Friday, June 1
Private Practice: Dynamic Psychotherapy and Bereavement Counseling (CEU)
Dynamic Psychotherapy and Bereavement Counseling: A Philosophical Framework
Perhaps life’s most profound contradiction is that from the moment we are conceived, we begin to change and die. Change is unstoppable, death inescapable. Consequently we live with loss, and since we are essentially feeling beings we react to our losses by grieving and mourning. But we don’t like to say it. We don’t like to hear it. Indeed the historian Arnold Toynbee proclaimed, “Grief is un-American.” And to a certain degree we arguably need our self-protective systems to shield us from the thought of nonexistence and to live our lives feeling less impeded. Unlike the rest of the animal kingdom though, we humans can reflect upon the meaning of our experiences, and the price we pay for this gift is our confrontation with the unmoving fact of mortality. However, that same capacity has resulted in the creation of therapeutic approaches and environments designed to help individuals go through the grief and mourning processes in as natural and supportive a way possible. Psychotherapy is often an environment in which loss—whether ushered in by change or death—can be supported and worked through. In order for it to be effective, however, the quality of empathy and attunement to the grief and mourning processes must be informed by a philosophy grounded in bereavement counseling.
As an outgrowth of our leading edge, person-in-environment perspective, social work has made important advances in many areas of the mental health field. Research and clinical treatment modalities have illuminated and provided caring pragmatic interventions to populations suffering with unemployment, rising violence, physical and sexual abuse, the cycle of poverty, alcoholism and drug addiction, broken families, suicide, gangs, increasing levels of stress, and major depression—to choose just a few. Despite all of these areas having their own policies and practices, they are all loss experiences. In fact, we might conceive of them as existing on a continuum of loss—an insight highlighting their commonalities and offering potential perspectives on optimal assessment and treatment.
Psychotherapy and Change
In addition to death, loss comes in many forms and is, in fact, inevitable due to the dynamics of change built into life itself. With this knowledge and the skills to help individuals react to and integrate their experiences of loss and change, dynamically-trained psychotherapists can help reframe grief and mourning in terms of going through natural phases such as shock and numbing (defense mechanisms), confrontation (awakening to the reality of the loss and the scope of change inherent in it), and accommodation (learning to return to pre-loss functioning/changing/growing). This therapeutic empathic responsiveness affords the potential for reduced helplessness, a greater sense of control and coping ability, and maybe even increased meaning—especially in troubled times.
In a sense, our lives are peppered with small dyings—losses along the way that are often unavoidable. Break-ups. Dashed dreams. Conflicts. Upset expectations. The list goes on. Such experiences constitute the terrain of psychotherapy. Each of us to some degree carries along a reservoir of losses. Yet by facing these losses with social support and personal determination, we can attempt to fill life with purpose and meaning even as they threaten to divest it of such values. Many Zen practitioners believe viewing changes as small dyings prepares us for actual death. “Die in the morning so you need not die at night.”
In the case of dealing with an actual death, I believe it is helpful for survivors to 1) Define grief and mourning, and 2) Learn about the three fundamental phases of the process: shock and numbing, confrontation, and accommodation.
Grief reactions are universal (though extremely personal), normal, spontaneous, and unlearned. They are acute and expressed physically, emotionally, behaviorally, cognitively, and spiritually. The quality, quantity, and timing of these normal reactions (not discussing so-called pathological forms of bereavement in this article) are influenced by many factors such as the circumstances of the death, the quality of the relationship, social support, developmental stage, educational and religious backgrounds, coping abilities, previous exposure to loss, and so forth. Social work’s person-in-environment perspective enables a clear understanding of these many factors. Mourning, on the other hand, is a larger, more encompassing process of which grief reactions are a part. Mourning is both socio-culturally influenced and psychologically driven; it is the long, arduous back and forth trek of avoiding, confronting, and finally accommodating to the world without the person who has died. Drawing from William Worden’s thoughts, it is the ongoing work of facing the fact that death occurred, feeling and expressing the pain, learning to get used to the environment without the deceased, and withdrawing the energy put into the old attachment in order to begin channeling it into new relationships and causes. It does not, however, mean severing psychological ties with the deceased. In fact, for most mourners, the liveliness of memory and the internalization of and identification with the deceased remain with them even as they learn to let go of the physical relationship. It is what Therese Rando calls the bittersweet nature of bereavement—moving forward with the scar of loss, holding onto what must be retained, and letting go of what must be relinquished.
With this philosophical stance in mind, psychotherapy and bereavement counseling can proceed optimally by responding to the often nonlinear presentation of grief and other life content through the therapeutic alliance. The following are guidelines to support this approach:
- Give explicit permission to grieve and mourn
- Follow and help name the range and depth of feelings in response to loss
- Recognize the phases and tasks of grief work
- Know and define the difference between grief and mourning
- Sometimes focus more explicitly on grief, other times on different content
- Listen for and attend to developmental needs
- Remember we cannot take away the pain from the bereaved
- Learn to tolerate feelings of helplessness (in self and others)
- Do not give pat answers to profound questions
- Be willing to view the loss from the person’s unique perspective (religious/spiritual or not)
- Elicit memories, lessons, identifications, details (both positive and negative) of the relationship with the deceased
- Hold out the hope/expectation that through the process of accommodation, the pain will subside and life will rebalance
- Promote social support and a family systems approach when warranted
In sum, by seeing the reality of loss in change itself, individuals can be helped therapeutically as it affords them better understanding, potentially increased meaning, reduced helplessness, and a greater sense of control and coping ability. In addition, learning the definitions of grief and mourning can be useful for many individuals to help with loss through death. Psychotherapy, with its focus on sustained empathic attunement to the client’s developmental needs as they are expressed in and through the therapeutic relationship, and bereavement counseling, which aims to help support directly the acute expressions of grief and the life-adjustment of mourning, are a potent combination. When interlaced, both approaches encourage psychological integration and movement through the natural phases of shock and numbing, confrontation, and accommodation, while promoting a purposeful life in spite of life’s most profound contradiction.
- T. Rando. Treatment of Complicated Mourning. 1993.
- W. Worden. Grief Counseling and Grief Therapy. 1992.
David Fireman, MSW, LCSW, directs the Center for Grief Recovery and Therapeutic Services (http://www.griefcounselor.org) as well as holds a practice grounded in the social work values of social justice and personal transformation. His approach draws from self and depth psychologies. His extensive background in helping others grows out of a sincere respect for inherent individual differences, social learning, the interplay of love and loss throughout the life span, finding purpose and meaning, and placing value in the power of the therapeutic relationship. He is an active and involved therapist and presenter who believes that the rare combination of honesty and courage bring about lasting change.
CEU Opportunity for Reading This Article!
NASW Illinois members can earn one CEU by completing an online quiz (LINK) regarding this article! The free CEU opportunity is only valid until August 1, 2012, after which the CEU fee will change to $15.00. Nonmembers must pay the regular $10.00 rate for the CEU, which will increase to $15.00 after August 1, 2012.