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Why would anyone choose a career in community mental health today?

By David Dan

By Rich Simon

 

A Complicated Grieving

Death, guilt, and anger are an explosive mix

By Sameet Kumar

Grief is an inevitable part of life, but that doesn't make it any easier to go through. Even so, grief often resolves itself. It may never entirely fade, and the loss that caused it certainly won't be forgotten, but it almost always changes and becomes incorporated into life, so the grieving person can move on.

There are times, however, when grief doesn't take this relatively straightforward path toward resolution. What we call complicated grief typically results from complex and often ambivalent relationships, leaving in the survivor unresolved feelings of guilt, shame, anger, and regret that can fester, sometimes for many years. For therapists, negotiating the troubled waters of complicated grief can be difficult because one partner in a complicated relationship has died or is unavailable for some other reason. In effect, were challenged to find a solution to an equation with only half the factors at our disposal.

Tracy and John comprised such a difficult equation. I first met Tracy while she was in the hospital receiving an intense form of chemotherapy for her metastatic melanoma. She was a 58-year-old woman, the cornerstone of her family and community, who'd risen from being a waitress to being the manager of a popular local restaurant. Her husband, John, visited her in the hospital regularly, while her children and grandchildren, who all lived at a considerable distance, came to see her as often as they could, and gave her their unflinching support.

Tracy showed a remarkable ability to tolerate her grueling chemotherapy regimen, which required regular hospitalizations. Typically during this kind of chemotherapy, people experience intense fevers, rigors or uncontrollable shaking, chills, and nausea, followed by complete exhaustion for the next week. However, Tracy had remarkably few side effects. She attributed this to sheer willpower. When I set my mind on something, you can consider it done, she said on numerous occasions. As proof, she reported that her restaurant had been losing money when she was given her management position, but became extremely profitable within a year of her taking over.


I saw Tracy intermittently for the next two years. Her busy schedule at work and at the cancer center made regular sessions difficult to schedule. Usually she'd see me when starting a new treatment modality or when faced with difficult treatment choices. I was both her therapist and coach, helping her navigate the maze of the medical system, while encouraging her innate fighting spirit.

As the months passed, even though she was trying various interventions, including chemotherapy, radiation, and surgery, and in spite of her formidable willpower, her melanoma continued to advance, though much more slowly than expected. It spread from organ to organ, finally invading her brain, liver, and lungs. Throughout this time, John was at her side whenever she was at our treatment center.

While many people at our center suffer and die alone, regardless of family size, income, and social standing, others seem to be blessed by a caring and dedicated network of family and friends. We can usually tell when support is genuine and when its superficial. John's support was consistently identified by all team members as selfless and commendable. He and Tracy appeared to be an ideal couple. His care of his wife seemed to draw on an inexhaustible well of a good feeling generated by a long, happy marriage.

John wasn't just emotionally supportive: he also grasped the fine details of Tracy's disease and treatment options. During one visit to our cancer center, he confided privately to me, fighting back tears, that he knew it was only a matter of time before Tracy died, and that he felt it was his duty to make sure that her quality of life was the best it could be for whatever time she had left.


Broken Trust

Then one day, Tracy asked to meet with me alone, an unusual request since our meetings had always coincided with one of her treatments. By now, she was much sicker than when we'd first met. During this session, I was shocked to learn that she and John were living apart, and had been separated for two years. Sensing my surprise, Tracy further revealed that their separation was a secret, known to their adult children, two sons and one daughter, their closest friends, and a few others. Most of their grandchildren weren't aware of the separation, and she didn't want me to reveal my knowledge of the situation to anyone, not even their kids.

She said she'd asked John to leave the house when she discovered that he'd had an affair with another woman almost 20 years previously, and had fathered a daughter who was now 18. The affair had lasted a year and a half, and John had sworn to Tracy that he'd been faithful ever since. John himself had revealed this information to Tracy only after her melanoma diagnosis. At that point, she'd asked him to leave their home.

Now that she was ill and her health had continued to decline, she was unsure about the separation. She wanted to explore the issue in therapy. As a devout Roman Catholic, she felt deeply torn between her religious obligation to forgive John and her anger at him, as well as her desire for justice. She couldn't bring herself to agree to live with him again, feeling that the bond of trust between them had been irrevocably destroyed. By now her eldest son, Geoff, who was 35, and her 14-year-old grandson, Bobby, were living in her house, so she didn't need John's constant attention at home. As she said to me, her mind was made up--she wouldn't let him come back, and there was no changing it.

Whatever her affection for John, Tracy felt she couldn't love him as her husband anymore, and didn't want to spend her final weeks or months living under the same roof with him. Moreover, she was adamant about never wanting to meet his adult daughter. I asked her if I could talk to John about this meeting, should the need ever arise after her death. She said yes.


As the session continued, it became evident that she wasn't emotionally prepared to work toward the forgiveness she felt obligated to offer John. She simply couldn't do it, and didn't feel bad about it. Tracy's last words to me on the issue were, "He made a bad mistake, and I guess he has to suffer the consequences. Why should I be the one who has to do all the work?" At this point, it became clear that our therapy focus was going to be preparing Tracy to die while keeping the rift in her family manageable, rather than finding a way to heal her relationship with her husband in the short time she had left.

Shortly after this conversation, the decline in her health began to accelerate. Each week, she developed a serious new symptom, requiring more frequent blood transfusions and hospital care. Through it all, John was by her side. During her final week, I saw her one last time. After she thanked me for the help I'd given, we shared a tearful goodbye. She died two days later, surrounded by her husband, their children, and her closest friends.

A Family in Shambles

The week after her funeral, at John's request, I met with him and their three children. Although I frequently meet with family members after the death of their loved ones, this was a particularly difficult session for me to anticipate, since I knew that there was going to be an elephant in the room with us--one that John and the kids didn't know I knew about. I wasn't completely sure what the purpose of the family meeting would be or what direction it might take.

Not surprisingly, just as he was dedicated to Tracy in life, John was now shepherding their clan through grief. Meeting privately with John prior to the family session, before I mentioned my meeting with Tracy, he disclosed their separation, talking about his guilt over his affair, as well as his anger at being exiled from his home during her final illness. Although he was relieved to know that Tracy had attempted to work through this issue with me privately, he was distraught at his wife's inability to forgive him. His own lingering guilt about his long-ago affair was almost overshadowing his grief for his wife. I asked John what would ease his guilt and his pain. He said that it would help if his children could have a relationship with his daughter.


When I met separately with all three children, it was clear that they all had considerable anger toward their father, which partially masked their grief for their mother. Just as my goal with Tracy was to keep the rift manageable around the time of her dying, my goal now became restoring cohesion between John and his children. It didn't seem fair to me that John would be sidelined from the family for a mistake he'd made so many years ago, and at the time when they all needed each other more than ever. I've seen many families disintegrate after the death of a parent. I didn't want to see this happen to Tracy's family.

In order to facilitate cohesion, I began to describe in detail the care that John had shown Tracy, even after he'd been exiled from their home. He'd been given every opportunity to leave the relationship, but had chosen to stick with Tracy to the degree she allowed. Surely, this counted for something.

Indeed, the three adult children were able to factor this into their feelings. Looking at the big picture, they were all able to forgive their father for his mistake. Still, none of them wanted a relationship with their half-sister. Like Tracy, they were set in their ways regarding this matter, and there was no budging them. It was as if their anger toward John was being transferred to their half-sister. They didn't think this unwillingness to have a relationship with her was a problem, and therefore saw no need to discuss the issue further. Even so, I felt that helping them find some measure of forgiveness for John was important to have attained. The relationship with the half-sister could wait. After all, their mother had died only days before.

By contrast, when the entire family met, it was obvious that John desperately wanted to normalize things quickly by bringing his daughter into the family. I didn't think this was realistic. It was clear that the family potentially was heading toward an explosive impasse; in fact, the children refused to discuss the matter with John in the room.


As the weeks went on, the impasse continued. They all came to weekly sessions for three weeks. Each of the children grieved in his or her own way. The middle child, a 30 year-old son, was almost completely disengaged from the family, and was unwilling to come to therapy after the third session. The youngest, a 25-year-old daughter, began drinking heavily again, and I referred her back to Alcoholics Anonymous. I then began to meet with the eldest son, Geoff, and John, individually and together, every two weeks. At this stage, they'd become fixated on Tracy's favorite grandson, Geoff's son Bobby, telling me that he was having a particularly difficult time grieving.

When I met with Bobby, however, it was clear that he was grieving in a reasonably normal manner. Certainly, he was doing better than some of his older relatives, despite his father and grandfather's concerns. When I asked him what the hardest part of Tracy's death was for him, he replied, I miss having a grandparent. This one comment seemed to provide a clear therapeutic goal for both John and Bobby. Since Bobby had been so close to Tracy, he really hadn't developed a relationship with John.

Turning Toward Life

Rather than seek to unify the family by bringing in John's other daughter, it seemed much more attainable to nurture a relationship between John and Bobby. In meeting individually with John at the end of my session with Bobby, I gave him homework to spend more time with his grandson, perhaps even doing some of the same things, in his own way, that Tracy had done for the boy.

Two weeks later, when we all met together again, I found that John had plunged into this homework with genuine dedication. He'd attended several of Bobby's baseball games, something he hadn't done when Tracy was alive. They'd even managed to carve out some quality time alone together, going fishing in one of the many canals that crisscross south Florida. Bobby loved this particular activity, commenting to me that Tracy was loath to fish and his father never seemed to have the time. In many ways, it seemed, John was now caring for his grandson, just as he'd cared for his wife.


When John and I met individually in this session, it proved to be one of our most intense meetings. When I asked him what the past two weeks had been like, he became teary eyed. It wasn't because he missed Tracy, even though he did miss her terribly--he was crying out of love for Bobby. I can see why she loved this kid so much, he told me. When I asked him directly about bringing his other daughter into the family, his answer surprised me. I can do that on my own. I need to focus on the family Tracy and I built together. I owe it to her.

As the session continued, we explored John's guilt toward Tracy. I disclosed to him that Tracy had tried to work this through in therapy but had been unable to genuinely forgive him. He didn't sound surprised. I don't know if I can ever forgive myself, he said. Sensing that a breakthrough moment was at hand, I encouraged him to continue, using his earlier comment about owing it to her as fuel. If you can't forgive yourself and she couldn't forgive you, you're pretty much stuck. If you're so weighed down with this heavy burden, how can you ever possibly make it up to her, and to the family?

In this moment, after spending more time with Bobby during the past two weeks, the answer seemed obvious. John had already articulated it, but now he knew it deeply, and so did I. I have to focus on the family Tracy and I built together. I have to be a better father and grandfather. I could almost feel the burden lift off him as the elephant of his guilt left the room.

For John, the better he felt about his ability to meet Bobby's emotional needs, the less anger and guilt he experienced about his complex relationship with Tracy. He reported that he'd been largely absent from Bobby's life before Tracy's illness, but now felt that nurturing a relationship with his grandson allowed him to atone for his past mistakes in his marriage. In many ways, Bobby had become a receptacle for the love he bore Tracy. In caring for Bobby, John was able to continue loving Tracy, while finding a sense of forgiveness after her death that had eluded him while she was alive.

John's relationship with Bobby was both redemptive and mutually rewarding. Bobby gained a grandfather at the same time that John was relieved of some of the burden of guilt he carried. By focusing on the immediate tasks of being a good grandparent, John's grief became transformed from pain and complicated guilt to a sense of meaningful engagement.

Working with Tracy's family touched on many of the issues of complicated grief. When a loved one dies and issues of guilt and anger color the already difficult, meandering path of grief, healing lies in the world of the living. Reinvesting in relationships often helps give meaning to incomplete or distressing feelings that can complicate grief. The pain of grief is intense, almost cruel at times. Yet for everyone experiencing grief, complicated or otherwise, the lesson is usually the same: life is short and precious. Nurturing life, nurturing relationships, and finding meaning in our ability to do so taps into our innate capacity for healing. These are the paths to explore in grief, and in life.

Case Commentary

By David Treadway

Complicated grief, involving varying degrees of guilt, anger, relief, and blame, separates people who might otherwise draw closely together after the loss of a loved one. That family members often grieve in very different ways may cause conflict among them, which can actually block the grieving process itself.

Sameet Kumar's case presents an excellent example of how delicate and difficult it is to address complicated grief. He does a superb and tender job of holding all the family members, despite their conflicts. Then, by sidestepping the impasse over John's daughter and triangulating in the grandson Bobby, he provides a connecting link that keeps them together despite their many unresolved issues.

He also shows the power of taking here-and-now action steps to promote healing, rather than being overly dependent on the sharing feelings method that most of us therapists are biased toward. Tears of joy in discovering a relationship with his grandson are just as healing for John as tears of sadness, perhaps more so. It seems clear that slowly, over time, the family will reunite and forgive their father.

Nicely done.

It's very important for all of us in the therapeutic community to respect the different ways people have of grieving and to guard against our own biases about what's the right way to grieve. In the last few years, four of my clients have had a child die during the course of our therapy. In the face of this unbearable tragedy, each grieving parent has struggled to survive in very individual ways, and each couple has shown profound differences in how they've coped. The essence of my role with each of them has been to provide support in whatever way of grieving seems to work best, and to avoid projecting onto them my assumptions about psychologically healthy ways of expressing grief.


In considering Kumar's case, I realized yet again that the simple principle of respect for differences that we apply to grieving families is just as important in how we understand each others approaches to therapy. Kumar did an exceptional job with this family, enabling them to find closure and healing. And yet, simply because I'm not Kumar, I probably would have handled the case using other approaches.

Here are a few aspects of the case I think I might have done differently.

Long before Tracy brought up the affair, I'd have initiated ongoing couple and family meetings, as well as meetings between Tracy and each of her children. I'd have encouraged family members to write to Tracy, describing what she'd meant to them, the memories they had of her, and other things that were on their minds. I'd have strongly recommended that Tracy write them also before she got too sick.

Once Tracy brought up the affair and separation, particularly if I already had a therapeutic relationship with John, I might have asked John and Tracy to meet together with me, even if there was only time for just one session. I'd have supported her need not to forgive and to stay separated. I'd also have encouraged John to really try to understand and fully acknowledge what his profound betrayal had done to Tracy. Not only had he harmed his wife by having the affair itself, but by keeping it a secret, he'd probably soiled for her, as she neared death, the memory of all the intervening years when she hadn't known. John's acknowledgement of how he'd harmed her might have allowed him to feel that at least he'd done everything he could do to make amends to his wife before she died.

Assuming I'd had a good working relationship with the family members before Tracy's death, I might have tried to keep the alcoholic daughter and the distant son engaged in the treatment, because their complicated grief was just as central as John's.


Because I'd have been more involved with all three siblings, I might have triangulated the family around responding to the sisters alcoholism after she started drinking again. Of course, this might well have been much less effective than Kumar's focus on the John/grandson relationship, which turned out so well. I can only too easily imagine the family and me sinking into the substance-abuse quicksand pit rather than walking around it.

So these are some of the differences in how I might have approached the case. Even with 20/20 hindsight, it isn't at all clear that my way would have ended up being as good as or better than Kumar's. Who knows? This is truly the nature of therapy, despite all our attempts to replicate evidence-based treatment models.

We therapists truly practice an arcane art. Every day, we have to risk giving our hearts and minds freely to those in our trust, without certainty that we can help them or even avoid doing harm. Sometimes it feels like the blind leading the blind. Despite that, like Kumar, we reach out our hands to our clients and, side by side, walk along with them together for a little while.

Sameet Kumar, Ph.D., is in private practice providing individual, group, and family therapy to cancer patients and caregivers. He also provides palliative care psychotherapy and bereavement therapy to patients with advanced cancer. His first book is Grieving Mindfully: A Compassionate and Spiritual Guide to Coping with Loss. Contact: sameetkumar@yahoo.com.

David Treadway, Ph.D., is director of the Treadway Training Institute in Weston, Massachusetts. Hes the author of Intimacy, Change, and Other Therapeutic Mysteries; Dead Reckoning: A Therapist Confronts His Own Grief; and Before It's Too Late: Working with Substance Abuse in the Family. Contact: dctcrow@aol.com.

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