Category: Therapeutic Issue

An Unexpected Loss

A few years ago, while working as a clinical social worker at a community mental health center, I was asked to start a grief group at the clinic. My supervisor gave me a copy of Shneidman’s Death: Current Perspectives, which I took notes on with reverence and intention. I learned about the concepts of primary and secondary losses. I considered the sociocultural construction of loss and its many manifestations. I even began to think about my own losses, and the many ways that I might be trying to lend voice to them, both in the therapy room and through the very identity I had chosen as a helping professional.

A few weeks after I began my research on grief, I experienced a sudden and unexpected loss. Just before meeting with a supervisor, I received a voicemail message from the neighbor of Chester, one of my closest friends. “Stephen, can you call me? I noticed that Chester hasn’t picked up his newspapers from the front step in a few days. I know you have a key, so I thought you may want to go check on him.” My dear friend Chester was an older man who lived alone and was a voracious reader. And “to anyone who knew Chester well, a report of piled-up newspapers was understandably unsettling”. So I left work early, raced home on my bicycle, cut through the little one-way streets in our neighborhood, and unlocked his front door. Fearing the worst, I walked into the blaring of the local NPR radio station. Odd. I climbed the creaky staircase and surveyed the hallway, my heart sinking more deeply as I entered each empty room. I found my dear friend in his bed, dead, most likely due to complications from diabetes and poor diet. In the days that followed, I helped to plan his funeral, I wrote and delivered his eulogy, and two days later, I boarded an airplane with my love, Rebecca, for a long-awaited two-week trip to Amsterdam.

I was exhausted during the trip, still caught off guard by, and unable to reckon with, the loss of Chester. In light of the impact of his death, I realized that I would not be able to go forward with the plan for the grief group at the clinic. My supervisor was supportive and understanding. And although I never started the group, the coincidence of exploring grief professionally while experiencing it personally was formative for me. And it was this uncanny parallel process that solidified my clinical interest in grief and loss. In recent times, still relatively early in my clinical career, I have devoted myself more fully to developing my own perspectives on the use of grief and loss in the therapy room. From what I have seen so far, just the mere introduction of the words “grief” and “loss” can serve as a catalyst for client self-examination and positive therapeutic change.

Grief is in the Room

Consider the following tales of loss. Elizabeth, a woman in her mid-thirties, has an obsessional fear that her beloved dog, Daisy, will die, and questions whether she could justify continuing to live following the dog’s death. Richard, a man in his late twenties, harbors the shame of a disjointed and unfulfilling collegiate career that was lost to debilitating depression. He develops a subsequent, chronic fear of mis-stepping in both his professional path and in life in general. Finally, Melissa, also in her late twenties, enjoys a budding acting career; however, the exhilaration that accompanies this new journey serves as a constant reminder of her early years sacrificed to the oppressive agenda of the religious cult in which she was raised. These are the experiences of some of my clients, who have collectively spoken to the issues of loss and grief in their various forms. As I began working with each of them, I soon recognized how the stress and pain of loss was woven into the fabric of their daily lives. Over time, I came to see these stories as reflective of significant, and sometimes traumatic, grief.

These clients had one thing in common—none of them was seeking grief counseling. Each client sought therapy for a particular problem, such as depression, OCD, or general anxiety, yet narratives of grief and loss gradually emerged as they shared seemingly peripheral issues or stories. I began to see many of my clients’ experiences as forms of what has often been called complicated grief.

Complicated grief, also sometimes called persistent grief, is described in the DSM-5 diagnosis of complex persistent bereavement disorder (CPBD). This type of grief is characterized by chronic rumination, persistent challenges to accepting the loss one has experienced, and sometimes difficulty trusting others following the loss. I would like to note that before the DSM-5 was published, members of its advisory task force worked to address issues related to conceptualizing persistent grief as part of a disordered condition. The resulting diagnosis of CPBD was eventually placed in the chapter for diagnoses requiring further study. In keeping with the ambiguity and potential pitfalls related to the assessment and labeling of grief, I try to remain flexible when talking about grief as “complicated.” I also try to practice active curiosity by examining my clients’ personal cultural beliefs about grief and loss.

Often, when a client of mine identifies with the experience of complicated grief, they endorse persistent feelings of loss without a corresponding process of connection to life beyond the loss. Moreover, they often express a chronic doubt in the possibility of meaningful discovery during examination of their grief. Complicated grief often drives a person to fixate on certain associations of loss and to avoid other associations, which can make it difficult for one to do the kind of thoughtful narrative work inherent in the grief process. Elizabeth, for instance, spent so much time fixating on her dog Daisy’s potential medical issues and feeling guilty that she was often unable to connect and be in the moment when they were together. Such complicated grief may leave a person feeling anxious, empty, or hopeless about various aspects of life. This, in turn, often leads to existential blockages, because the grief-stricken person feels unable to engage with the meaning of life in one way or another. This makes me think of Richard, who felt so preoccupied with the idea of approaching life “the right way” that he often found his relationship with his values and his deeper motivations in life to be elusive. Exploring them in session often felt pointless and painful.

Identifying and understanding stories of loss and grief have been difficult processes for me, as loss often carries with it complex ambiguities with respect to the size and duration of its consequences. A client might think the following: “Was something, in fact, lost?” Elizabeth had difficulty understanding how she could be constantly mourning her dog Daisy while she was still alive. A client may also ask if they are destined to never regain or recover from that which was lost, as did Richard following his traumatic college experience. Finally, one may wonder, “What is the right way to feel about my loss?” Melissa often asked how she should feel about the loss of her religion and the accompanying metaphysical disorientation she experienced. The above questions can feel especially complicated when we consider clients’ attachments to abstract things such as identity, whose definitions can be less convenient to identify or communicate in therapy than, say, the death of a loved one. Regardless of any challenges, I have tried to see loss and grief in my clients’ stories and to talk about the impact of losses with my clients. In doing so, I’ve found that grief work is a deeply meaningful, effective, and surprisingly welcome therapeutic endeavor.

Recognizing My Grief Blindspot

Because the characteristics of complicated grief may coincide with the symptoms of OCD, generalized anxiety, PTSD, and major depression, at times I have initially failed to identify and appreciate grief as an experience in its own right. But the overlap between diagnostic features is not the only reason I have been slow on the draw. In 2011, I took my first mental health job as a residential counselor in a behavioral, CBT-focused residential unit for people with OCD. Treatment on the highly respected unit focused on the “here and now” of clients’ experiences, and I learned to deemphasize the narratives of grief and loss in treating patients. I was trained, tacitly, to see the nature of patients’ activating triggers as relatively unimportant, and I remained incurious about the source or meaning of patients’ obsessions and compulsions, including any possible connection to grief or loss. After a year or so, and after many in-depth discussions with patients, I became bothered by the lack of attention paid to the grief that many of the patients seemed to carry. I was frustrated with the fact that our treatment, which was evidence-based and internationally known, seemed to be limited to a focus on concrete OCD triggers and behavioral responses.

A colleague at the OCD treatment program once said, “”If we only treated OCD, this would be the easiest job in the world.”” His point was that our patients often came in the door with many co-occurring forms of distress and pathology, which made it difficult to concentrate optimally on the OCD symptoms. But the reality was that we did only treat the OCD. Meanwhile, many patients, in my observation, carried complex grief stories related to their illnesses. These stories, when expressed during private check-ins, or after dinners during quiet time, often reflected experiences of stigma and alienation, as well as deep feelings of inadequacy. Patients’ personal narratives tended to give voice to an experience so familiar to those with both OCD and chronic grief—the feeling of being stuck. For many patients, the longstanding grief, the stuck feeling, reflected a perceived lack of momentum in their lives, along with understandable challenges in accepting the way things had turned out for them. Their narratives were often anchored by the belief that they were inherently dysfunctional. And whether in treatment or at home, the patients I worked with often found little opportunity to confront their own grief narratives and to make meaning of the upsetting losses they experienced throughout their lives.

Grief and the Illuminating Power of Loss

Since I have begun working through a grief lens, I’ve absorbed two valuable pieces of wisdom: (1) a single event of loss almost always contains multiple losses, and (2) a current loss often triggers past losses. Recently, a client in her 40s spoke frankly to me about “feeling like a loser” when reflecting on her decision, ten years ago, to say no to a wedding proposal of a friend. She maintained a close connection with that friend, and one day, while in the midst of a severe depression, that friend ended his life. After I spoke frankly with my client about the idea of grief and the significance of loss and explored these concepts with her, she led us to discussions of more internal, personal losses. In addition to grieving the death of her friend, she was left struggling with the notion that the past 10 years of her life had been lost. “Would I have children now?” she asked. “Would I have had beautiful memories associated with a partnership?” Her feelings of loss were further stoked by the presence of a power struggle and of a cultural conflict: “What if I had stood up to my parents, who wanted me to marry an Indian man?” she once asked me.

My client then began to mourn what was to come: the future life she feels she will never have. “I believe, Stephen, that I have lost the best years of my life,” she said to me during one session. Very quickly, our sessions broadened from talking about a primary loss (loss of her relationship to her friend), to some secondary losses (loss of identity as a married person, as a parent to children, as a person of culturally normative social development/achievement). While my client struggles with depression and some obsessional tendencies, her stories of grief and loss led us most reliably to some of the more meaningful reparative work in her life, and also appeared to increase her investment in the therapy. She attended sessions more regularly, appeared more thoughtful and creative in her reflections, and gave me more feedback. I’ve noticed an increase in therapeutic engagement with other clients who embraced grief and loss as well. Taken together, grief work has demonstrated to me its wonderful ability to help clients examine a broad spectrum of relationships and perspectives ranging from functional to existential.

Another interesting example of how one grief exposes another involves the case of Elizabeth. Initially, she shared chronic health anxiety concerning her dog, Daisy. Her anxiety manifested as obsessions related to Daisy’s getting sick and dying and compulsions aimed at assessing her health. It wasn’t until later on, after I had introduced the concept of grief, that she decided to focus on something that had previously been peripheral to our work: the story of her birth. Elizabeth had shared with me, a year prior, that she had a twin brother who died in childbirth. Later on, when Daisy experienced more serious health complications, Elizabeth explored the connection between her mother’s guilt over her brother’s death and her own subsequent lifelong attachment to health anxiety. More specifically, she began exploring her preoccupation with the health and welfare of her dog, whose relationship to her was getting crowded out every day by her obsessions and fears. An important question emerged in one session. It was a question that my client had written on a white board in her apartment and looked at periodically during the day: How can I survive after my dog dies? The question, she said, was very activating, and ultimately cut to the core of her grief. At this core seemed to be a strong element of survivor’s guilt that was a part of her birth story. Directly addressing the recurring theme of survivor’s guilt helped to disrupt the obsessions that had taken the place of real grief processing and meaning making. Elizabeth began to report a more authentic, self-compassionate exploration of the events of her birth as well as of her relationship with her family and with her beloved dog.

Final Thoughts on Grief, Love, and Loss

Far from confining them to the examination of a single relationship, grief work has allowed my clients to journey beyond the scope of the lost relationships in order to circle back to the self. In excavating the internal devastation, like old wreckage, this work has helped my clients examine their histories, their early attachments, their developmental phases, their defenses, and their cultural backgrounds. Thinking about loss has also made me a more sensitive therapist. I am more aware of my power to trigger feelings of loss in therapy. Once, when a client notified me of a sudden insurance change, I wrote them back, stating frankly that we might not be able to continue working together. In the next session, she expressed feelings of rejection, and questioned whether I cared that our relationship might end. When I reminded a client that I would soon be leaving the health center where we had worked together for two years, he became very upset, accusing me of being just another provider who was destined to abandon him. His reaction came after a couple of months of his knowing I was leaving, and of seemingly being well-adjusted to the idea.

Sometimes I feel the loss as well. Recently, after raising my session fee, I received feedback from a client. In addition to worrying if she could afford to continue seeing me, she reported being upset by a change in her perception of me as an egalitarian-minded therapist. “I thought you were for the people, Stephen,” she said. Ouch. That really threw me off. I rode my bicycle home after that session, upset that maybe she was right, that maybe I had in fact lost a piece of myself.

I want to end by touching on an idea that can at once be liberating and invalidating: that not all losses cause grief, and that even losses that cause tremendous grief can also provide relief, instill curiosity, and provide new opportunities for growth and connection. At times, I’ve worried that this sentiment reflects some of the toxic positivity and anti-grief attitudes that I see in modern day American, consumerist culture, and sometimes in evidence based, solution focused modalities. But the truth is, we have a responsibility to explore the many associations our clients, and we ourselves, have with loss.

When my friend Chester died, I felt I had lost a significant older male role model. But at the same time, his death brought about this sudden and unexpected sense of growth and preparedness that I hadn’t experienced before; it was a coming of age moment, albeit at 30 years old, that had me thinking of myself as more of an adult, maybe even more of a man. And when my client accused me of being money hungry, it was an opportunity to examine my relationship with the ethics and philosophy of value exchange in therapy. It was also an opportunity to question my attachment to an identity I sometimes feel obligated to occupy—that of the selfless helper. “What if I’m abandoning my beliefs, or acting selfishly? What if I’ve lost myself?” I asked.

In the end, I am better for asking these questions, as they have brought me to a more engaged and fulfilling, albeit uncertain, place in my practice. And I think all of the experiences outlined above, those of my clients and of my own, lead to an important reflection: that maybe it’s possible for loss to lead to connection, or reconnection, with something of value. Reflecting on grief and loss may bring us back to a purpose, an identity, or even a community. And maybe the experiences of loss and the grief we hold can help bring about a reintegration within ourselves. After all, it is often these new, and renewed, relationships with the self that we have been searching for all along.