The Therapist in Mourning

From the Faraway Nearby

Kerry Malawista, Anne Adelman

• Verlag: Columbia University Press
• Jahr: 2013
• ISBN:
  9780231534604
• Thema: Psychology
• Thema: Psychotherapy Counselling

The unexpected loss of a client can be a lonely and isolating experience for therapists. While family and friends can ritually mourn the deceased, the nature of the therapeutic relationship prohibits therapists from engaging in such activities. Practitioners can only share memories of a client in circumscribed ways, while respecting the patient's confidentiality. Therefore, they may find it difficult to discuss the things that made the therapeutic relationship meaningful. Similarly, when a therapist loses someone in their private lives, they are expected to isolate themselves from grief, since allowing one's personal life to enter the working relationship can interfere with a client's self-discovery and healing.

For therapists caught between their grief and the empathy they provide for their clients, this collection explores the complexity of bereavement within the practice setting. It also examines the professional and personal ramifications of death and loss for the practicing clinician. Featuring original essays from longstanding practitioners, the collection demonstrates the universal experience of bereavement while outlining a theoretical framework for the position of the bereft therapist. Essays cover the unexpected death of clients and patient suicide, personal loss in a therapist's life, the grief of clients who lose a therapist, disastrous loss within a community, and the grief resulting from professional losses and disruptions. The first of its kind, this volume gives voice to long-suppressed thoughts and emotions, enabling psychologists, psychiatrists, counselors, and other mental health specialists to achieve the connection and healing they bring to their own work.

Part I

The Therapist’s Experience of Loss

IN THIS section, our authors explore grief and loss from three different vantage points. In our first chapter, Kerry Malawista and Linda Kanefield approach the experience of loss through the lens of artistic representation, fictional narrative, and neurological and psychoanalytic understanding. They suggest that rather than moving through “stages” or “phases,” mourning is more like a Möbius strip—a form both simple and elegant that has no beginning or end but rather weaves around itself in a continuous loop. With this perspective, there is no clear endpoint to grief nor any specific goal for mourning. Instead, the mourner finds herself in a transitional space, a state Malawista and Kanefield refer to as the “middle-distance.”

As we discussed in the introduction, the realm of the middle-distance provides a psychic holding place where the mourner can gradually assimilate and integrate the reality of the loss while still maintaining a phantom presence of the loved one. For the mourner, life progresses without the deceased, yet at the same time the memory of the loved one remains right alongside, always in one’s peripheral vision. One need only turn one’s head slightly to catch a glimpse—a reminder that can bring a stab of pain or a cherished memory. We will return to this notion of the middle-distance as a way to capture the mourner’s dual experience of the loved one as simultaneously present and irrevocably lost.

Judith Viorst describes the primary themes uncovered over the course of sixteen interviews with analysts who were invited to discuss their personal experience of terminating with long-term patients. All but one of her interviewees acknowledged that ending treatment invariably elicits feelings of loss. She highlights that this is an intimate relationship from both sides of the couch. Each analyst organizes and makes sense of these feelings in a unique way that then affects their clinical decisions during the termination. Each participant is subject to a range of feelings that can complicate the process of ending treatment. She brings the hopeful idea that during the termination phase both patient and analyst have new opportunities to mourn.

In the next chapter, Sandra Buechler describes the oft-unacknowledged reality that we really do miss our patients when they go, whether they plan to leave or end treatment abruptly, or, in some instances, when they die. She introduces the idea that when a treatment ends we lose the opportunity to become the person we glimpsed in ourselves with that particular patient. What was unique and only possible within this distinct patient-therapist dyad is now gone. It will never again be the same two people in the room together in quite the same way. Our imagined future is forever altered by the loss.

Buechler addresses the question that each of our authors in this section touches on in one form or another: How are we to behave in the face of such a loss? She writes that, within our profession, there is a general reluctance to acknowledge the gratifications we receive from our patients or the benefits we as therapists gain from our work. We are taught to be wary of allowing our own needs into the room. Buechler demonstrates how this complicates the grieving process. Though we may not admit it, the loss of a patient is inextricably linked with the loss of a certain kind of personal satisfaction, or as Buechler calls it, “joy.”

Chapter 1

FROM THE FARAWAY NEARBY

Perspectives on the Integration of Loss

Kerry L. Malawista and Linda Kanefield

GEORGIA O’KEEFE’S 1937 oil painting From the Faraway Nearby depicts the remains of an elk’s skull and antlers above a range of pink and white mountains in the desert. The painting, like its title, captures the dualities of life: the haunting idea that something can be both distant and, at the same time, dangerously close. O’Keefe’s painting is filled with contradictory images—light, representing life, and bones, the marker of death. It denotes the dual experience of something that is simultaneously present and immediate yet absent and elusive. Curiously, the canvas lacks a middle-distance, an artist’s term for the space between the foreground and the background. In O’Keefe’s painting, objects appear either starkly nearby or eerily far away. As we view the painting, we are jarred and confused by the absence of the middle-distance. Visually, we try to make sense of the odd perspective: we seek to comprehend whether we are near or far from the juxtaposed images of life and death. The absence of this middle-distance on the canvas unsettles us, and we try to create a middle realm that would allow the apparent contradictions inherent in life and death to coexist and comingle more quietly.

As in the painting, so it is in life: a middle-distance is necessary. Experientially, we need to navigate a middle-distance to absorb and integrate death. At times, the middle-distance is the perch from which we safely encounter our lost loved one. From this perspective, we can glimpse the past in the distant background, evoking a time before the death. Without the middle-distance, we are assaulted by the starkness of our loved one’s absence in the foreground. At other times, from this perch we can see the possibility of calmer, more serene times in the future, when we are no longer haunted by the intrusive shock of our loss. The middle-distance is not only the position from which we can gain perspective; it is also the emotional and private place in which the deceased temporarily, or even enduringly, resides. When we feel their presence, they are there, not completely gone from our awareness but not alive in the way we have known them to be. Our relationship to the middle-distance is a dynamic and compelling one. Our capacity to periodically visit there—or allow our lost one to reside there—is critical in coping with a recent death.

This duality of life and death is familiar to most people who have experienced a personal loss. Over the years, our conversations, shared reactions, and struggles generated by our personal losses have led us to this chapter. These conversations have served as support and consolation and eventually led to the desire to organize our musings with the hope that it might be useful to us as therapists, as well as others, allowing us to make sense of how loss affects us privately and in our work. Our understanding of this aspect of life became the background for a more focused inquiry and exploration. It became clear to us that any notion positing a rigid or linear progression through grief, implying a static outcome to its resolution, is entirely inadequate. Likewise, a return to life and its pleasures does not signify a completion of mourning as much as it does a capacity to tolerate this duality.

The intrinsic paradox that a deceased loved one can be concurrently experienced as both present and elusive guides our exploration of mourning and our struggle to make peace with grief. How do we make sense of this seemingly irreconcilable contradiction that someone is dead but not gone from our internal world? We believe that the space between the psychological foreground and background, what we call the middle-distance, may serve as a psychological waystation where the bereaved struggles to integrate the loss and form a new cohesive self-narrative.

In fact, we contend that mourning can be understood as a process through which the death is first experienced in the foreground, as a raw, unintegrated trauma, then in the middle-distance, where memories are gradually woven together into a coherent picture. Then, over time, the loved one is internalized, new self-narratives are created, and the loss recedes to the background. This capacity to exist in the middle-distance, to bear unbearable feelings, is healthy yet often undervalued. It is a dynamic and non­linear process that allows for movement, permeability, and integration, and it unfolds over the course of one’s life. For example, someone who has lost a parent may revisit the loss and continue to feel that parent’s presence at developmentally significant times, such as a wedding, a birth of a child, or a graduation.

While grief generally proceeds along this trajectory, we focus primarily here on the middle-distance experience. At the same time, we also appreciate that every loss is different. For example, in coping with the death of a child or the early loss of a parent, one faces unique challenges in mourning. For most parents, a child is experienced as an extension of oneself, as is the parent for a young child. Parents often look at their children and see the promises of their future. In ordinary parenting, these dreams for the future help buffer the blow of life’s inevitable disappointments or setbacks. However, when a child dies, the loss is dual—the very real loss of the child as he or she has been known and the loss of the imagined future for and with the developing child. With no new or anticipated memories to weave into the current self-narrative, one may remain in the middle-distance.

In this chapter, we rely on a variety of points of view. We draw on our personal voices as well as on the more universal voices that emerge from other losses. As we explore the movement toward integration, we incorporate the words and vision of artists and the thinking of psychoanalysts and neuroscientists. For us, these seemingly disparate standpoints, like the ever-changing perspectives from which we all experience a death of a loved one, come together to provide a more complete notion of loss and grief.

Contributions from Psychoanalytic Theory

The psychoanalytic understanding of grief begins with Freud’s “Mourning and Melancholia” (1917). With considerable sensitivity, he explores how the loss of a loved one is dealt with through one of two processes: mourning or melancholia. Both allow for the gradual “bit by bit” (245) withdrawal of attachment from the loved one. Freud considered mourning to be normal, a process that when “completed” (245) allows for the freedom to form new attachments. Melancholia, a more complex process, is characterized by unconscious ambivalence, a loss of self-esteem in the bereaved, and by self-reproaches shifted away from the loved one onto the self. In melancholia, there is an ongoing and consuming struggle to loosen the tie to the object.

Freud brings our attention to subtle questions about the process of mourning. With Freud’s insights in mind, we consider mourning a continually evolving process rather than one defined by reaching a distinct endpoint. Although the deceased is never completely relinquished, the bereaved is not necessarily melancholic. The distinction between a normal process of mourning and a pathological one need not be as absolute as Freud originally posited. In fact, he later questioned some of his earlier assumptions about mourning being a finite process (2003).

Rather, life is compromised by how limited, inhibited, or emotionally shut down one becomes while traversing this middle-distance. The intensity of the intrusive thoughts and the unrelenting or all-encompassing nature of the loss also affect the degree of anguish one experiences during this process. These feelings of grief exist on a continuum of experience, not as a dichotomy. Even denying aspects of the loss, especially when traumatic, does not intrinsically indicate pathology. Instead, the ongoing presence of a lost loved one in the periphery provides stability when the world is threatening to fragment. Such continuity, a thread to the deceased, allows the bereaved to maintain self-cohesion through the passage of time in the middle-distance. Memories of lived experiences with the deceased provide this thread.

The concept of disavowal is one way to understand what occurs psychologically when we are in this middle-distance. In 1924, Freud described disavowal as a psychotic defense against overwhelming feelings of grief following the death of a significant loved one. Later, however, in An Outline of Psycho-Analysis (1938), Freud argues that not only psychotic patients but all individuals have the capacity to deny and accept simultaneously an unwanted reality. He came to see disavowal as ubiquitous and not necessarily an indication of pathology. Indeed, we all continually blur fantasy and reality, sometimes emphasizing one reality when the other is too painful to confront.

In fact, fantasy and playacting all require imagination and the suspension of reality. Winnicott refers to this when he explores the landscape of “playing and reality.” While not directly referring to mourning, he notes that “no human being is free from the strain of relating inner and outer reality” (1971, 13) and suggests that it is a psychological “intermediate experience”—or, in our words, the middle-distance—that provides a respite from this tension. Disavowal protects the mourner from overwhelming pain. In this way, the individual may acknowledge the reality of the death but not yet completely integrate the meaning and acceptance of the loss until the truth can be tolerated fully.

In our view, the deceased’s enduring presence in the middle-distance is adaptive for the mourner. It is a way to preserve one’s sense of self in the face of disruptive loss or trauma. Philip Bromberg’s (1998) work describing “the multiplicity of self” and dissociation may help us understand what occurs in this transitional or intermediate space. Bromberg describes dissociation as a “complex system of discontinuous and shifting states of consciousness” (251). He notes that it “is not inherently pathological, but it can become so.… It is intrinsically an adaptational talent that represents the very nature of what we call ‘consciousness.’ Dissociation is not fragmentation” (244). In other words, it is a way to protect one’s psyche by having an alternate way of experiencing, a way of staving off an unbearable reality. A familiar form occurs in acute grief, when mourners often are able to function in the outside world—describing all the facts of a loved one’s death, or planning a service and burial—while nonetheless still expecting the deceased to return to them. In other words, they function as if in a dissociated state, having not yet integrated the loss as a traumatic piece of a personally comprehensible self-narrative.

Certainly, a death, especially that of a child, poses a significant threat to the experience of the self as whole and intact. The bereaved moves between states of acute grief and adaptive functioning. Bromberg writes that “it is the ability to stand in the spaces between realities without losing any of them; the capacity to feel like one self while being many” (256) that allows the integration of experience. This movement between psychological spaces captures our idea of the middle-distance and the flexible nature of the permeable boundaries between the bearable and unbearable states of mind that we experience during mourning—the acute sensation that someone is gone but still present.

Melanie Klein places the process of mourning into a developmental context. She notes that the longing to “save and restore the [lost] loved ones” (1940, 349) is heightened because it evokes an infantile and painful awareness that the mother can, in fact, be lost. Therefore, according to Klein, the loss of a loved one deeply threatens the stability of the internal world. To stave off the danger of the inner world collapsing, there must be a gradual renewed link to the external world. These links, in which the reality of the loss is encountered, serve to restore psychic equilibrium. Klein notes: “Without partial and temporary denial of psychic reality, the ego can not bear the disaster by which it feels itself threatened” (1940, 349).

Otto Kernberg describes how he came to question some generally assumed characteristics of “normal” grief and mourning after his own “deep personal mourning experience.” He states, “perhaps mourning processes do not simply end, but rather, evolve into something more lasting or permanent” (2010, 601). Through a process of identification, he notes, there is a continuing, active internal relationship with the deceased. Gat...