PSYCHOLOGICAL SUGGESTION TO TREAT PEOPLE WHO ARE IN MOURNING
THERAPY TO ASSIST IN THE MOURNING PROCESS
USUALLY THOSE THAT ARE GOING THROUGH THE PAINFUL SITUATION TO CONFRONT A PROCESS OF DEEP MOURNING, RELY ON THEIR OWN PSYCHOLOGICAL RESOURCES TO TRY TO ASSUME THE DRAMATIC REALITY THAT THEY HAVE TO LIVE.
THESE PEOPLE WILL NEED NOT TO BE LEFT ALONE, BUT, BE IN TOUCH WITH THE PEOPLE THEY LOVE, AND OTHER PERSONS WHO HAVE SUFFERED THE SAME LOSSES.
The mourning process is a long one, since we cannot determine an exact amount of time for it. But it is evident that this process cannot last forever. It is also evident, and we must warn those that seek our help, that the mourning process is an active one, that requires their personal participation. This, we will see, as they come to accept situations and personal changes. It is an error to think that time and passivity will solve all their sufferings.
The mourning process, in itself, despite the deep pain that it causes, is not an illness.., and doesn’t require medication during this initial period.
Only, in those cases when the mourning process continues in time, and doesn’t process its different stages, (obstacles that we shall discuss shortly), or that it installs itself onto a personality that had previous pathologies, then it is advisable for the intervention of a professional.
Some characteristics differentiate the mourning process, of an announced death, such as a terminal illness, from the mourning process, produced generally by accidents, of varied nature.
In the first case, the terminal illness, the professionals dedicated to accompany the illness, have at their disposal, in the last decades, many different therapeutic treatments, for the patient and for this family and friends.
These treatments provide enormous benefits to those who suffer painful and prolonged illness, and also they help the whole family structure, that could otherwise fall into chaos and despair.
For those that have lost a dear person after having suffered a prolonged and incurable illness, might feel, besides their sincere pain for the loss, a sense of relief, not always confessed, to have seen the end of so much deterioration and pain.
We, professionals, must occupy ourselves on this subject with their ambivalent feelings that mortify them, (ambivalent feelings, characterized by terminal illness). We must help them, verbalize their fantasies, that accompanied them on this long process. In other words, between the need to become involved or to take distance from the patient and from his daily deterioration, as a painful strategy facing so much suffering of a loved one. These feelings are lived with great guilt.
This is the most important aspect, in my experience, to deal with, in these cases. Those that seek help, expect to find peace and recover their auto esteem. They must be convinced that they have done absolutely everything in their power, and that these fantasies, that they can today comment on, with deep pain and guilt, are very common in these mourning process.
We shall later see that these mourners don’t have any differences in their mourning process, when we compare them with people who suffer the death of a loved one suddenly. The fact that they have accompanied a long terminal illness, doesn’t mean that they have finished with their quota of grieving. This grief is discontinued when the loved one dies, and the process of mourning starts.
It is not the same to know rationally, that something shall occur, than when it actually does occur.
The unexpected mourning, on the other hand, of a sudden death, and its dramatic implications, are greater at the moment it occurred. There was no time to say farewell, nor repair strained relations. The defenses of the ego, overwhelmed, have not been able to implement any emotional warning, in order to calm the enormous confusion and despair of the first moments.
I cannot affirm, that the evolution of the grief process is better in one case or in another, since each mourner feels his grief is eminently singular, and depends on a variety of circumstances.
Some studies indicate that in the case of sudden death, and above all, early death, the process of mourning present greater difficulties, and have a tendency to last longer. They present greater difficulties than those cases where there has been a possibility of saying farewell. I only describe certain characteristics that are typical to each one of them. Characteristics that we should be aware of, by those of us that assist in the mourning process, in order to act efficiently.
I must stress one characteristic that causes the mourner more pain; the death of young children and infants.
We seem to accept with greater resignation the death of older people, since in one way or another, for better or for worse, they have been able to accomplish a Life Project.
The therapist should be sure of his objectives, if he finds that his patient is overwhelmed by grief and confusion, that all meaningful death causes.
Those patients that ask for his assistance, usually are overwhelmed by grief, with no previous therapeutical experience, and they are not disposed to embark on a long, conventional, treatment. Often they come on the advice of a friend, relative or family Doctor, to the therapy, without a clear picture of what an interview could mean, but possibly with the only conviction that they cannot cope alone, and are seeking help to continue.
The patient comes because of his great confusion, grief and despair, to confront the cruel reality.
He needs to talk and be listened to, he needs to shout his anger and his pain.
I shall try to describe a probable, first interview with those that have recently lost a dear person ( days or weeks ).
In these cases, the “ego” of the patient is filled with grief, therefore it is not necessary to do a therapeutical work with his defenses; here we see the primary function of the therapist confronting grief; his ability to listen. He should NOT BE rigid with the time with his patient and permissive with the needs of the patient; the patient might wish to smoke, or ask for a glass of water, or want to go to the bathroom, or change chairs or walk around the office, or needs to be near a box of tissue, or would want to lean on the therapist arm.
All this can happen suddenly, with a certain decontrol and the therapist will feel impotent at not being able to contain so much pain. The therapist migh feel overwhelmed by the circumstances.
He should only Listen with much sympathy, of course, but try to preserve himself from the flood of emotions ( burnt out ), that can cause such events. For the therapist to give in to the flood of emotions of his patient, doesn’t do the patient any good. The patient surely has people with whom he or she can cry. But we therapists, must give him or her another kind of contention, even though, at first, the patient cannot understand it.
Only listen and agree, hardly speaking, since at this stage of catharsis, the patient has very little capacity to listen to explanations or complicated suggestions.
During future meetings, the patient will calm his feelings of anguish, and it is then, that a dialogue can ensue. It will be possible to suggest some basic rules to continue with the following sessions. Rules that in the beginning of the therapy we have been reluctant to impose. In this first, initial interview, it is not always the case that the patient comes through with his dramatic story, but it is necessary to be prepared for it to happen, if we want to help the desperate mourner. The theoretical differences between the sudden death mourner, and the terminal illness mourner, is minimized in a therapy of these characteristics, since in both cases, it is the recent death of a very dear person, the point that originates the wish to relieve himself or herself of his anguish.
We must the be familiar with the general theoretical rules of the mourning process, and have analyzed them, possessing sufficient training, ( that we shall acquire with time and practice). These are; Never work in solitude, participate of a control group or be in touch with other professionals with the same specialty, with whom we can meditate and analyze our own emotional state. We should have been able to confront and overcome our own personal mourning.
The patient is interested knowing, that not only have we studied the mourning process, but that we have also suffered deep mourning processes, ourselves.
These conditions will make us trustworthy in their eyes and they shall then accept the fact that we are capable to understand a common language. The catharsis or initial testimonial discharge must be able to be complete in its delivery, without imposing a rigid time limit. We must listen patiently, demand a minimum explanation on some commentaries, if necessary, but try to avoid, since they add nothing significant to the discourse, the most painful details, associated with the last moments of the death. We can see pictures and writings that the patient may want to show us (photos of shared, happy moments), since no one will take photos of situations that one wants to forget!
Once the testimony is concluded, as if it felt like a long and resigned sigh of relief, (for the patient and maybe, also, for the therapist), we must proceed to the second stage of the therapy, inviting him or her to examine his or her personal existential analysis.
We must now examine in what way the patient can face the different obstacles that normally complicate the mourning process.
We must try to investigate the patients feelings of Guilt, Resentment or of Idealization, or his or her tendency to feel victim of others, also we must explore feelings of Denial or of Bonding that prevents him or her to realize his own Life Project. We can also find out about the tyranny of the past, with its feared scenes, and with the inappropriate comparison with other deaths. We should probe his or her feeling of inadequacy, also if there is a tendency to mourn according to what the family or society imposes on them, distancing them from their own authentic way of mourning. We can also probe his or her feelings of loyalty to the dead person. We should also find out what is the patient’s idea of Death, as something outside of Life, or that forms a part of Life?
Each one of these obstacles must be carefully examined, inviting the patient, as he feels more confident in his relation with his therapist, to talk not only about his pain, but also about his fears, and his fantasies.
If we succeed to accomplish this, we shall then enter in the most beneficial stage of the mourning therapy: the stage where the patient accepts to “let go” and reflect on probable life projects.
I copy here some lines that will describe this concept:
The “letting go”, as a possible, healthy way, does not mean to forget, nor to love no more. It is only a change in the possibility to create a space between the pain for the loss of the loved one, and the chance to continue with a personal Life Project.
The overcoming of the mourning process, implies;
The ability to remember without feelings of deep suffering and continued complaints.
The ability to accept new relations.
Accept the challenge of coping with our life as it presents itself.
We now enter into the full existential analysis therapy.
Of course, our basic theme, will be the absence of the dear departed person, but already, the patient will want some of his sessions, to reflect on himself and on his probable Life Project. We are now talking about the possibility of transcending the pain and grief.
I copy some lines on this possibility:
“We have here a Life Crisis. No one is the same after having lost a son or a daughter. There is an epistemological rupture, and all our system of beliefs are modified. We have the opportunity to search, to revise our objectives, and our spirituality, in order to first incorporate the pain of having suffered so much, and then transcend it, confronting the challenges that Life offers us, and later reaching out to help others in their pain.”
We have overcome the Crisis. We have helped a patient to go through the most difficult and painful stages of his mourning process. We have helped to guide him with a Life Project, when he thought that would be an impossible task. We have helped him to grieve in a “normal” way. In other words, we have helped overcome a pathological grieving process
With reference to that fearful word “ to mourn “, I would suggest to my colleagues, to adopt this definition: “ all mourning process is normal, following the death of a dearly loved person.”
In this manner, we differentiate the mourning process, which is an existential crisis, from the depression, which is pathological. In this way, we need not prescribe initially, anti - depressives to those whom do not need them. Medication that would make the patient feel, in his great pain, that he is going through an illness that didn’t exist before.
Only, when the level of anguish disorganizes the personality, to the point of not being able to communicate at all, I don’t advise medication (against attacks of anxiety). If they are really needed, they should be prescribed in its minimal doses.
In order to apply a therapy of existential analysis, individual therapy is the correct procedure.
The therapist could also suggest, at the same time, the participation of self-help groups for mourning people, or therapeutics groups that grieve all kinds of losses.
In those cased when the initial interview is about a death that happened a year or more ago, the situation is quite different .The patient that comes for the interview, probably doesn’t show the dramatic impact described earlier. They usually come with an enormous feeling of sadness, for they have been stuck in the very painful nostalgia that prevents them to continue with their life. In these cases, they are more conscious of the need to start individual therapy, a treatment, since they consider themselves to be ill. Their mourning has been more denied than accepted, and now they have a feeling of vulnerability and feel handicapped to confront the demands of Life. The therapy for these cases must follow those already described.
There can also be times when we are called to assist a new patient that consult us, because of a psychological problem,; work conflict, marriage stress, or psychic symptoms, and, in the course of several interviews, we learn, that some time ago, the patient had suffered the loss of a son or a daughter, ever though that had not been the reason for the consultation.
In these cases, we cannot start by the last theme; the mourning therapy is first priority Those that come to us, must be able to deal with their grief with lucidity and not be doped artificially. The grief process is filled with “first times”, that cannot be evaded or postponed indefinitely., and we must suggest to start it, even though the patient, finding refuge in denial and trying to prevent new grief, feels reluctant to consent. To be a psychiatrist, or a psychologist, psychoanalyst or psychotherapist, especially those that have decided to intervene in the mourning therapy, doesn’t only mean to have a bunch of interpretations more o less ingenious, to distribute among our patients in the willingness to help them, or maybe to confuse them.
The professional needs to know that those that come to him with a state of conscious unhappiness, or conscious despair, using adjectives of the Hagelian dialectic, and that their anguish brings no answers to confront the existential crisis, and that they want to find transcendental sense to their Life.
All therapeutical intervention that prevents the search of the essence of this existential anguish, shall only be symptomatic medication, and thus, only temporary in its relief and in its results.
Realizing our own imperfections, it is probable that we shall not reach the end of the road, but, it is possible that we travel with HOPE. This is better than to have arrived.
Finally, some suggestions to preserve the therapist that assist in the mourning process:
Explain and Limit our Function.
Try to get advance training, information, etc.
Know our personal limits.
Never work in solitude.
Try to forma Work Group.
Review our personal emotional state and have someone with whom to talk to.
We also need to feel, since our fob is voluntary, the appreciation, support and affection of the patients.
Dr. Carlos J. Bianchi