Category: Grief/Loss

Motivational Interviewing in End-of-Life Care

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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.  

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.

The Therapist Mourns His Mother’s Death: Being With Clients While Heartbroken

Posted on by rezendevknowfully.com

My mother died Dec. 18, 2005. She was 84 years old and died of complications from open heart surgery. I am a psychotherapist in private practice and had to return to work shortly after her death. I wondered how I would deal with my deep and heart-stabbing grief while I tried to help my clients work through their issues. Yet, little in graduate or post-graduate training prepares us to deal with such a time in therapy, let alone our lives.

I was fearful that a client would make a comment that would trigger me to sob in the middle of a session. Although I felt very raw in those days after her death, I knew I needed to maintain the boundary between therapist and client. After all, the therapy sessions were for my clients' benefit, not mine. Breaking down and sobbing would definitely make the session about me.

I was also worried that my level of concentration would not be one hundred percent. Normally, I can focus naturally on what a client says while seeking out a helpful response at the same time. I've become adept at checking in on my countertransferance, noticing if the client is saying anything to stir up my issues or causing me unexpected anger, sadness, or confusion. It is important for me to be aware of these feelings because they may indicate unresolved issues. In this period of grief, I wondered if I could be anywhere near as effective at this as I normally was.

As a therapist, I expect myself to be entirely present throughout the therapy hour. I expect myself to help heal clients' wounds, help them feel better about themselves, and assist them in alleviating their pain. During optimal circumstances, these goals are difficult to attain. While in the throngs of grief, it was going to be exponentially harder.

Still, I wondered what insights, revelations, and understandings I would develop while in a state of grief and mourning. Was it possible I could use my own grief during therapy sessions to help clients work through their grief? “How would I react with clients who were grieving their own losses? Would I hide my grief, break down myself, or make use of my grief for the client's benefit?” I soon found I had a chance to face these questions when I began engaging Abe about the loss of his father.

Abe's Loss

I have been working with Abe, an 18-year-old man whose father died when he was three years old. He is very bright and has a basic curiosity about how the mind and emotions interact. Abe is a seeker of all life's truths. He is very social, does well academically, and also has strong interests in drama, sports, and politics. Abe came to see me because, for the first time, he was experiencing a myriad of feelings about his father's life and death. He found these feelings to be at times overwhelming and unpredictable. He would start crying out of the blue or become agitated for no apparent reason, all the while struggling to make sense of what was happening to him.

Abe's father was only 37 years old when he died from cancer. His dad was active in city and regional politics, and a successful attorney. He loved baseball, politics, marathon running, and his family. Abe imagined that his dad was a larger-than-life figure who he should have had the opportunity to bond with. Instead, he never got to know the man and had no memories of him at all. Over the years he heard stories about his dad, but felt guilty, angry and hurt because he felt no connection with him.

Throughout his childhood, Abe's mother and older brother talked often of his father, their memories and their sadness from missing him. But Abe could not relate to their sadness since he had no memories of his father. When Abe reached his late teens, he began to notice that his life was off kilter. He found himself being sad and angry for no reason. At other times, he had difficulty with rejection and was quite moody. Abe noticed these changes and wondered if they were part of normal adolescence or if they had something to do with his father's death. As he began to face his loss, he began to grieve for the first time. He began to understand that a void was created within him after his father died; when he tried to conjure up memories of his father, nothing was there but his own sadness and anger. He was overwhelmed with the pain of not having his father's guidance and love in his life. Abe found that he felt emotional much of the time and that his feelings of loss were right on the surface. “Abe told me he had a bittersweet relationship with these feelings of grief, yet he let on that, "It feels good to grieve; it makes the loss so much more real."”

Disclosing My Mother's Death to Abe

As Abe spoke, I felt as though he was hitting the same complex note that I was facing in my life. I'd been thinking the same thing about my mother. I wondered if I should share my feelings with Abe. Would this approach be over the top and way too intense for him and me? Was I doing this because it would make him feel better or was I really doing it because it would make me feel better? I paused a moment and decided that my words would likely be helpful to him. It is difficult in the moment to know for certain if our self-disclosures will be beneficial for our clients, yet we must proceed with sharing based on what we sense and intuit.

I told Abe that I thought I understood what he was feeling. I shared that I run five miles every day while listening to music and I cry deeply when memories, thoughts, or feelings about my mother arise. Abe said that he had similar feelings about crying over the loss of his father. The powerful sadness opened a door that allowed him to make his father's death real instead of some distant intellectual construct. Although he had no memories of him, he truly knew that his father loved him, and he feels this love when he is immersed in tears. This spiritual connection provided solace to Abe.

“I learned from this encounter that although I was grieving and not operating on all cylinders in the regular world, in the therapy office it was okay to trust my intuition to intervene.” There is always some risk with a powerful intervention that clients will feel frustrated, misunderstood, and even possibly shamed. Yet, at the same time, mistakes can be utilized in the therapy if the therapist is open to dealing with the client's disagreement or fallout. With Abe, though, I felt confident that I was connecting with him in a meaningful way and that he was having none of these negative reactions. In fact, it led him to reveal more about what was going on inside of him.

Deciding to Hold Back Certain Grief Reactions from Abe

Abe talked about his experience of sharing his feelings about his father with his peers. Most of them seemed to suggest that he needed to "get over it." It seems that exploring themes of loss in a deep way is as taboo now as it was when my father died in 1966. This was the same attitude I felt from peers and adults at the time. I found my mind drifting back to the day of my father's death and I began to feel angry.

“Yet, I knew that this was not the time to process my memories of the loss of my father, and I would have to come back to it later.” Instead of sharing those awful memories, I encouraged Abe to continue searching for people who could support him. I realized that he believed this type of support was almost non-existent, but I nonetheless urged him to persevere.

Abe found one. During a tour of historic sites of the civil rights movement, he met the daughter of a slain civil rights worker and they shared their common story of losing their fathers when they were young. Abe was able to feel a deep connection with this woman and express his anguish over his loss. This experience served to move the grief along. As Abe told me about this experience, I remembered what it was like when I first heard of my mother's death. Unlike my father's death, where I didn't feel anything but numbness for years, my mother's death affected me immediately. My sister called to say that my mother had died during the early morning. The doctors did their best to save her, but she only fought as long as her body and spirit would allow. When I heard this, I moved from panic to sorrow to relief in a matter of moments. This pattern would repeat itself continually after that horrible day.

I thought about sharing the details of the day my mother died with Abe, but I decided that this was more about my own work and would not necessarily advance his mourning process. I knew that I could drift into the terrible memory and totally lose the therapeutic focus. So, I decided to process this experience on my own during my daily run the next day and in the present listened more carefully to Abe.

Using My Own Grief to Connect to Abe's Grief with Few or No Words

Abe told me that he was worried about what his grief would be like as he got older. Would he feel resolved about his father's death? If so, what would that feel like? Would he ever feel more of a connection with him than he did now?

I was facing a very similar existential dilemma. I was unclear if I would ever feel resolved about my mother's death. Would this pain ever let up? I decided to keep this struggle to myself, and said to Abe that it was wonderful that he was so introspective and that he valued challenging himself emotionally. I also said that he did not have to worry about finding answers to these questions, because he would discover solutions over time.

There were times during my sessions with Abe that he would experience deep, intense, overwhelming sorrow. I would empathize with his angst and at the same time have sharp, clear memories of my mother's last days in the hospital. I knew that I could not let these memories overtake me, which might lead me to obvious distraction or painful screams—at least not while Abe was in the room. I felt a deep empathy for Abe. I needed to use few words, and mostly utilized the invisible therapeutic bond between us. This was a moving and healing time for Abe. At times my grieving energy connected with his without me having to state directly what I was thinking about regarding my own losses; the unspoken connection was what was needed. I felt the presence of my mother's spirit in the room, filled with warmth and wisdom. I felt her smiling over me and letting me know I was doing great work. “I was learning to use my grief, sometimes directly, and, as in this moment, indirectly in my work with Abe.”

Abe, as an 18-year-old, fluctuates between the need for independence and the need for being dependent upon his mother. While this dilemma plays out with all the adolescents I work with, Abe is unique in that he is aware of these forces literally pulling him apart. I continue to be amazed at the level of his insight. He knows that on the one hand he wants his mother to grant him unconditional freedom. On the other hand, he realizes that at times he is motivated by the look of disappointment upon her face.

He told me that he and his mother had been fighting because she felt he was not giving his best efforts academically, socially, or in his drama work. It became clear that his mother's definition of best effort was not the same as Abe's. After a long and, at times, difficult discussion, both Abe and his mom cried. They came to accept each other. Abe now realizes that deep down inside his mother only wants him to be happy.

As Abe recounted this story, my eyes filled up with tears, but didn't stream down my face. I am unsure if Abe noticed this, but it would have been fine with me if he had, because my crying validated his feelings of loss. My showing of emotion also enhanced my alliance with him, and I am sure he realized that I was moved by his story and resonated with what he was going through.

I stated that he was fortunate to discover his mother's unconditional love for him at such a young age. My mother and I did not feel at ease with each other until I reached my forties. As time went on, we became closer and closer. I let down the wall that I had built up since I was 15 when my father died. When my mother died, we knew we loved each other without any reservations. The pain of her loss is often overwhelming and sometimes I miss her so much I can hardly breathe. I'm grateful, though, that I had the opportunity to experience unconditional love—a feeling you can never have if your heart is sealed shut.

I shared with Abe that I felt that he was way ahead of the game in this respect, and that he was ahead of where I was at that age. He was able to appreciate the his mother's good attributes , as well as notice her less than admirable qualities, such as being overly protective. I mentioned that being able to tolerate as well as appreciate the good and the imperfect in his mom would make it easier to tolerate those aspects inside him. He responded to my comments by affirmatively nodding his head while tears formed in his eyes. He was aware that he had a special relationship with his mother; he could share most anything with her and she would still love and accept him. He felt that I understood his relationship with his mother and this tightened my connection with him.

Finding Some Grace in the Sorrow of Grief

“I was so raw during those first few weeks after my mother's death. At times I felt that I had lost the means to filter out any kind of physical or emotional pain.” This stark vulnerability somehow increased my need to do my job well. Even in this early stage of loss, I realized that having a purpose helped in the recovery process. My main purpose was to help others heal from loss and trauma.

I feel that my work with Abe has been successful. I was able to help him understand that the loss of his father did impact his feelings of rejection from peers. I also helped him discover the gifts of grieving: the release of the angst and ultimately a real connection with his father. As I experienced this sense of a successful therapy with Abe, I felt a sense of spiritual grace surround me. This phenomenon seemed more important to me now than at any other time of my life.

During one session, I asked Abe why he thought his dad died at such a young age. Abe told me that he supposed his father died when he did because he learned all the wisdom that he was meant to learn, and therefore it was time to leave this earth. He recognized that it was comforting to give himself a reason why such tragedies occur but that these words did little to heal him.

I think that each client has the right to have his own spiritual and religious beliefs. Just the same, it is worthwhile to explore their beliefs. I shared my feelings with Abe to illustrate this point. I mentioned to Abe that I have no idea why my parents died when they did. I haven't uncovered any words of wisdom that give me solace. Expressions like, "It was God's will," "She is in a better space now," or, "It was her time to be with God" do nothing for me. This terminology may be well intended, yet is often not meaningful to the newly bereaved. I much prefer people to be good listeners and share their experiences of loss than to repeat some Hallmark Card homilies. I noticed how cynical I sounded, and decided to change the subject and come back to it later. I didn't think my words were harmful to Abe, nor did I believe they had therapeutic value. Indeed, Abe did not seem to connect to those comments one way or another, so it was best to move on.

When I first began working with Abe, he was very sensitive to rejection. He would feel rejected at times even when it wasn't clearly the case—such as when he joined a conversation with his friends late and they would not immediately respond to him. This level of sensitivity can occur while one is in the midst of grieving. I shared a story with Abe that he related to: One recent Saturday soon after my mother's death, I was feeling angry towards my wife because she could not anticipate what I was going to think or feel in the next five minutes. I cannot know what I will feel in the next five minutes, so how could I expect her to do so? However, I was feeling so raw and lost that I put those expectations on her. Suddenly I began to sob and said to my wife, "I'm really missing my mother." She hugged me and said. "I didn't know you cared for your mother so much." "Neither did I," I replied.

Feeling the Presence of the One who Died

I recently celebrated my 55th birthday, the first one without my mother. She used to call me and we would talk endlessly about the condition of the world. I knew she was on my side and I was grateful. As I headed out the door for my run that morning, I noticed something different. The sun was shining immediately after an early morning downpour. I felt my mother's presence caught between my imagination and the spirit world.

As I started to run, I listened to Etta James singing "Somewhere There's a Place for Us" and it felt as though my mother was actually listening with me. I saw her alive, laughing. Then I imagined her dead, eyes closed, smile on her face, and felt a deep sense of gloom. I wondered if this was the only connection I would ever have with her again. Although I was still running, I suddenly felt as though I was standing still. A brand new thought entered my mind: Will my spirit join hers when I die? If so, how will it be? Will I be surrounded by her unconditional love? Will I have the ability to move from the spirit of one loved one to another? Is this what heaven is like? This was the first time I ever considered that there might be an afterlife. Before this, I had always been so cynical about it. Perhaps this major gift comes out of my mother's dying.

I shared this story with Abe, and I asked him if he believed in an afterlife. He wasn't sure, but he felt that he was in touch with his father's spirit. He talked about coming-of-age events like shaving and dating. When he reached these events, he felt that his father was instructing him how to succeed at them. Tears came to his eyes as he shared this story. He was aware that these grief-filled moments brought him closer to his father's spirit.

I shared this experience with Abe, because I sensed that he was wondering about the afterlife and I hoped it would be another experience where I could connect with him. I did not have a sense that Abe would feel pressured to agree with me, but that it would stimulate his own thinking and feelings, which would further his healing process.

I didn't share Abe's experience of not having any memories of a deceased parent and I attempted to help him come to terms with this burden. He knew innately that his father loved him, and this grounded him for the deep work he immersed himself in. I felt that my job was to guide him from the point of numbness, to healing his deep wounds and gaining a fuller understanding of what happened to him when his father died. When possible and relevant, “I often direct those clients who are dealing with mixed feelings about the loss of a loved one to find a place inside to hold that loved one in a peaceful manner.”

I am not sure what Abe will go through or what this place will be like when he discovers it, but I feel honored to participate in his voyage. I do know that I have been blessed with the rare opportunity to help a client face his grieving process while dealing with the death of my mother. And I believe that going deeper into my own grief helped me understand Abe's losses more fully, connect to him in a real way, and assist him in coming to terms with the loss of his father. The pain of loss can be a powerful means to heal others.

Suggestions for therapists in the initial stages of recovering from the loss of a loved one

Have a strategy in place

Now is not the time for flying by the seat of your pants. If your style is to not share your personal life with your clients, there is no reason to change that now. My style has been to self-disclose and share parts of my life with clients when I believe that this information will enable them to work through conflicts and grow emotionally. I continued this way of working after my mother died. Still, I needed to remind myself that I was telling my story for the client's sake, not mine.

Take Care of Yourself

How often have we instructed our clients that self-care was of supreme importance? This principle also applies to therapists who are in the early stages of grief. I exercise almost every day, and writing has also been a healing vehicle. Individual therapy, grief support groups, and other self-help groups are viable options. I feel that it is important to face and embrace the pain of my mother's loss every day. This way of mourning is not for everyone. We all need to discover our own pace and our own means to work through the anguish.

Be Self-Aware

Whether you are alone or in a therapy session, you are always grieving. You cannot just turn it on and off like a light switch. If you suddenly feel profoundly sad during an interaction with a client, you need to ask yourself why you are feeling this way. During the past month, my despair came from the death of my mother. I trained myself to be aware of why I felt the way I did, what triggered my feelings, and what the client said that caused me to feel sad. Then I would determine if I would use this experience to illuminate what the client was facing.

Integrate your knowledge of grief and your own loss

Sometimes I am overwhelmed with feelings of hopelessness. I recently came down with a sinus infection for the first time in a decade. There are nights that I do not sleep very well. I realize that all of these unwelcome changes are the result of losing my mother and that they are normal. I also know from experience that my grief will gradually subside and at some point in time I will not feel as devastated as I do today.

Suggested Resources on Grief and Mourning

Livingstone, B. (2002). Redemption of the Shattered: A Teenager's Healing Journey through Sandtray Therapy, http://www.boblivingstone.com.

Livingstone, B. (Planned August, 2007). The Body-Mind-Soul Solution: Healing Emotional Pain through Exercise, Pegasus Books.

Simon, S, & Drantell, J. J. (1998). A Music I No Longer Heard: The Early Death of a Parent, Simon and Schuster.

Grollman, E. (1995). Living when a Loved One has Died, Beacon Press.

James, J. W. & Friedman, R. (1998). The Grief Recovery Handbook, Collins.

Worden, J. W. (2001). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Professional, Springer Publishing.