly halted when Betty said, “Oh. Well I’m glad to know this, but even if I gave him just a little, it couldn’t hurt him that badly, right?”

A Circuitous Route to Change

I was unsure how to move Betty out of her now entrenched sustain talk. Betty was trying to argue for feeding, even just a small amount of food. Sustain talk can be difficult to address, so I decided to offer some compromise and then affirm and reflect. With empathy, I said, “Well that is something that we can discuss with the nurse. I would just like to affirm what the food represents in your relationship. This is the way you’ve shown your love for your whole marriage, so that’s hard to stop that now. I know you don’t want to hasten his death by not feeding, but the scientific knowledge we have indicates that feeding could be more harmful.”

Betty immediately interjected with more sustain talk. “But he may be hungry,” she protested.

“I think that’s a great point,” I replied. “Unfortunately, we don’t know for sure if he is hungry or not.”

Betty interrupted and asked, “Do you think it’s better to not feed him because it’s more dangerous?”

I realized that Betty was looking to me as an expert, and as the hospice social worker, I was more of an expert on the issue. This is another temptation to resort to the righting reflex and simply use my authority to tell her she couldn’t feed him. But I reminded myself that this was Betty’s life and I did not know what was best for her. Any decision I made for her, she could still reject. She had to come to it herself. Furthermore, I needed to support her self-determination and autonomy. “Well, I think it’s better that you do what you feel most comfortable with,” I told her.

Betty appeared to appreciate this point as she sat back in her chair and relaxed her shoulders. My statement affirmed her autonomy and validated that I supported her self-determination. I realized I may not have acknowledged before that the choice had to be hers.

Although Betty had relaxed, she was somewhat hesitant. “I just don’t know,” she said. “This is so hard.”

I knew then that I needed to help Betty navigate the pros and cons of this decision. For this, I used an MI technique referred to as a decisional balance. Betty already had the information about the advantages and disadvantages of feeding and not feeding, but I needed to help her sort through them.

I asked Betty, “Well, what are some of the dangers of continuing to feed Frank?”

Betty reflected for a moment. “Well, he could choke. And you said the food could get stuck and he could aspirate.”

“Yes,” I replied, adding, “The body also cannot digest the food well, so it could store in his body and cause an infection. And what are some of the good things about continuing to feed him?”

Betty looked puzzled, but said, “Well, he wouldn’t be hungry.”

I gently replied, “Yes. If he is hungry, which we don’t know for sure and likely never will, the food could satisfy his hunger. But if the food doesn’t break down correctly or pass through his stool, then it could be more painful for him.”

Using the term “pain” seemed to resonate with Betty. Her eyes widened and she sat up in her chair. “Oh! I hadn’t thought of that. It could cause him pain?”

“Yes, think of it like this: if you eat more food than your body can handle, you get a stomachache. Now imagine not being able to get that built-up food out through your stool. That’s likely what it feels like.”

Betty smacked her arms down on the armrest and said, “Well, I definitely don’t want him to be in pain. Do you think that his pain and agitation last night was because I gave him some mashed potatoes?”

Betty seemed ashamed by this prospect. She moved in her chair and did not make eye contact with me.

Sensing her uneasiness, I softly said, “You know, we will probably never know. I’m glad that you knew to call for help when he was having new symptoms. That was very intuitive and shows that you knew what to do in a crisis.” I did not want Betty to feel guilty, because a number of factors could have played a role in her husband’s symptoms.

I wanted to return to the decisional balance to speed up our arrival at Betty’s decision about feeding her husband. “What are some of the bad things that could happen if you stop feeding him?” I asked.

“Well he could be hungry and that would make him more uncomfortable. But after talking to you, I'm not sure if he would be hungry because maybe he’s just too sick to be hungry,” Betty said sadly.

“So you’re thinking maybe he’s hungry, but we don’t know for sure. You also see that he could be far enough along in the disease process that his body isn’t feeling hungry anymore.” She nodded. To continue with the decisional balance, I asked, “And what would be the benefits of not feeding him?”

“Well you said that feeding could cause infection, so if I don’t feed him hopefully he won’t get sicker. Maybe he would live longer?”

A Breakthrough

I was so relieved to hear change talk: an acknowledgment of the possibility that Betty might stop feeding her husband. I felt that we were finally getting somewhere with her ambivalence. “He could live longer, and maybe even be more comfortable,” I told Betty.

“Yes, I want him to be comfortable,” Betty nodded.

“I want you to know that we really do understand how confusing it is to not feed your loved one at the end-of-life,” I affirmed. “It seems so unnatural because feeding is typically associated with us feeling better. And also with your relationship, feeding is not only part of your role as his caregiver for the past sixty-four years, but also the way you show him how much you love him.”

I wanted to ensure I normalized Betty’s ambivalence regarding feeding at end-of-life, as this is something that hospice clinicians discuss with families every day. Like many therapeutic interventions, normalizing is useful in MI because it makes clients feel comforted that they are not alone. This is especially critical in hospice because family members often feel isolated as their loved ones transition through the dying process. Affirming and normalizing Betty’s confusion regarding feeding, while also providing a complex reflection of Betty’s role as caregiver and how she expressed her love, helped us transition from the issue of feeding to ideas for how Betty could continue to express affection towards her husband in his final days.

“If we can brainstorm together other ways you could express your love,” I continued, “then maybe we can implement those into your caregiver role. Maybe things that are less risky, like reading to him, holding his hand, playing music for him. How does that sound?”

“That sounds nice. He loves reading.” A note of relief emerged in Betty’s voice. “We used to go to the library together and get books. Sometimes he’d read to me at night.”

“Wow,” I replied, “that is really special. So now you could maybe do that for him.”

She paused briefly. “Yes, I think he would like that. But can he hear me?”

Again, I wanted to avoid jumping into an expert role here, especially with what must have been an emotionally loaded question for Betty. “Well, what do you think?”

“I’m not sure,” she said. “He doesn’t respond like he can.”

“Would it be okay if I gave you some information about senses that some other families like to know?” I asked.

“Of course,” Betty said, “You’ve been so helpful, I want to know.”

“Well, we always ascribe to the belief that if there is breath, then there is hearing. Some studies have shown that hearing is the last sense to go before someone dies, so I always tell families to behave like their loved ones can hear them.”

“Yes, you’re right. I think he can hear me,” she said hopefully.

Peaceful Passing

Betty’s husband lived just two more days after this visit. I learned from the nurse that Betty’s husband declined even more the day after our visitand was actively dying, so I followed up with Betty and her children with telephone calls to assess the status of feeding and how they were coping. Betty and her children all confirmed that Betty had not tried to feed her husband again after our visit.

I learned from my bereavement telephone call that Betty spent the last two days she had with her husband reading his favorite books to him, writing him a long letter that reflected their life together and the impact it had on Betty, playing their favorite music on an old record player, and holding his hand and providing a supportive presence.

My visit with Betty not only provided her with important education about her husband’s dying, but also helped her process some of that anxiety so she could help Frank’s dying process be more dignified and peaceful. Like so many of the families I see, Betty needed someone to validate what she was feeling and also hear, understand, and affirm what feeding represented to her relationship with her husband.

Motivational interviewing skills, such as reflections and the decisional balance that I used with Betty, have been effective in my clinical practice with hospice patients and families who experience ambivalence with administering morphine for pain, hiring caregivers, or asking family members for help to protect the primary caregiver from burnout, and processing denial related to rapid decline.

Often families I work with are extremely concerned with doing everything “right,” so affirming that they are doing an excellent job caring for their loved one is very important for them because the feel empowered and validated. Although they may not be ambivalent about providing care, they are still at risk for becoming so overwhelmed that effective coping and a healthy life balance are damaged. Emphasizing individual strengths through genuine affirmations empowers the caregiver and results in better care and support for the patient. The patient having a peaceful death with dignity is not only valuable for the patient, but also for caregivers and family members as it decreases their risk for complicated bereavement.

The spirit of MI is rooted in the notion that the practitioner and client have a collaborative relationship. Once that relationship is established, the practitioner is responsible for evoking the client’s motivations, perspectives, and autonomy. Starting the visit with exploring and reflecting Betty’s motivations, understandings, and feelings regarding feeding allowed us to make progress on this issue. If I had come into her home telling her why she should not feed her dying husband, she likely would not have listened. Furthermore, she would not have had the opportunity to process their life and the emotional impact of her husband’s death.

MI techniques emphasize and foster a collaborative therapeutic relationship, which is critical in hospice work, and more generally in working with individuals and families coping with terminal illness. We clinicians are not the experts in our patients and families’ lives or their dying process. Using MI techniques not only helps hospice patients and families process their ambivalence, but are also extremely valuable in conveying empathy in a way that moves towards change.

My work with Betty was the first experience I had in applying MI to my clinical work in hospice. I was initially unsure how the MI skills, specifically reflections and affirmations, would help Betty resolve her ambivalence, but this experience showed me their value. I believe that my ability to avoid the righting reflex and simply repeat back to Betty her confusion and fear helped her feel heard and validated. The reflections also allowed her to process her thoughts that supported the ambivalence. These skills helped us establish a collaborative relationship as I was sure to never make her feel I was the “expert.” Although Betty saw me as more knowledgeable of the issue of feeding, I was not more knowledgeable in what was best for her. These skills allowed me to use the decisional balance, which ultimately led to her resolving her ambivalence and not feeding her husband again.

I feel tremendously honored to have the opportunity to work with hospice patients and families. Being present with patients in their dying process, and supporting their families as they navigate the demands of caregiving and effects of anticipatory grief, is an incredible privilege. I believe strongly that everyone deserves a peaceful death with dignity and am passionate about being part of providing that experience to all of my patients and families.  

Psychotherapy with Older Adults: Unjustified Fears, Unrecognized Rewards

Posted on by rezendevknowfully.com

I am a geriatric clinical psychologist. I love working with older adults. I have often wondered, though, why there are so few of us around. Ten thousand people in America turn 65 every single day now. There is an accelerating rate of this already underserved segment of our society, and there is a huge and growing but untapped market of potential revenue for psychotherapists wanting to expand their practices. Why, then, are there so few psychotherapists actively working with older adults? While it is estimated that 70% of psychotherapists see adults on their caseload, only 3% of them have had formal training in working with older adults. What has stopped clinicians from getting training that could be so valuable in their professional development? Despite the general finding that the motivation and attitude of the older adult toward psychotherapy is as positive as it is in other age groups, many clinicians doubt this nevertheless. As I began working with older adults, I confronted these issues, and as I did, I found new joy in my work. What I discovered was this: I have as much to learn from my older clients as they may have to learn from me.

Many clinicians prefer not to work with older adults, and I have a great deal of respect for those preferences. In my own practice, I'm not inclined to work with children or adolescents. Oftentimes, though, the therapist’s preference is based on a view of older adulthood that is grounded less in fact and more in myth. When I first started seeing people in nursing homes, I felt like a fish out of water. I was trained in two of the best graduate psychology programs around, but when I was in a nursing home, I was consumed with doubt and fear.

It was 1999. I had just become licensed as a psychologist, and I was offered a job with a firm that brokered psychological services to nursing home residents. I was excited about making a living as a psychologist, energized about venturing into this new application of my skills, and eager to ply my trade—that is, up until the first week I actually saw clients! It was then that the reality of working with older adults eclipsed my fantasies of doing so. It was then that I confronted my awareness that this was incredibly challenging work for which I felt ill prepared.

My main fear: could my cognitively compromised clients even benefit from psychotherapy? I asked myself, How much of my work with them could they actually comprehend? How capable were they of working through their emotional struggles and inner conflicts? To what end would our psychotherapy serve if their lives would soon come to a close? I was overwhelmed with confusion, uncertain of my effectiveness, and scared I might be practicing outside my area of competence. Out of an amalgam of fear, guilt, and good sense came a series of consultations with a wise geropsychologist, and it was there that I began my schooling about the cognitive, emotional, and functional eccentricities of the older adult.

I am here to tell you, though, that 13 years later, I have come full circle. My acquired knowledge and experience in geriatrics have been invaluable, but I see now that, with respect to the essence of effective psychotherapy, it turned out that I had been sufficiently trained to do the work all along. Becoming technically proficient as a gerontologist has taken me on an invaluable path, but I see now that my former fears about conducting psychotherapy with older adults were driven almost entirely by my own introjects from the social stigma of aging. That’s what this article is about—to describe my own journey as a clinician framed within the cultural mythology around aging.

Myth #1: Psychotherapy with the elderly is time wasted, because the elderly client has so little time to enjoy any gains that might be made.

There is a film released in 2011 entitled Beginners, for which Christopher Plummer won the Oscar for Best Supporting Actor. The story involves a widower who, at age 75, joyously begins living a sexually authentic life as a gay man. To justify such a change, how many years should this man have left to live? Is the length of time he would have to enjoy his newfound emotional freedom really the issue? I am reminded of the elderly client who responded to her therapist’s query why she wanted psychotherapy by saying, “It’s simple; all I have left is my future.” At age 49, Freud is well known for having contended that anyone over 50 was uneducable, and I wonder if some of our biases working with older adults might stem from this overstated assertion.

Due to a very severe stroke, Estelle had for some four years been living in a nursing home. At 75, this was her home now. She was referred to me because she could not stop getting into heated arguments with other residents, and she was sad a lot. She had a history of drinking moonshine; she had been an ironworker and a barmaid, drove a semi, and had graduated high school with honors.

As with most nursing home residents, she was on a ton of meds, including an antidepressant, two anxiolytics, and an antipsychotic. When I first met her, she told me she had multiple personality disorder (which wasn’t the case), but due to her stroke, she did have memory problems and severe aphasia (difficulty expressing herself with language). In fact, her aphasia was so pronounced that it took her as long as a minute to express a complete sentence. She grinded out each word—one by one—with persistent determination. Her desire to communicate was relentless, and this was what allowed her to stay connected to others.

My psychotherapy with Estelle lasted two years, and I learned a great deal from her. I learned about the incredible courage and fortitude it takes to cope with an abusive upbringing, the loneliness and isolation that can accompany nursing home life, and the debilitating physical ravages of vascular dementia. I also learned about the connection that occurs between two souls—where words are often not needed.

More than her aggravated depression, though, Estelle wanted to work on emotional abuse issues from her childhood and the disparaging way her mother and father had treated her. She was open to the idea that those images—and the ways she coped with them—were influencing how she related to others and to herself. And this was how we approached her psychotherapy.

I am tempted to say that Estelle was a wonderful psychotherapy client, but the temptation to do so implies that it was Estelle’s characteristics that made the therapy meaningful. It was not. What made the psychotherapy beautiful—even reverent—evolved from the exceptionally meaningful way the two of us found to communicate with each other. And not unlike Victor Frankl’s odyssey through Auschwitz, what was most meaningful to me was to witness Estelle’s search for meaning in the limitations of her own life.

In the beginning, our therapy focused on relieving her depressive and angry feelings, and Estelle made comments like,

I have been fighting lately—it’s enjoyable … and it’s not enjoyable. It relieves tension, but I am crying all the time. If I told you all that is going on inside of me now we would have to meet all day!

Take a minute and think about her, though—grinding out each sentence—me wondering where in the world it was going to go—waiting almost interminably for each idea to unveil itself—and to eventually experience just how wondrous it was to witness such life-revealing self-reflection. How could a therapist not marvel at the human capability that was co-existing with such daunting a physical disability!

As our therapy progressed, the emotional work Estelle and I did together chronicled her evolution in becoming a more whole person. She created a process where she found her inner self in a way she had never done—developing her own autonomy and independence by resolving longstanding introjects that, for the first time in her life, she was now ready to expel. Toward the end of our work together, she proclaimed,

I’ve overlooked myself … but I can discover me … I can see the good inside me now. That surprises me to hear myself say that, but I see I will make it … and I know now who I’ve been angry at, and I see that I don’t need to be angry at everybody anymore. I’m not quite proud yet, but I do like being alone with me now … I really do enjoy my company. I’m on my way.

When I began doing psychotherapy with older adults, I didn’t realize that the kind of emotional and spiritual trek that Estelle would make was more similar than different from the journey I made with clients in other age groups. This is my joy of working with older adults—to see them unveil to themselves and to me their indomitable wisdom. For me, this is a revelation perhaps most profound in those who have lived with their darkness for so long.

Myth #2: The grief, loss, and somatic and socioeconomic burdens of the elderly are too excessive to warrant believing they could get better.

There is a great deal of pessimism about doing effective psychotherapy with older adults. Many of these clients have limited resources to face unimaginable social, medical, and economic struggles, and many clinicians tacitly believe that the elderly’s frustration, deprivation, fear, and dependence are so emotionally injurious that no amount of psychotherapy could really help them. When I began my psychotherapy career with the elderly, I wondered about these things too. With experience, though, what I learned was that it was not my clients’ deprivation and burden that was too excessive—it was my own. It was my inability to cope with my fears and frustrations working with excessively burdened people, and I was projecting these issues into my elder clients.

Marge was a ten-year resident of her nursing home. Legally blind, she had a longstanding diagnosis of mild mental retardation and had been institutionalized with paranoid schizophrenia for much of her life. When her mobility began to fail and her dementia and other medical conditions became too much for her family caretakers to manage, she was admitted to a skilled nursing facility. In order to address issues of depression and to help her manage her psychotic symptoms, for almost three years I saw Marge weekly for psychotherapy. I wondered if the odds of Marge overcoming her burdens were too great. I wondered if she could fight the good fight. What I came to learn, though, was that I was actually asking that of myself.

Like many people with schizophrenia, Marge was an isolationist, and this often exacerbated her psychotic symptoms. The structure and consistency of our weekly visits, though, allowed her to quell many of her paranoid thoughts, and she made remarkable progress. For the first time in many years, she was successfully managing most of her troubling and longstanding paranoid symptoms. Her solitary lifestyle, however, unintentionally reinforced her chronic feelings of loneliness.

As does happen sometimes, changes in my own life forced me to turn her psychological care over to another clinician, and we spent two months planning for the transfer. As you might imagine, my concern was that my departure would lead her to regress into further isolation. As it turned out, though, my underestimation of her strengths and concerns about her succumbing to her fears were a projection of my own issues.

In the waning weeks before my departure, Marge began to voice her sadness with our impending termination, and this was clinically therapeutic for her. She also began to tell me about the new and pleasant experience she was having on "the boat," so asked her about it.

Marge: "I will miss you."
Dr. Kraus: "Yes. It's sad that our therapy together is going to end. You have made great progress, and I am proud of you. I know you will continue your good work with Dr. Hamilton. … You had mentioned to me about a boat. Can you tell me more about it?”
Marge: "Oh, yes! We travel around."
Dr. Kraus: "Do you, now! Where have you been?"
Marge: "Well, we're going to France."
Dr. Kraus: "Really! How nice! It sounds like a cruise ship."
Marge: "Not really.{whispering} It's a submarine, but you can't tell anyone."
Dr. Kraus: {with curiosity} "How come?"
Marge: "Because they might throw me off!"
Dr. Kraus: "I see. What's it like for you traveling to all these places?"
Marge: "There's a group of us … my roommate … and a few more … and Nancy {one of her nursing assistants} … I like it."
Dr. Kraus: "That's terrific. It sounds like you're seeing that while you are sad our therapy is ending, you also see that you will have some good friends here with you after I am gone."
Marge: {Smiling and in a very calm and self-assured voice} "Yes, I will." 1

And so it was with Marge that I learned two very important lessons: 1) even with a mentally retarded, schizophrenic, aging nursing home patient with dementia, extraordinary things can be accomplished, and 2) the fears and discounting of her strengths that I imagined within her were really projections of my own.

Myth #3: Old people are staid in their ways; they are too stubborn to change.

In some of my geriatric workshops, I ask the audience what the four essential signs of aging are. Invariably, they will say things like grey hair, illness, and memory loss. Then I tell them my four: wisdom, confidence, character, and strength! I tell them that I threw them a little curve-ball, but they get the point that we often ignore or minimize the tremendous assets and capacities possessed by older adults. We overfocus on their liabilities and underrecognize their strengths. We miss how many competencies increase with age: appreciation, authenticity, desire to help, maturity, patience. Being stubborn can imply having mettle to take a stand and stick to it, and it is often quite effective for a psychotherapist to run with a resistance than to try to overcome it. It also occurs to me that to say that the elderly are staid may again say more about the patience, optimism, and confidence of those who serve them than anything else.

In Psychotherapy with the Elderly, psychologist George Bouklas offers an extraordinary account of a conversation with Errol, an 82-year-old patient of his with mild dementia, who entered a nursing facility for rehab following a colostomy. Errol never accepted his surgery, was constantly angry and agitated, and would routinely resist medical care. He was referred to Bouklas for ripping off his colostomy bag and spreading its contents across the room. He then would ask the staff what the fuss was all about! Here’s a powerful and provocative excerpt from their therapy:

Errol: (in an angry tone) "I stopped spreading shit on the floor.”
Bouklas: (silence)
Errol: "I told you, I stopped spreading shit on the floor! You act like that doesn’t matter! Well, does it matter to you?”
Bouklas: "Should it matter to me?”
Errol: "I thought you might be proud. The room doesn’t smell like shit anymore.”
Bouklas: "What’s wrong with the smell of shit?”
Errol: "You mean you liked it?”
Bouklas: “I like everything about you, no matter what it looks like, what it sounds like, or what it smells like.”
Errol: (now weeping) “You son of a bitch, if you’re lying to me I’ll kill you.”
Bouklas: “If I was lying to you I would deserve it.”2

Errol is typical of most elderly clients in that their stubbornness is a defense, albeit maladaptive—an indication that something more loathsome, more unacceptable, more humiliating may lie beneath. From my point of view, the word “staid” is an exemplar to some extent characterizing every psychotherapy client.

All clients resist—they all hold on to old patterns of thought and action. Resistance is the sin qua non of all psychotherapy, and it is no less true of the elderly. But when clients are unblocked, when resistance evaporates, psychotherapy with the elderly is an amazing thing. When we can help our clients abandon their defenses—even for just a moment—we create in the therapy a transcendent experience that elevates and inspires. It takes something special to really dare to live, and I feel privileged to witness them doing it. If we are open to our undeniable emotional connection to our clients, we can truly witness their transcendence—and it then emphatically becomes our own. With the elderly client, the metamorphosis is no less exalting, no less divine.

Growing old changes the way people relate to themselves and to others. The aged are often dealing with three principal issues: (1) how to adapt to the biggest transition of their lives—their changing health, the idea of getting older, and their changing family and work roles, (2) how to cope with the grief and loss that accompany their advancing age and decreasing abilities, and (3) how to manage their interpersonal relationships with others. As people advance in age, they go through an immense life transition—their role in their family changes, their view of themselves as a healthy person changes, and their sense of their own longevity and mortality changes. If kept silent or hidden, the feelings underlying these transitions often get acted out in disguised forms. Listening to and being there for the elderly client is invaluable to them not only because it makes available a problem-solving process that may ameliorate their distress, but also because it brings a heightened sense of connectedness and bonding with you. When this happens, they are not alone, and in that moment, neither are you.

Grief over family that's passed on, sadness over their sense of lost usefulness, loss of their former and more active pursuits that once gave them so much pleasure all make it more difficult for aging people to emotionally cope with their circumstances. Simply listening with supportive understanding and making meaningful emotional contact can bring them a sense of calm and solace. More than that, though, most of my older clients have the capacity for and can benefit from deeper emotional work. Not always are they aware they are engaged in such work, but my experience has been that it doesn’t really matter whether they are aware of it or not. It can go on, and they can reap the benefits of it nevertheless. Although the person's memory for recent events may be lacking, long-term memory, especially for well-learned actions, events, and knowledge, is one of the last cognitive abilities to decline. By helping them share something important and meaningful about their own lives, you bring into your here-and-now relationship with them the feelings of closeness they have experienced or longed to experience with others. In my view, this is so important in facilitating the growth process.

Geraldine was one of my depressed nursing home patients. Her Alzheimer's was at a moderate stage, and she could not remember my name to save her life. I met with her every week for months, and at every session she had trouble recognizing me. "Its Dr. Sparky," I would say. The social worker at the nursing home who introduced me to each of the residents there liked telling them my nickname, and that's how everybody soon started knowing me. When she would hear this, Geraldine's brow and eyelids would rise ever so slightly. "I'm your psychologist," I would say. I would prompt her recall with a verbal sketch of my role and why we were meeting. With this, you could begin to see her recognition building and she began feeling more at ease with me. I never really knew for sure that she actually was recognizing me, but it really didn’t matter, because she felt more comfortable with me.

As a rule, Geraldine's mood was irritable, she had a cynical view of the world, and she isolated herself excessively. Keeping to herself was a real problem for her, because she had begun to develop sores on her backside from lying in bed so much. When she wasn't in her bed, she was lying in her recliner. Her sores were becoming so severe that the medical staff felt they would soon threaten her life. Despite forgetting who I was and what we had talked about the week before, after a number of sessions together she began to learn that she could trust me. This is not learning that is taking place in the cerebral cortex but learning that new neuroscience research explains is occurring at a subcortical level. One thing was true—I enjoyed her sarcasm, and she could see that. I encouraged her to socialize more with others, to give others a second chance, but it was not my expertise or even my words that made a difference—it was her trust in me that eventually allowed her to risk taking my suggestions to heart.

You see, underneath her rough exterior, Geraldine really was a sweetheart. As she allowed herself to trust me, she learned that she just might be able to trust others as well. As she allowed others to know her, they began to see her sweetness, too, and as she socialized more, her depression began to lift, she spent less time in her bed and chair, and her sores began to heal.

Along with her physical healing, Geraldine experienced a significant emotional healing. Just how emotional healing occurs in therapy is still quite a mystery, but for Geraldine, it seemed to occur at a level that went well beyond what she could articulate in words or what she could remember. In this sense, her Alzheimer's did not prevent her emotional recovery. Her learning seemed to take place not within her cognitive self but as a consequence of how she felt about her relationship with me and, later, with others. Communication with her took place beyond words, beyond logic, beyond conscious thought.

“What I learned from Geraldine was that in psychotherapy, words are overrated—I learned that it is the relationship that can heal.” I have often mused about how insightful my interpretations were in a session and believed how it may have been my pithy comment that was a turning point in the therapy. That seems almost never to have been the case. When my clients recall their own turning points in therapy, it almost never has to do with anything I have said but almost always relates to something I have done or been for them. Being with them in their “staidness” may be the most effective thing I do with my older clients.

This type of healing occurs because an emotional reconciliation is reached within the aging client that has more to do with restored faith, with renewed hope, and with enhanced trust in the world, in themselves, and in their relationships with others than it has to do with cognitive functioning per se. Granted, cognitive decline generates fear, anger, suspiciousness, loss, and any number of other difficult and challenging emotional experiences—but the aging process impairs emotional functioning on a biological level only in its final stages. And that's why many people with Alzheimer's can be comforted and counseled, can feel support from others, and can reach a greater sense of peace with their experience. It's your empathy that eases their suffering. It's your empathy that cultivates their sense of joy in the life they might see they are blessed to be living and can give thanks to have lived.

How Clinicians Get Stuck: Some Emotional Risks in Working with the Aged

For several years, I led a biweekly consultation group with psychologists and master’s-level clinicians interested in learning from their own experience with their elderly clients. Some of what we discussed had to do with gerontology, cognition, testing, contracting, and the like, but much of what we discussed related to the emotional lives of the clinicians when they were with their clients.

Despite the growing evidence on the effectiveness of psychotherapy with the elderly—even with those who have dementia—psychotherapists underserve this population of clients. One of the reasons for this stems from how clinicians defend against the knowledge of their own physical and emotional mortality and the terror of their own vulnerability and dependency. I believe that this is especially true in psychotherapy with the dementia patient, where, in some form, the death of the cognitive self is confronted.

Another reason psychotherapists shy from involvement with older adults arises from the necessity for therapists to manage their own unresolved internal representations of parental and grandparental figures. Much has been written about how the older client sees a younger therapist as a younger (adult) child. When this occurs, the client needs to work through issues within the therapeutic relationship that mirror unresolved issues in the client’s relationship with his or her own children. Younger therapists, especially, can have a difficult time addressing an older client’s provocative comments like “You’re just a kid. What do you think you know about what I am going through?” In the reality of older adulthood—where the older client is increasingly dependent on younger caretakers—the unjustified but prejudicial attitude that older clients can develop toward their younger therapists can be exceptionally challenging.

It is generally understood that psychotherapy occurs within an intersubjective field—where the therapist and the client affects and is affected by the other. At some level, the therapist is always experiencing what is emanating from the client, and the client is always projecting into the therapist his or her needs, fantasies, and stereotypes. And the therapist cannot help but do the same. When skillfully observed, this can lay the groundwork for significant therapeutic gains. The therapy progresses when the therapist is aware of these processes and can use them to move the therapy forward. The less therapists are trained to do so, or the more they are hampered by their own complete internal resolution, the more likely that these processes will be acted out within the therapeutic relationship, and the less likely these processes will be therapeutically worked through. The less therapists are aware of their own projections, the more their idealized and devalued stereotypes of “old age” will unknowingly creep into the therapy, and the meaning they unknowingly assign to “old age” will color their relationships with their clients. Signifiers that should alert therapists that they may be developing distorted attitudes toward their clients are:

  • the assumption that an elderly client would not benefit from therapy,
  • the assumption that medication would be preferable to psychotherapy,
  • the attitude that a client may be too old, too stubborn, or too burdened to benefit from psychotherapy, and
  • prominent feelings of boredom, anxiety, or frustration when with a client.

In America, we honor the young for their beauty, strength, and vitality. However, in other places on the globe, old men and women are objects of veneration. This leads to a curious consequence: the less we acknowledge what can be respected, admired, or even venerated in the parents and grandparents of the world, the more we make ourselves orphans who lose a piece of our faith, security, and connection to a past that we risk repeating. This has been part of my joy in working with older adults: I am able to honor them, to sit at their feet, marvel, and learn. As their therapist, I have become their faithful student, their privileged witness, and my life is ever richer because of it.

Footnotes

1 Kraus, G. (2006). At wit's end: plain talk on Alzheimer's for families and clinicians. West Lafayette, IN: Purdue University Press.

2 Bouklas, G. (1997). Psychotherapy with the elderly: Becoming Methuselah’s echo.Lanham, MD: Rowman and Littlefield.

Kenneth Doka on Grief Counseling and Psychotherapy

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Defining Grief

Victor Yalom: Let’s start with the basic building blocks. What is grief and what is its function?
Kenneth Doka: I think it’s probably important to acknowledge and recognize that grief is a reaction to loss. We often confuse it as a reaction to death. It’s really just a very natural reaction to loss and so we can experience grief obviously when someone we’re attached to dies, but we can also experience it when we lose any significant form of attachment. You can certainly experience grief in divorce, in separation, in losing an object that’s particularly meaningful or significant, in losing a job that has meaning or significance. Whenever we experience an attachment and we experience loss in that attachment, grief becomes the natural way we respond to that. We used to look at the function of grief as kind of allowing a process of detachment and a restoration of life in the absence of that person. Now we no longer really use that old sort of Freudian model. We really emphasize that people really don’t detach. They have a changed and continued bond with the person. It’s the process of adjusting to in many ways what’s going to be a new relationship and a different relationship rather than simply the abolition or detachment from a relationship.

VY: What’s your understanding of how grief helps that? Why is it necessary?
KD: I don’t know—necessary is sort of a strange word in this context. I think it’s just a natural reaction as we respond to a significant loss.
VY: There’s so much being written about evolutionary psychology these days. Is there anyone thinking or hypothesizing about some evolutionary or Darwinian function of grief?
KD: I think Bowlby points out that the initial response to grief arises from an evolutionary desire to reattach. We signal distress as a way of gaining attention and support and maybe rebuilding the bond—think of the child who’s lost in a store and the toddler all of a sudden starts crying and gets help and assistance and maybe even the mother hears the cries. Grief may come from that very basic sense of attachment, but even from an evolutionary standpoint, you can say, even then for an animal who loses a significant attachment, calling attention to oneself is a mixed blessing.
VY: You write that we’ve moved away from universal stages, such as the Kubler-Ross stages to individual pathways of grief.
KD: We used to look for some kind of universal reactions and Kubler-Ross was one such pattern. Actually, Kubler-Ross never really spoke, until later in her work, about applying this to grief; she was talking about a particular aspect of coping with dying, but even there, we move toward more individualized reaction. There are other people who attempted to find—Colin Murray Parkes at one point in his career attempted to find these kind of universal sort of stages that everyone goes through. But now what we recognize is that grief is highly individual and individuals grieve in their own way. Certainly their responses to grief can include a number of dimensions. We can respond to grief physically, on a very visceral physical level with aches and pains and all kinds of physical reactions. We can respond with emotional reactions—sadness, loneliness, yearning, jealousy even, anger, guilt are all relatively common reactions, as well other ones—just a sense of relief sometimes, when a person’s suffering has been very, very long. We can respond cognitively. We may think about the person. We may experience a sense of depersonalization. We may find it hard to focus or concentrate. We can respond behaviorally—again, acting-out behaviors or withdrawal or lashing-out behaviors or even things like avoiding or seeking reminders of the person who died or the thing that was lost. Of course, it can affect us spiritually. Again, everybody’s pattern of grief is highly unique.
VY: You make a point about denial, that people go in and out of denial. It’s not a black or white thing. How do you think about denial?
KD: I think probably most of my writing and talking about denial has probably been in the context of illness. There, what I would say is, again, denial is a basic defense mechanism. Avery Weisman uses a very good term when he talks about life-threatening illness. He talks about middle knowledge.
True denial is very, very difficult to maintain, but people sometimes choose not to focus on their illness, so it is more of a selective inattention than actual denial.
True denial is very, very difficult to maintain, but people sometimes choose not to focus on their illness, so it is more of a selective inattention than actual denial. Again, I think you see that same pattern in grief. It’s hard to really deny a significant loss, but sometimes we choose not to focus on it.

Intuitive vs. Instrumental Grieving

VY: Let’s get back to grieving styles, as that’s been one of your major contributions. You developed these ideas of the intuitive grieving style, which is a more emotional style of processing grief, versus the instrumental style, which is more cognitive and action oriented. Tell us about these and how you came up with these concepts.
KD: That was work I did with Terry Martin from Hood College. Originally, what we were doing was exploring the issue of gender and grief—on differences between the ways men grieve and the ways women grieve. As we moved on into that work and began to do some research, we found that these “male patterns” and “female patterns” were really more widely distributed than we had perceived.
VY: It wasn’t purely male or purely female.
KD: Exactly. We first moved into what we called—kind of with a Jungian perspective—masculine and feminine grief, knowing that men or women could have a more feminine pattern or vice versa. Then we realized that the gender connection was probably unhelpful and inappropriate, so we moved away from gender, although not entirely. We’re saying gender is one of the factors, certainly, that influences one’s grieving style, and certainly we would be comfortable in saying more men may have an instrumental style or lean toward the instrumental style in U.S. culture and probably in many Western cultures. So it’s influenced by gender, but not determined by it. And we look at this as a continuum, so many people are sort of in the middle or maybe an alternate visualization would be two overlapping Venn diagrams with some space separate and lots of space sort of shaped. People who are highly intuitive as grievers will often—when you ask them about their experience of grief, they’ll often talk about waves of affect and waves of emotion. When you ask them how that grief was expressed, it’ll mirror those reactions, “I just kind of felt this. I cried. I screamed. I shouted.” Their expression of grief mirrors their inner experience of grief. When you ask them what helps, how they adapted to grief, they’ll often talk about the fact that it really was helpful for them to find some place, whether in therapy, whether with a confidante, whether in a support group, whether in their own journaling or internal process, to sort of explore their feelings.

On the other end of the continuum are what we call instrumental grievers, and with them the very experience of grief is different. When you ask them how they experience grief, they often will talk about it in very physical or cognitive ways: “I just kept thinking about the person. I kept running over it in my mind. I felt I was kicked in the stomach. I felt somebody punch me.” When you ask them how grief was expressed, sometimes they’ll be curious about that question. They might respond at first “I guess I didn’t express much grief,” but then when you really talk to them about it, they’ll say, “I did talk about the person a lot” or “I was very active in setting up this scholarship fund.” They may not always recognize that as an expression of grief. They may actually be perplexed by their lack of affect. It’s not that they lack affect. Their affect is more muted. When you ask them what helps, it’s often the doing.
VY: You give a great example in your book, Grieving Beyond Gender, of a man whose daughter crashed into a neighbor’s fence and died, and he spent his time after the death rebuilding the neighbor’s fence.
KD: Right, and it’s important to recognize that was the most helpful thing he did. One of the things that sort of helped us think about this was — in my book on disenfranchised grief, Dennis Ryan does a chapter on the death of his stillborn son, which as we were thinking about this, really was a kind of enlightening moment. Dennis is a professor by vocation, but a sculptor by avocation. He talks about after his son was stillborn, this long-awaited child,
his wife would come back from work each day and go upstairs and have a good cry and he would be working, crafting the perfect memorial stone out of a piece of granite. As he’s chipping away at this granite and hearing his wife cry, he’s saying, “Why aren’t I grieving?
his wife would come back from work each day and go upstairs and have a good cry and he would be working, crafting the perfect memorial stone out of a piece of granite. As he’s chipping away at this granite and hearing his wife cry, he’s saying, “Why aren’t I grieving? Where is my grief?” Of course, it’s obvious where his grief was.

Bias in the Mental Health Profession

VY: You said that the mental health profession has had a strong bias toward intuitive or emotional grieving.
KD: Sue and Sue, in their book in Counseling the Culturally Diverse, describe western counseling as swallowed by affect, meaning that the quintessential counseling question is, “how do you feel?” In grief, we’d say a better question would be, “How did you react?” or “how did you respond?” By saying, "How do you feel?" you take one of the dimensions of the ways to respond to grief and make that the primary one.
VY: If this has been the dominant paradigm in counseling and therapy for grief, what kind of problems does that cause for the instrumental griever?
KD: For the instrumental griever, it may simply not validate the honesty of his response. There is one other type of griever we talk about in our book too. We certainly recognize that lots of people are blended. They’re sort of in the middle and they have characteristics of both. We also talk about dissonant grievers. Dissonant grievers are people who really experience grief one way, but find it difficult to express it that way. This might be the male who feels he has to maintain a strong image and though he’s strongly intuitive in his experience, he does in fact repress his emotions.
VY: You also mentioned disenfranchised grief. Can you define that?
KD: Sure. Disenfranchised grief refers to losses that people have that aren’t always acknowledged or validated or recognized by others. You can’t publically mourn those, receive social support or openly acknowledge these losses. This actually started with research I did on ex-spouses — what happens when your ex-spouse dies. A lot of these people really couldn’t get time off from work, because after all, ex-spouse isn’t in the grief rules, the bereavement leave, but whether it’s an ex-spouse or not, you often had a strong relationship and a continued relationship with that person. Then we expanded it. Now when we talk about disenfranchised grief, we talk about a host of relationships that aren’t recognized—teachers, mentors, coach, therapist, patients. Think about that. This would be an interesting dimension. You have a profound relationship with a patient—in some cases, on either end, and when the therapist dies, especially if nobody knows they’ve been seeking therapy, they may have had a significant loss and yet really no opportunity to openly acknowledge or mourn that loss.
VY: When it’s disenfranchised, it’s not noticed or valued or accepted by others that this is really a significant loss.
KD: Or you may just be ashamed to bring it up. In other cases where the loss isn’t always recognized, such as divorce or…we’re better on perinatal loss than we used to be, but for mothers, not necessarily for fathers and siblings and grandparents and others. It’s sometimes when the griever isn’t recognized as being capable of grief—somebody with intellectual disabilities or sometimes the very old or the very young. Sometimes it’s a result of the type of loss that the person experiences—suicide, AIDS, homicide. Then just the ways the person grieves—grieving styles may not be always acknowledged. We do a strange thing with grieving styles. I always say we disenfranchise instrumental grievers early in the process. “What’s wrong with this person? Why isn’t he crying?” We disenfranchise intuitive grievers later in the process. “What’s wrong with that person? He or she is still crying. Why haven’t they gotten over it yet?” Of course, sometimes it can be for cultural reasons. Again, different cultures have different rules about how one is to mourn and especially in bicultural families, others may look askance at different people’s grief.
VY: Once you start throwing in all these factors—different grieving styles, disenfranchised grief, cultural differences—if we move into the area of counseling, how do you help bereaved people? It can get fairly complicated.
KD: It can, which shouldn’t be surprising, because it is always complicated.
VY: Let’s start with the grief styles. Grief is a fairly universal process, but as you pointed out, people grieve differently. How do you even know if grief counseling or a support group or some other type of intervention is necessary to begin with?
KD: I think that’s a very good question, because I think the truth is that most people—and studies vary between 80% to 90%—probably do pretty well without any formal intervention or may just need what we would call grief counseling in the sense of just some validation that says, “No, it’s understandable. No, you’re doing okay.”
VY: So, that would be normal, uncomplicated grieving in?
KD: Yes, that would be a normal, uncomplicated kind of grieving. Bibliotherapy can be so effective with these people, as it provides that basic validation. It provides some good psychoeducation. It may provide some ideas for coping and certainly says that most people get through this. That may be all that’s needed, or they may benefit from psychoeducational seminars, or support groups, or even in short-term counseling. Others may have more significant reactions. One of the things that’s kind of interesting now is there’s some movement to create a category for the next DSM, the DSM-V, called Prolonged Grief Disorder. There are some critics about that, but at this point in time it’s probably an even bet as to whether it’s going to be included or not. Certainly people who are self-destructive, certainly people who are destructive with others, certainly when grief is disabling—where a person really is having a difficult time functioning in a work role or functioning in another role—these are good examples of grief which is more problematic.
VY: Okay, so say you have someone who, for whatever reason, has sought out grief counseling or is already in therapy and then experiences a significant loss. You’ve written that it’s important to first assess what their grieving style is. How do you go about doing that?
KD: First, you ask them about how they’ve tended to experience grief. You ask them about their history about how they’ve dealt with losses before, how they’ve experienced and expressed and adapted to losses before. There are a variety of ways you go about that. And then you ask them about how they have responded to the current loss. An intuitive griever might say, “I just feel sad all the time. I have this overwhelming sense of sadness.” An instrumental griever would probably answer in another domain: “I just can’t concentrate. I just can’t focus since he died. I feel like somebody punched me in the stomach.” So the key to any assessment is asking questions that don’t necessarily prompt one response or another, and then really listening to the language that they use. The book I’d really recommend for people who are starting out in this field or who just need a little bit of a refresher is Worden’s book Grief Counseling and Grief Therapy. Beyond grieving style, there are a lot of things you have to assess.
VY: And as you’ve said, some people are fairly clear-cut, whereas others are blended grievers.
KD: You’ll get a sense for blended grievers as you hear them describe how their grief experience is now versus how they’ve reacted historically to losses. The tip-off would be that if somebody says, “I’ve had a very close relationship with this person and I responded this way,” but you notice that they’ve tended to respond other ways in the past. Maybe they’ve always responded in an intuitive way before and now they’re dealing in a much more instrumental way; that’s when it really becomes kind of intriguing and you really want to ask, “Why the difference now when historically you’ve coped and responded in these other ways?”
VY: I think most counselors or therapists have a pretty good sense of doing therapy with an intuitive or emotionally-based person. That’s the paradigm we’re used to. That’s what we think of. If you have someone who is pretty clearly on the instrumental end of things, what implication does that have? How would you conduct therapy differently?
KD: You start out by respecting and validating that style and helping them draw on their historic strengths. You don’t try to push them to an emotional place that’s going to be very uncomfortable for them. You say, “You’ve mentioned that you’re dealing with a little bit of this guilt. What has helped you before?” Maybe it’s helping them construct some kind of active way to deal with that guilt or to memorialize that person or to do something else. You build on their strengths.
VY: You support them and normalize their reactions.
KD: You support them and normalize. For instance, if I had a Dennis Ryan who said, “I don’t know. I’m not grieving. My wife cries every day and I just hammer away at this stone,” then you might try to help them recognize that that is his expression of grief and it’s a legitimate expression of grief. And you might ask, “Where does that help you? Where are its limits? What else do you need to work with as you deal with this?”
VY: You said there are some more complicated cases. Someone may be an intuitive griever, but for one reason, they’re not accessing their natural response or vice versa. Why might that be?
KD: I think you try to ask what are the inhibiting factors. Maybe the person needs a safe space. For instance, one case I had was a person whose young daughter died of cancer. He tended to be very emotional with other losses, but in this case he removed all the pictures of his daughter—he didn’t want any reminders—and that caused a conflict with his wife. That’s what brought them, really. His wife basically said, I can’t deal with you this way. You need to seek help.
VY: This can create real conflict among couples.
KD: Sure. If they have a different grieving style and they don’t recognize that. This is an extreme case in which it did cause conflict. This guy was an engineer by training, and it was very, very clear that from his past history that he tended to experience things on a very emotional level, but was really repressing emotions in this case. We talked about that and he said, “I’m really fearful if I start letting go of some of these emotions, it’ll be like a dam bursting and I won’t be able to control myself.” And I responded “Don’t dams have an overflow valve?” I’m sort of well known among my friends for not being particularly mechanical or handy. The joke is that my favorite tool is my checkbook. So I was very proud that I figured out that analogy! Then we used that analogy, that he has to find safe places to release some of this emotion and we talked about the strategy of dosing. You can control it. You can dose it.

He found ways to do that. One of the things he used to do was he had a particular song that reminded him of his daughter and he played that on his way home from work and he’d weep. That would reduce some of the energy of his grief, the issue. Then, over time, he was able to begin to talk about his daughter and begin to become confident that he didn’t always have to keep things bottled up. He was able to talk about it and release some of his emotion and at times cry with his wife, and this wasn’t going to leave him fully losing control.

Grief Counseling in Action

VY: Would you say it’s still the case that most therapists don’t get much specific training in grief counseling?
KD: It scares me, yes.
VY: Why does it scare you?
KD: I think that there’s been a real explosion of material about grief in the last 20 years. In my mind, it’s become a specialty. I see clients who have come and say, “I’ve been working with my therapist, but I still can’t accept the loss.”
And you know they’re coming from a kind of Kubler-Rossian kind of model and you’re thinking, “My God, people haven’t been doing that stuff for 15, 20 years in the field.
And you know they’re coming from a kind of Kubler-Rossian kind of model and you’re thinking, “My God, people haven’t been doing that stuff for 15, 20 years in the field.” What we’re saying is that you continue a bond with the person, that it’s very, very normal throughout your life, that you’re going to have surges of grief maybe 30 years later. Your dad died and 30 years later, your granddaughter’s walking down the aisle and you’re thinking, “I wish my father were here to see that.” This is very normal stuff and as I said, there’s a lot of poor information about grief out there, which I think is being filtered into some therapeutic context. I think people who are going to do grief counseling need to really keep abreast of the literature in it.
VY: All therapists have to know how to deal with this. I mean, even if you’re not trained as an addictions counselor, you’re going to have clients who come in for one reason and then you’re going to find out that they have an addiction. Similarly, you’re going to have people that come in to your practice as a general practitioner that are dealing with grief—either as a presenting complaint or in the course of therapy, they’re going to have losses. But I think they really don’t know how they should respond to a grieving client, other than of course being empathic and supportive.
KD: I think there’s some basic information that, therapists ought to be aware of. As I said, we’ve moved away from stages to more universal pathways. We’ve moved away from detachment to a paradigm that emphasizes that we continue a bond with the person. There’s a number of ways that our understanding of grief has changed.
VY: If you had to give some bullet points or a primer to a therapist who does not have specialized training in grief counseling, what are the things you think they need to know or skills that would be good to develop?
KD: I think number one would be to recognize grief in its many manifestations, not just as a response to death, but as a response to any significant loss. I think to understand the fact that we have our own personal pathways, that we do not detach but continue a bond with the person who died, that we recognize the increasing importance of how culture frames our response to grief.
VY: You mentioned culture a couple of times. Can you think of any cases you’ve dealt with or supervised where cultural aspects have been important?
KD: It’s a hard question to answer, because I think culture always has to play a role; every case I supervise has a cultural aspect. I’m half Hispanic and in Hispanic culture, godparents are very, very important. If somebody comes in, they may very well in fact be mourning a godparent and a therapist who’s not familiar with that culture may be trying to figure out why that role is so significant. They’re actually called comadres, compadres—meaning literally co-parents or parenting with.I think understanding how culture affects attachment, how it affects the expression of grief, how different cultures have different rituals—these are all critical pieces to take into mind.
VY: Any case examples jump out as you’re talking about it?
KD: I remember dealing with a client who is Native-American and we used some of the expressive arts. Ultimately he did some wood carving as a way to memorialize the loss, and I think that was very culturally compatible with who he was and what he was and with his culture. It’s kind of a totem-like thing that he ended up carving as a memorial to the person who died.
VY: Was that something he did on his own or did the therapist encourage him to do this?
KD: The therapist encouraged him, by first asking, “What do you normally do?” Again, it’s a sensitivity to what interventions and what strategies work well with what types of people. I just want to go back to make one other comment on those bullet points. The last bullet point I would emphasize is that, I think one of the things we’ve moved away from, as a field, is just asking the question, how do we cope with grief to how has this loss changed us? I think there’s also been a recognition of what some theorists have called post-traumatic growth, that for some, a significant loss is sometimes a spur to significant personal growth.
VY: People that are with their partner or loved ones at the time of death often talk about this being a powerful experience, even a sacred experience, although they might not identify themselves as being religious or spiritually inclined.
KD: They may not be religious, but inevitably it’s a spiritual experience, because it has to do with issues of meaning and transcendence.
As an aftermath of death, people may experience growth in skills, they may have new insights, new priorities in their life, a renewed spirituality
As an aftermath of death, people may experience growth in skills, they may have new insights, new priorities in their life, a renewed spirituality—there’s lots of changes that can occur. Again, sometimes they can go on and use these losses to make very significant changes. I think of John Walsh, host of America’s Most Wanted, whose son Adam was kidnapped and ultimately found decapitated. When he first realized his six-year-old son was missing, the police took a very nonchalant attitude and they said, “If he’s still not here in 24 hours, we’ll go look for him.” He then went on a crusade to change the way we as a society responded to the issue of missing children. The woman who founded Mothers Against Drunk Driving again used her grief to change the way we looked at drinking and driving in the US. It’s very different now than it was 30 years ago. Even teenagers are aware of the fact that there are real complications if you do this. So sometimes grief can be a spur to significant social action as well.
VY: What are some common mistakes or countertransference issues that therapists and grief counselors deal with?
KD: Again, I think failing to recognize the personal pathways, to accept that the client’s ways of grieving, and of not being aware of whatever countertransference issues you have in terms of loss or working through loss. I think using outmoded theories, using outmoded methodologies or even having a single approach.
VY: What about burnout or compassion fatigue?
KD: I think that’s a big issue in grief counseling, because you’re working with people in the midst of suffering. The research on that has really kind of emphasized that self-care is critical in the sense that you validate your own loss, especially if you’re working with people who are dying or ill, and you look toward your own spirituality, however you define it, as to how you deal with suffering and loss and that you find significant ways to find respite.

I think it’s also emphasized that organizations have a responsibility which includes providing support for their staff, providing validation for their staff and maybe even providing opportunities for the staff to engage in their own rituals as a way of validating and supporting their loss. Years ago, I worked with a project where staff dealt with foster parents who were taking on HIV positive kids and this was right at the very beginning of the epidemic, when the standard rule of thumb was that a third of the kids died within six months, another third died within the first year and everybody was dead within three years. They found their social work nursing staff was deeply affected by these losses and so they provided a range of supportive services, including an in-house ritual whenever a child died and a staff support group, as well as and the informal support of administrators recognizing the significance of those relationships and losses and really trying to be supportive to staff in whatever ways they could be.
VY: It seems there’s also a particular problem—you’ve talked about the bias towards intuitive grievers in terms of clients, but it seems there’s also a problem for therapists or counselors who are more instrumental in their grieving style, because working in the mental health field, they can easily be made to feel that they’re not empathic enough or that there’s something defective about them.
KD: I think there’s a paradox there and the paradox is that very often people who get into grief counseling field do it as an instrumental way of coping—so they often can find themselves disenfranchised by the field they selected. I think that was why when I worked on styles of grieving, which we thought was so contrary to the conventional wisdom at the time—that it was so supported by grief counselors, because they acknowledged and recognized what they saw in themselves.
VY: Ron Levant has a different terminology for that, what you’re referring to as instrumental grievers, he talks about as action empathy. Empathy is not just feeling another person, but you can act in ways that are empathic. You give examples of that in your book as well—that someone who takes care of their dying spouse and does a lot of things after the death, but they still feel like they’re not empathic enough because they don’t feel the loss as much as other people do. I think there tends to be a confusion between feeling intensely and empathy, which are in fact two separate concepts. I mean you can feel a lot, but that doesn’t mean you’re actually behaving in a way that’s empathic toward someone.
KD: Right. I would agree with you.
VY: And conversely, you may not feel others so intensely, but you can care deeply about someone and act in a way that is putting their needs first.
KD: Yeah, very definitely.
VY: So, it seems that this can really be troubling to counselors or therapists that are doing good work but have this idea that if they don’t feel a lot—and that idea may be reinforced by their colleagues—that there’s something wrong with them.
KD: Well, a lot of the clinical training is affectively based.
VY: Any thoughts about individual counseling versus group counseling or support groups. How might you make that determination on what would be most appropriate?
KD: For uncomplicated people who are grieving, a support group can be very, very fine. When you look at the research on grief counseling it shows that you need a careful assessment and an individual targeting of intervention. As far as the question of support groups, you need to look at whether the support group is well run, and does it have an emphasis on positive coping and even potentially transformation? You know, how is this experience changing you?
Sometimes the problem with support groups is they can be just places of what we call "shared anguish" where everybody just kind of comes in and says, "Hey, if you think that story’s bad, let me top it off."
Sometimes the problem with support groups is they can be just places of what we call "shared anguish" where everybody just kind of comes in and says, "Hey, if you think that story’s bad, let me top it off." And so you come out of the support group thinking, "Wow, you know, the world’s hostile." So, a good support group leader would say, "Okay, yeah, that was a pretty horrible experience, but how did you cope with that, and how have others of you coped with experiences like that and what have you learned from those?" So there’s got to be this notion of emphasizing not just the sharing of anguish, but also how we kind of deal with that anguish.
VY: I imagine support groups also can be problematic for instrumental grievers if the focus is primarily on expression of affect.
KD: Yeah, it can be. There was the Harvard bereavement study found that, for instance, single dads benefitted more from more problem-oriented support groups like "How to be a good single dad,” rather than groups that really focused on their grief experience.
VY: So, that would be, of course, important to assess that grieving style in making a referral. What are you currently working on now?
KD: Well, we’re doing a book now on spirituality in loss for the Hospice Foundation of America, and so that’s my current project right at the moment. We’re looking now at the issue of spirituality a little bit more deeply.
VY: And just to wrap up, what are some of the most meaningful things you have learned personally and professionally working in this field for several decades?
KD: Well, I’ve very much enjoyed my involvement with two professional associations, The International Work Group on Death, Dying and Bereavement, and The Association of Death, Education, and Counseling. The International Work Group is an invited group—you have to be involved in the field to be invited to join it. But the Association, anybody who’s really interested in grief counseling should join and you’ll benefit tremendously from your experience in that. I very much have found my work with the Hospice Foundation of American to be extraordinarily meaningful, because in many ways—we publish a newsletter for the bereaved called Journeys—and I think what’s really been exciting about that is getting some of the best people in the field to do some writing, really with a self-help emphasis, and really taking some of the best of current theory and practice and really translating it to a lay public. And that newsletter goes out to 60,000 people a year, so that’s a significant segment of people for a bereavement newsletter. And then, of course, I love teaching graduate students at the college in New Rochelle. That’s always a meaningful experience for me.
VY: Well, I think this has been a great—we’ve packed a lot of material into one interview and I think it will be of great interest to our readers. Thank you for taking the time.
KD: Thank you for the thoughtful interview.

Staring at the Sun: Overcoming the Terror of Death

Posted on by rezendevknowfully.com

THE MORTAL WOUND (from chapter 1)

Self-awareness is a supreme gift, a treasure as precious as life. This is what makes us human. But it comes with a costly price: the wound of mortality. Our existence is forever shadowed by the knowledge that we will grow, blossom, and, inevitably, diminish and die.

Mortality has haunted us from the beginning of history. Four thousand years ago, the Babylonian hero Gilgamesh reflected on the death of his friend Enkidu with the words from the epigraph above: “Thou hast become dark and cannot hear me. When I die shall I not be like Enkidu? Sorrow enters my heart. I am afraid of death.”

Gilgamesh speaks for all of us. As he feared death, so do we all—each and every man, woman, and child. For some of us the fear of death manifests only indirectly, either as generalized unrest or masqueraded as another psychological symptom; other individuals experience an explicit and conscious stream of anxiety about death; and for some of us the fear of death erupts into terror that negates all happiness and fulfillment.

For eons, thoughtful philosophers have attempted to dress the wound of mortality and to help us fashion lives of harmony and peace. As a psychotherapist treating many individuals struggling with death anxiety, I have found that ancient wisdom, particularly that of the ancient Greek philosophers, is thoroughly relevant today.

Indeed, in my work as a therapist, I take as my intellectual ancestors not so much the great psychiatrists and psychologists of the late nineteenth and early twentieth centuries—Pinel, Freud, Jung, Pavlov, Rorschach, and Skinner—but classical Greek philosophers, particularly Epicurus. The more I learn about this extraordinary Athenian thinker, the more strongly I recognize Epicurus as the proto-existentialist psychotherapist, and I will make use of his ideas throughout this work.

. . . Had I been a citizen of ancient Athens circa 300 B.C.E.(a time often called the golden age of philosophy) and experienced a death panic or a nightmare, to whom would I have turned to clear my mind of the web of fear? It’s likely I’d have trudged off to the agora, a section of ancient Athens where many of the important schools of philosophy were located. I’d have walked past the Academy founded by Plato, now directed by his nephew, Speucippus; and also the Lyceum, the school of Aristotle, once a student of Plato, but too philosophically divergent to be appointed his successor.

I’d have passed the schools of the Stoics and the Cynics and ignored any itinerant philosophers searching for students. Finally, I’d have reached the Garden of Epicurus, and there I think I would have found help. Where today do people with unmanageable death anxiety turn? Some seek help from their family and friends; others turn to their church or to therapy; still others may consult a book such as this. I’ve worked with a great many individuals terrified by death. I believe that the observations, reflections, and interventions I’ve developed in a lifetime of therapeutic work can offer significant help and insight to those who cannot dispel death anxiety on their own.

. . . Why, you may ask, take on this unpleasant, frightening subject? Why stare into the sun? Why not follow the advice of the venerable dean of American psychiatry, Adolph Meyer, who, a century ago, cautioned psychiatrists, “Don’t scratch where it doesn’t itch”? Why grapple with the most terrible, the darkest and most unchangeable aspect of life? Indeed, in recent years, the advent of managed care, brief therapy, symptom control, and attempts to alter thinking patterns have only exacerbated this blinkered point of view.

Death, however, does itch. It itches all the time; it is always with us, scratching at some inner door, whirring softly, barely audibly, just under the membrane of consciousness. Hidden and disguised, leaking out in a variety of symptoms, it is the wellspring of many of our worries, stresses, and conflicts.

I feel strongly—as a man who will himself die one day in the not-too-distant future and as a psychiatrist who has spent decades dealing with death anxiety— that confronting death allows us, not to open some noisome Pandora’s box, but to reenter life in a richer, more compassionate manner.

So I offer this book optimistically. I believe that it will help you stare death in the face and, in so doing, not only ameliorate terror but enrich your life.

OVERCOMING DEATH TERROR THROUGH CONNECTION (from Chapter 5)

THE POWER OF PRESENCE

One can offer no greater service to someone facing death (and from this point on I speak either of those suffering from a fatal illness or physically healthy individuals experiencing death terror) than to offer him or her your sheer presence.

The following vignette, which describes my attempt to assuage a woman’s death terror, provides guidelines to friends or family members offering aid to one another.

Reaching Out to Friends: Alice

Alice—the widow whose story I told in Chapter Three, who was distressed at having to sell her home and her memory-laden collection of musical instruments—was on the verge of moving into a retirement community. Shortly before her move, I left town for a few days’ vacation and, knowing this would be a difficult time for her, gave her my cell phone number in case of an emergency. As the movers began to empty her house, Alice experienced a paralyzing panic that her friends, physician, and massage therapist could not quell. She phoned me, and we had a twenty-minute talk:

“I can’t sit still,” she began. “I’m so edgy I feel I’m going to burst. I cannot find relief.”

“Look straight into the heart of your panic. Tell me what you see.”

“Ending. Everything ending. That’s all. The end of my house, all my things, my memories, my attachments to my past. The end of everything. The end of me—that’s the heart of it. You want to know what I fear. It’s simple: it’s no more me!”

“We’ve discussed this in other meetings, Alice, so I know I’m repeating myself, but I want to remind you that selling your house and moving to a retirement home is an extraordinary trauma, and of course you’re going to feel major dislocation and major shock. I would feel that way if I were in your place. Anyone would. But remember our talks about how it will look if you fast-forward to three weeks from now—”

“Irv,” she interrupted, “that doesn’t help—this pain is too raw. This is death surrounding me. Death everywhere. I want to scream.”

“Bear with me, Alice. Stay with me—I’m going to ask that same simplistic question I’ve asked before: what precisely is it about death that so frightens you? Let’s hone in on it.”

 “We’ve gone over this.” Alice sounded irritated and impatient.

“Not enough. Keep going, Alice. Humor me, please. Come on, let’s get to work.”

“Well, it’s not the pain of dying. I trust my oncologist; he will be there when I need morphine or something. And it has nothing to do with an afterlife—you know I let go of all that stuff a half century ago.”

“So it’s not the act of dying and not the fear of an afterlife. Keep going. What is it about death that terrifies you?”

“It’s not that I feel unfinished; I know I’ve had a full life. I’ve done what I’ve wanted to do. We’ve gone over all this.”

“Please keep going, Alice.”

“It’s what I just said: no more me. I just don’t want to leave this life . . . I’ll tell you what it is: I want to see the endings. I want to be here to see what happens to my son—will he decide to have children after all. It’s painful to realize I won’t ever be able to know.”

“But you won’t know you’re not here. You won’t know you won’t know. You say you believe (as I do) that death is complete cessation of consciousness.”

“I know, I know, you’ve said it so many times that I know the whole litany by heart: the state of nonexistence is not terrifying because we won’t know we are not existing, and so on and so on. And that means I won’t know that I am missing important things. And I remember also what you’ve already said about the state of nonbeing—that it’s identical to the state I was in before I was born. It helped before, but it just doesn’t help now—this feeling is too strong, Irv—ideas won’t crack it; they won’t even touch it.”

“Not yet they won’t. That only means we have to keep going, keep figuring it out. We can do it together. I’ll be in there with you and help you go as deep as you can.”

“It’s gripping terror. There is some menace I cannot name or find.”

“Alice, at the very base of all our feelings about death there is a biological fear that is hardwired into us. I know this fear is inchoate—I’ve experienced it too. It doesn’t have words. But every living creature wishes to persist in its own being—Spinoza said that around 350 years ago. We just have to know this, expect it. The hardwiring will zap us with terror from time to time. We all have it.”

After about twenty minutes, Alice sounded calmer, and we ended the call. A few hours later, however, she left a curt phone message telling me that the phone session felt like a slap in the face and that I was cold and unempathic. Almost as a postscript she added that, unaccountably, she felt better. The following day she left another message saying that her panic had entirely subsided—again, she said, for reasons unknown.

Now, why was Alice helped by this conversation? Was it the ideas I presented? Probably not. She dismissed my arguments from Epicurus—that, with her consciousness extinguished, she wouldn’t know that she’d never find out how the stories of people close to her ended, and that after death she would be in the same state as she was before her birth. Nor did any of my other suggestions—for example, that she project herself three weeks into the future to gain some perspective on her life—have any impact whatsoever. She was simply too panicky. As she put it, ““I know you’re trying, but these ideas won’t crack it; they don’t even touch what’s here—this anguished heaviness in my chest.””

So ideas didn’t help. But let’s examine the conversation from the perspective of relationship. First, I spoke to her on my vacation, thereby indicating my full willingness to be involved with her. I said, in effect, let’s you and I keep working on this together. I didn’t shrink from any aspect of her anxiety. I continued inquiring into her feelings about death. I acknowledged my own anxiety. I assured her that we were in this together, that she and I and everyone else are hardwired to feel anxious about death.

Second, behind my explicit offer of presence, there was a strong implicit message: “No matter how much terror you have, I will never shun or abandon you.” I was simply doing what the housemaid, Anna, did in Cries and Whispers. I held her, stayed with her.

Although I felt fully involved with her, I made sure that I kept her terror contained. I did not permit it to be contagious. I maintained an unruffled, matter-of-fact tone as I urged her to join me in dissecting and analyzing the terror. Although she criticized me the following day for being cold and unempathic, my calmness nonetheless steadied her and helped allay her terror.

“The lesson here is simple: connection is paramount. Whether you are a family member, a friend, or a therapist, jump in.” Get close in any way that feels appropriate. Speak from your heart. Reveal your own fears. Improvise. Hold the suffering one in any way that gives comfort.

Once, decades ago, as I was saying goodbye to a patient near death, she asked me to lie next to her on her bed for a while. I did as she requested and, I believe, offered her comfort. Sheer presence is the greatest gift you can offer anyone facing death (or a physically healthy person in a death panic).

SELF-DISCLOSURE

A great deal of a therapist’s training, as I’ll discuss in Chapter Seven, focuses on the centrality of connection. An essential part of that training should, in my opinion, focus on the therapist’s willingness and ability to increase connection through his or her own transparency. Because many therapists have trained in traditions that stress the importance of opaqueness and neutrality, friends willing to reveal themselves to one another may, in this regard, have an advantage over professional therapists.

In close relationships, the more one reveals of one’s inner feelings and thoughts, the easier it is for others to reveal themselves. Self-disclosure plays a crucial role in the development of intimacy. Generally, relationships build by a process of reciprocal self-revelations. One individual takes the leap and reveals some intimate material, thereby placing himself or herself at risk; the other closes the gap by reciprocating in kind; together, they deepen the relationship via a spiral of self-revelation. If the person at risk is left hanging without the other reciprocating, then the friendship often flounders.

The more you can be truly yourself, can share yourself fully, the deeper and more sustaining the friendship. In the presence of such intimacy, all words, all modes of comfort, and all ideas take on greater meaning.

Friends must keep reminding one another (and themselves) that they, too, experience the fear of death. Thus, in my conversation with Alice, I included myself in discussions of death’s inevitability. Such disclosure is not high risk: it is merely making explicit what is implicit. After all, we are all creatures who are frightened at the thought of “no more me.” We all face the sense of our smallness and insignificance when measured against the infinite extent of the universe (sometimes referred to as the “experience of the tremendum”). Each of us is but a speck, a grain of sand, in the vastness of the cosmos. As Pascal said in the seventeenth century, “the eternal silence of infinite spaces terrifies me.” The need for intimacy in the face of death is heartbreakingly described in a recent rehearsal of a new play, Let Me Down Easy, by Anna Deavere Smith. In this play, one of the characters portrayed was a remarkable woman who cared for African children with AIDS. Little help was available at her shelter. Children died every day. When asked what she did to ease the dying children’s terror, she answered with two phrases: “I never let them die alone in the dark, and I say to them, ‘You will always be with me here in my heart.’”

Even for those with a deeply ingrained block against openness—those who have always avoided deep friendships—the idea of death may be an awakening experience, catalyzing an enormous shift in their desire for intimacy and their willingness to make efforts to attain it. Many people who work with dying patients have found that those who were previously distant become strikingly and suddenly accessible to deep engagement.

RIPPLING IN ACTION

As I explained in the previous chapter, the belief that one may persist, not in one’s individual personhood, but through values and actions that ripple on and on through generations to come can be a powerful consolation to anyone anxious about his or her mortality.

Alleviating the Loneliness of Death

Although Everyman, the medieval morality play, dramatizes the loneliness of one’s encounter with death, it may also be read as portraying the consoling power of rippling. A theatrical crowd pleaser for centuries, Everyman played in front of churches before large throngs of parishioners. It tells the allegorical tale of Everyman, who is visited by the angel of death and learns that the time of his final journey has arrived.

Everyman pleads for a reprieve. “Nothing doing,” replies the angel of death. Then another request: “Can I invite someone to accompany me on this desperately “lonely journey?” The angel grins and readily agrees: “Oh, yes—if you can find someone.”

The remainder of the play consists of Everyman’s attempts to recruit someone to be his companion on the journey. Every friend and acquaintance declines; his cousin, for example, is indisposed by a cramp in her toe. Even metaphorical figures (Worldly Goods, Beauty, Strength, Knowledge) refuse his invitation. Finally, as he resigns himself to his lonely journey, he discovers one companion, Good Deeds, who is available and willing to accompany him, even unto death.

Everyman’s discovery that there is one companion, Good Deeds, who is able to accompany him is, of course, the Christian moral of this morality play: that you can take with you from this world nothing that you have received; you can take only what you have given. A secular interpretation of this drama suggests that rippling—that is, the realization of your good deeds, of your virtuous influence on others that persists beyond yourself—may soften the pain and loneliness of the final journey.

The Role of Gratitude

Rippling, like so many of the ideas I find useful, assumes far more power in the context of an intimate relationship where one can know at first hand how one’s life has benefited someone else. Friends may thank someone for what he or she has done or meant. But mere thanks is not the point. The truly effective message is, “I have taken some part of you into me. It has changed and enriched me, and I shall pass it on to others.”

Far too often, gratitude for how a person has sent influential ripples out into the world is expressed not when the person is still alive but only in a posthumous eulogy. How many times at funerals have you wished (or overheard others express the wish) that the dead person were there to hear the eulogies and expressions of gratitude? “How many of us have wished we could be like Scrooge and eavesdrop on our own funeral?” I have. One technique for overcoming this “too little, too late” problem with rippling is the “gratitude visit,” a splendid way to enhance rippling when one is alive. I first came upon this exercise at a workshop conducted by Martin Seligman, one of the leaders of the positive psychology movement. He asked a large audience to participate in an exercise that, as I recall, went along these lines:

Think of someone still living toward whom you feel great gratitude that you have never expressed. Spend ten minutes writing that person a gratitude letter and then pair up with someone here, and each of you read your letter to the other. The final step is that you pay a personal visit to that person sometime in the near future and read that letter aloud.

After the letters were read in pairs, several volunteers were selected from the audience to read their letters aloud to the entire audience. Without exception, each person choked up with emotion during the reading. I learned that such displays of emotion invariably occur in this exercise: very few participants get through the reading without being swept by a deep emotional current. I did the exercise myself and wrote such a letter to David Hamburg, who had been a superbly enabling chairman of the Department of Psychiatry during my first ten years at Stanford. When I next visited New York, where he lived at this time, we spent a moving evening together. I felt good expressing my gratitude, beamed with pleasure when reading my letter. As I age, I think more and more about rippling. As a paterfamilias, I always pick up the check when my family dines at a restaurant. My four children always thank me graciously (after offering only feeble resistance), and I always say to them, “Thank your grandfather Ben Yalom. I’m only a vessel passing on his generosity. He always picked up the check for me.” (And I, by the way, also offered only feeble resistance.)

Rippling and Modeling

In the first group I led for patients with terminal cancer, I often found the members’ despondency contagious. So many members were in despair; so many waited day after day listening for the approaching footsteps of death; so many claimed that life had become empty and stripped of all meaning. And then, one fine day, a member opened our meeting with an announcement: “I have decided that there is, after all, something that I can still offer. I can offer an example of how to die. I can set a model for my children and my friends by facing death with courage and dignity.”

It was a revelation that lifted her spirits, and mine, and those of the other members of the group. She had found a way to imbue her life, to its very end, with meaning.

The phenomenon of rippling was evident in the cancer group members’ attitude toward student observers. It is vital for the education of group therapists that they observe experienced clinicians leading groups, and I have usually had students observing my groups, sometimes using TV monitors but generally through a one-way mirror. Although groups in educational settings give permission for such observation, the group members generally grumble about the observers and, from time to time, openly voice resentment at the intrusion.

Not so with my groups of cancer patients: they welcomed observers. They felt that as a result of their confrontation with death, they had grown wise and had much to pass on to students and regretted only, as I mentioned earlier, that they had waited so long to learn how to live.

Note: Signed copies of Staring at the Sun and other Ivin Yalom books are available here.