Q: I’ve had several cases this week in which clients have come in with devastating losses. I feel overwhelmed by these situations, and I don’t feel I can give much help. What should I do?
A: Although witnessing suffering in all its raw intensity can be a grueling and exhausting experience, the fact that you feel deeply touched by the losses of your clients signals your natural capacity for empathy and compassion–essential qualities in a therapist. Your own distress can provide powerful motivation to help–if you weren’t moved by your clients’ suffering, you wouldn’t be able to help them as well. The question is, how do you harness these feelings without being overwhelmed by them, and use them as the springboard to do truly effective therapy?
Generally, people suffering a major loss or life-threatening illness are frightened that the intensity of their emotions is somehow abnormal, over the top, and out of control. The first step in helping them is to normalize their distress by letting them know that their feelings are to be expected of anyone in their circumstances. The fact that you yourself are visibly touched, even distressed, when you hear their stories is itself evidence for them that their feelings aren’t peculiar or, as some clients believe, signs of mental illness.
Identifying distressing emotions as normal human reactions is particularly empowering and reassuring for clients who’ve never seen a mental health practitioner before, precisely because this information is coming from an “expert.” The response I hear most often, uttered with tremendous relief, is, “You mean I’m not crazy?” Normalizing distressing emotions in clients also disrupts the secondary emotional process–distress about distress–that so often complicates grief, depression, and other mood disorders.
The second vital step in helping these clients is to make it very clear that you’re ready to listen wholeheartedly to whatever they have to tell you. It seems obvious, but many people who are suffering don’t have anybody to whom they can talk openly. They may fear that others in their lives, even people in their own support networks, would be unable to tolerate the intensity of their pain if they let it show, or they may simply want to protect others from the full brunt of their suffering. But the “social rules” of therapy are different from those of ordinary life, which means they have full permission to tell their tale.
Since I work in a medical setting, I’m often put in touch with clients who wouldn’t seek out a therapist otherwise. For example, I once worked with Tim, a 50-year-old, unmarried man who was finishing radiation treatment for a curable head and neck cancer. Much to my surprise, he didn’t want to talk about his own illness, but about the death of his elderly mother, which had occurred two years before his own diagnosis. He’d been her only child, and there were no other family members with whom he could share the story of their final days together. The session was emotionally intense–Tim cried uncontrollably for its duration. Then, at the end of the session, he thanked me, but refused a follow-up appointment. I heard, however, from the medical staff that during the next few weeks of his treatment, his overall level of distress noticeably diminished. The most effective clinical “intervention” in his case was simply being fully present with him in his sorrow.
The emotions experienced during a crisis or after a major loss come and go, bringing startling swings from one feeling to another, even while the situation remains unchanged. There are good days and bad days. Most of my clients are bewildered and overwhelmed by this emotional instability, having always assumed that their basic emotional temperature is more or less fixed and permanent. Simply explaining to them that, in their position, it’s normal to experience some emotional lability–even moments of joy or relief–provides assurance that they’re not losing their minds. Then I present tools for riding the waves of distress.
Mindfulness practice is one of the primary tools I use regularly in my work with distressed clients. Not all clients are able or willing to fully begin practicing mindfulness meditation. However, they most likely will be able to practice deep diaphragmatic breathing, which I’ve found to be amazingly helpful. Once clients begin practicing this belly breathing during moments of acute distress, I’ve found that they invariably become curious about meditation itself and more interested in learning how to do it.
I once had a client, Alice, whose mother had recently died of colon cancer. Alice was the youngest in a large family, and had been doted on by her mother. As a result, she was overcome with grief and deeply afraid that nobody could ever love her as her mother had. She developed panic disorder and hypochondriasis, a deep, irrational fear that her panic attacks (palpitations, shortness of breath, dizziness, chest pain) were symptoms of cancer or of a serious heart condition. In fact, her mother’s oncologist referred her to me because she was making weekly appointments with him about these fears, which numerous tests had shown were unfounded.
After I normalized her root feelings of distress, we began to address her anxiety about getting panic attacks and her fear of getting cancer. Although initially resistant to learning mindfulness practice, she was open to learning diaphragmatic breathing to calm herself down when she felt symptoms of panic. Within two weeks, she’d gotten significant results: by breathing diaphragmatically when she felt an attack coming on, she could usually prevent it, or at least lessen the feelings of dread and terror.
Later she grew curious about the mindfulness practice and began to meditate, a practice she still maintains regularly. She still grieves for the loss of her mother, but her grief now follows a normal course, becoming particularly acute during holidays and birthdays. When she feels a wave of sorrow coming on, she’s learned to use mindfulness to “ride it out,” embracing its ups and downs, rather than fighting the feelings and becoming consumed with anxiety in the process.
Finally, you can help your clients by helping them set existential and behavioral goals for themselves. Who they want to be as they go through loss or suffering, and how they want to be changed by the experience are two topics I explore with clients at this stage. Most important, however, is the question of what positive changes they can make in their lives as a result of their suffering. Many of my clients find their answers in religion or spirituality, but even those who aren’t drawn to any particular religious or spiritual path search for meaning in their lives. In the process, they become more aware of the potential beauty and richness within each moment of life and the pleasure and satisfaction to be found with the people they love.
I first met Sasha minutes after she was diagnosed with metastatic pancreatic cancer. She was devastated by the news. I counseled her on how to disclose her diagnosis to her children and grandchildren, and even in the first session, we discussed some positive life goals to maximize her quality of life. During the next few months, we were all amazed at the level of energy and passion she developed toward life, despite weekly chemotherapy. Although neither religious nor spiritual, she actively explored life’s opportunities, traveling to remote parts of the world she’d long wanted to see, learning to do sculpture, going fly-fishing, and swimming with dolphins.
Two years later, she’s defied medical expectations, and despite her advanced illness and occasional feelings of depression, she reports to me that she’s living with more meaning and joy than at any other time in her life. She embodies the potential within people to find strength of purpose and the ability to extract the richest marrow from life, even in the midst of great suffering.
Sameet Kumar, PhD, is a clinical psychologist, storied author, international speaker and expert in mindfulness-based therapies in grief and end-of-life care. He is the author of Grieving Mindfully: A Compassionate and Spiritual Guide to Coping with Loss (New Harbinger, 2005), as well as The Mindful Path Through Worry and Rumination (New Harbinger, 2010) and Mindfulness for Prolonged Grief: A Guide to Healing after Loss When Depression, Anxiety, and Anger Won’t Go Away. He has more than 15 years of experience with grief counseling, and working with cancer patients and caregivers, and has studied with numerous Hindu and Buddhist teachers. Dr. Kumar practices at the Memorial Cancer Institute in Broward County, Florida.