Working With the Bereaved

Multiple Lenses on Loss and Mourning

Simon Shimshon Rubin, Ruth Malkinson, Eliezer Witztum

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781136947902
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Working With the Bereaved summarizes the major themes in bereavement research and clinical work and uses the authors' own cutting-edge research to show mental-health practitioners how to integrate these themes into their practice. It provides clinicians with a framework for exploring their own emotional and intellectual assumptions about loss and bereavement, and it goes on to summarize state-of-the-art thinking in the field. The heart of the book focuses on the theoretical and clinical implications of the empirically validated Two-Track Model of Bereavement, as well as a variety of therapeutic techniques designed to help the bereaved both reapproach life and manage their continuing bonds with the deceased. The later chapters examine methods for integrating systems and family perspectives in therapy, for attending to the implications of culture and religion, and for meeting crises and emergencies in bereavement care. The concluding chapter addresses self-care, well-being, and resilience, offering practical guidelines for both the bereaved and those who treat them.

Section III

Integrating Various Therapeutic Approaches With Insights From the Two-Track Model of Bereavement

Figure S3.1 Yafa Sonia Witztum, “Many Faces of the Persona.” Thanks to the Eliezer and Menachem Witztum families for permission to reproduce this image.

Section III is devoted to developing the ramifications of what we have presented in the previous two sections for a variety of models of psychotherapy. The five chapters in this section make liberal use of clinical material to illustrate the concepts and how they are applied in practice. The presentation of different models conveys our belief that there is no right model to use in working with the bereaved, but rather the richness of each enables therapists to tailor the most suited one for each client. Chapter 7 presents a psychodynamic perspective whose concepts and therapeutic applications are relevant to almost all clinicians. Past and present, conscious and unconscious, then and there and here and now are considered in the case presented. The cognitive behavioral approach, emphasizing the centrality of cognitions, is addressed in Chapters 8 and 9. These incorporate the insights and practice of the Rational Emotive Behavior approach, as well as imagery and mindfulness. Chapter 10 discusses the strategic integrative approach, which combines concepts, tools, and structural analyses of clients’ needs to demonstrate its contributions to the therapies in grief and bereavement demonstrating its application in letter writing as a ritual leave-taking. Finally, in Chapter 11, the family perspective is considered from the systemic approach. Interpersonal loss is about relationships, and the family’s interactions are often best understood in that context. What the family therapies do, of course, is to work directly with that system. Including a systemic perspective can broaden and deepen what is seen through the therapist’s lenses working with the individual bereaved. The insights of the Two-Track Model of Bereavement contribute to the therapeutic models presented. The chapters inform each other. Individually and jointly, they are written to be relevant for all practitioners, irrespective of the models of therapeutic practice they may identify with.

7

Psychodynamic Psychotherapy
Traditional and Relational Aspects of the Encounter

This chapter considers features of dynamic therapy that are relevant and effective in treatment with the bereaved. The most sweeping contribution of psychoanalysis is its focus on the complexity of forces that influence and drive human experience and behavior from an intrapsychic perspective. The psychoanalytic tradition emphasizes that our conscious understanding of ourselves and our lives is an important but incomplete organizer of our lived experience. From the time of Freud’s early writings until today, as a culture, we in the West have come to accept that we are subject to psychological forces beyond our control.

The psychodynamic corpus approach to interpersonal relationships includes a well-developed worldview that sees these relationships, historically termed object relations, as the very core of human development and organization (Bowlby, 1969, 1973, 1980; Frankiel, 1994; Mitchell, 1988; Sandler & Sandler, 1978). The significance of interpersonal relationships for individual development and lifelong well-being is central to bereavement because of the interpersonal nature of loss. The conscious and unconscious aspects of our relationships with others reflect both their ongoing influence in our mental lives and the opportunities to rework them so as to change their effects on our current thoughts, feelings, and behaviors (Bollas, 1987).

Many of the elements of psychodynamic psychotherapy have found their way into other systems of treatment, often under different names and with differing emphases (Weston, 1998). Not surprisingly, the influences of other theories and approaches, coupled with the spirit of the changing times, have found their way into the range of dynamic therapies as well. The result is that psychoanalytic and psychodynamic thinking and therapies refer to an entire range of theory and technique that defy easy classification, but whose applicability extends to practitioners with alternative conceptual frameworks.

It makes more sense today to speak of soft psychodynamic approaches to psychotherapy and psychoanalysis rather than hard and narrow psychoanalytic approaches to change. In contemporary psychodynamic treatment of bereavement, we choose to highlight elements of treatment that are relevant for the therapist meeting bereavement. These include the appreciation that conscious and unconscious features of the response to loss are operant; that past and present features of the relationship to the deceased are significant; and that the relationship between therapist and client is always relevant. Finally, in evaluating the response to loss, we may paraphrase Freud’s reputed designation of mental health as “to love and to work” and observe that bereaved individuals need to evolve a balance between the intensity of the ongoing relationship with the deceased and their openness to living in the world. The layers, themes, and dimensions that run through psychodynamic therapy with the bereaved are many (Mitchell & Black, 1995). Among the most relevant themes in bereavement are those related to the apportionment of emotional involvement post-loss, the experience of the self, how the bereaved’s psychological and actual interactions with others are conducted, and finally and most importantly, the pre- and post-loss relationship and organization of the memories of the deceased.

EXPLORING GRIEF

In addressing emotional well-being, there is much for the therapist to learn. To what extent does the bereaved experience grief? Does this grief interfere with the responsiveness to other aspects of life demands and invitations? What does the grief entail from the emotional, cognitive, somatic, and behavioral perspective? What does this grief and mourning remind the bereaved of and have these been encountered in the past? What previous losses were experienced and what were their trajectories?

Exploration of the experience of the self is very important. How is the post-loss self experienced? Harry Stack Sullivan spoke of the personified self to convey what it was that people meant when they describe the “I” (Sullivan, 1970). To help us understand, we seek answers to questions such as: How empty does the bereaved feel? How guilty? How despondent? How relieved? How angry? How bereft? How abandoned? How empowered? How emancipated? How scared? These are a number of emotions and their accompanying cognitions that clarify the experience of self following significant interpersonal loss.

Next, the management of interpersonal relationships with others who are not the deceased nor necessarily associated with him or her considers the realm of the social fabric of the bereaved. Whom is the bereaved close to? What is the history and the change in those relationships? Irrespective of one’s theoretical orientation, these questions help orient us to understanding what the bereaved is going through.

BEREAVEMENT AND RELATIONSHIP

The most central theme, however, in grief and mourning revolves around the pre- and post-loss experience of the deceased, the relationship to him or her, and the nature of the function, quality, and primacy of the bond. A helpful way of thinking about the functions of psychological relationships may be found in a short story. Primo Levi (1989) makes one of the clearest statements about the nature of self and other representations in a story titled “The Mirror Maker.” As is often the case with others of Levi’s fictional characters, the hero is a technical expert who is unsuccessful in making a success of his expertise. Timoteo has invented a mirror that is placed on the forehead of another person. This special mirror, called the Metamir, is a metaphysical mirror that allows the gazer to see him- or herself reflected in the mirror exactly as the other sees him or her. On the hero’s mother, the Metamir reflects Timoteo as an angelic pink-cheeked young boy. On his current female companion in a relationship that appears to be doomed, the Metamir shows a balding unattractive and overweight man. On the forehead of the woman who seeks his affection, however, he sees himself reflected as a handsome, gallant, and dashing figure.

The idea here is that the way in which we believe we are seen and appreciated by others has meaning and influences our sense of well-being (Kohut, 1971, 1977; Rogers, 1951, 1957). When bereavement occurs, the communications from the internal psychological organization of the relationship may be distorted. For example, if we think of the bereaved “as if” communicating with a Metamir following bereavement, it is possible to experience the loss as acting to have smashed the mirror so that no further communication has any chance of being received. Death has effectively stopped all communication. Alternatively, the Metamir may have survived, but the ability to transmit communication has been disrupted following the death and can be restored. This would be the equivalent of disruption following bereavement, resulting in avoidance of memories or any number of intrusive thoughts and feelings that allow for partial, albeit incomplete, connection to (and communication from) the deceased. A third possibility is that the Metamir continues to send the messages of positive regard and support despite the death of the person who had initially transmitted them. This basic communication continuing to be sent out from the Metamir of those who love us has powerful and continuing effects. Having been loved as children by our parents, our continued sense of well-being need not be affected by the death of the parents of our childhood—and so the experience can feel as if the Metamir has continued to send forth its positive message. The fourth possibility is that the Metamir continues to send mixed or predominantly negative messages that require a reworking of elements of the relationship itself.

Looking to the nature of the ongoing relationship to the deceased carries with it implications both for the experience of the self as well as the experience and recollected relationship to the deceased. The openness of psychodynamic thinking to the illogical, conflictual, and irrational aspects of one’s inner psychological world gives them a place in the therapeutic space. In bereavement, this allows these contradictory and confused emotions, thoughts, and memories to enter into the therapy and permits modifications in these aspects of his or her inner psychological world. The modern attachment literature, based on Bowlby, has focused on the nature of the attachment bond and the readiness to form attachment bonds particularly in the developmental and pair bonding contexts. Bowlby himself, however, skillfully blended his attention to real-life interaction and to the nature of the psychological and intrapsychic construction of self and other. He linked up “internal working models” of self and other that characterize persons to bridge internal and behavioral dimensions.

A second critical aspect of psychodynamic thinking relates to the value of not drawing a sharp distinction between “alive” and “dead and gone” in some areas of the emotional life of the bereaved. This understanding of bereavement directly relates to the transitional space and play phenomena so wonderfully described by Winnicott (1971). What makes Winnicott so compelling for the work of bereavement is his concentration on the space of play and the construction of things that allow persons to transition from where they are to where they need to be. For the child, holding a “security blanket” or engaging in security behaviors in the absence of parent figures can allow adaptive functioning. Allowing the bereaved space to think, feel, and have reveries not entirely in the realm of “reality” or of “fantasy” is extremely important in both spontaneous and psychotherapeutic adaptation to loss. We return to Winnicott in the context of linking objects in Chapter 10.

In contrast to a perspective that defines successful bereavement as acknowledging the reality of the loss, the implication for Winnicott’s attitudes to the creation of a space of possibility are many. These allow for playful and creative engagement with possibilities and wishes outside of the limits and demands of harsh reality. This space is essential for healthy development of children and also for adults. In bereavement, such transitional spaces span a wide range. They may include belief in the afterlife and the continuation of the spirit or soul which may flourish totally out of context and inconsistent with the logical and organized belief system of the bereaved. Even deeply spiritual persons who profess belief in the continuation of the spirit also have a side that may doubt the veracity of these same beliefs. The transitional space of the bereaved allows for detection of the “presence” of the deceased in signs, sensations, and feelings experienced by the bereaved. Using this transitional space for activities such as talking to the deceased, “being” with the deceased, writing to him or her, and other ways of blurring the distinction between living and dead can be very helpful for adapting to change. Dreaming, chair work, letter writing, and visiting places where the spirit of the deceased has had some association all operate, at least partially, within the space that in the psychodynamic corpus is associated with Winnicott.

For the bereaved, being open to the inner reality of continuing existence of the representations and impact of the person who has died can be highly adaptive. This works so long as that blurring is not confused with external reality. In other words, so long as the cognitive ability to recognize the reality of death is present, there are adaptive aspects of allowing a transitional space where the real world and its constraints are not the dominant aspect of one’s emotional life (Winnicott, 1971). The mental processes often referred to as the “unconscious” in shorthand does not distinguish between inner and external reality. There are many “ego” functions that attend to the demands of external reality. If they extinguish the connection to the space where reverie and transitional phenomena are allowed, the bereaved can lose important sources of emotional support and potential for growth.

ON THE MEETING OF THERAPIST AND CLIENT

In recent decades, developments within psychodynamic thinking have focused on the interaction between therapist and client from perspectives that extend far beyond the conceptions of transference and countertransference in their myriad variations. The intersubjective and postmodern influences upon the therapeutic frame have sharpened greatly current sensitivity to the therapist’s personal history and ongoing experience of the human encounter with the bereaved (Berman, 2004; Davies, 2004). Most simply put, the therapist’s own attitudes and history to the gamut of loss and bereavement are major players in creating the conditions for successful bereavement work. Who the therapist is, both generally and moment to moment, sets the stage for the therapeutic encounter. At times, the therapist may work within a more classical view of the therapist–client interaction, which addresses the therapy focus through the lens of a one-person psychology (Kirman, 1998). There what the client brings with him or her to the bereavement experience is relevant, and the therapist works with the processes in treatment with relatively little formal attention to his or her own contributions to the process. The notion that the primary transference relationship is not with the therapist but with the deceased functioning as a variant of selfobject has been addressed in earlier work and will not be developed here (Hagman, 1995; Rubin, 2000). This is not to say that the relationship between therapist and client is not important, but rather to emphasize that much of the work rela...

Table of contents

• Cover Page
• Half Title page
• Series Title Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Series Editor's Foreword
• Preface
• Acknowledgments
• List of Contributors
• Section I Choosing Life After Loss
• Section II The Two-Track Model of Bereavement Continuing Bonds and Continuing with Life
• Section III Integrating Various Therapeutic Approaches with Insights from the Two-Track Model of Bereavement
• Section IV Expanding Horizons Culture, Clinical Challenges, and Facilitating Resilience
• Appendix The Two-Track Bereavement Questionnaire (TTBQ2-70)
• References
• Index