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, we’re 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.
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.
Turning Toward Life
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.
This blog is excerpted from "A Complicated Grieving" by Sameet Kumar. The full version is available in the September/October 2006 issue, Couples Adrift: What Science is Telling Us About Helping Troubled Relationships.
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