The first time I met Cynthia (not her real name) was in my office. She was in her late 20s and came to me because of a fear of driving. Initially, I believed her case would require cognitive behavioral work, and having received advanced training in rational emotive behavior therapy, I began formulating an outline of how to handle the case in my head. I thought it would be an interesting case in which to apply the techniques that I usually use with clients who come in with some form of anxiety-related problems.
During intake, I inquired about deaths or other losses Cynthia might have experienced. I usually do this when meeting with new clients to gather information and better assess them. Cynthia told me her sister had died. There was a fresh sadness to Cynthia’s mood and affect when she talked about her sister, which made me think the loss was recent. Her sister was two years older than Cynthia and had lived in another state. Before Cynthia had moved, she and her sister were very close, going shopping together, taking road trips and sharing secrets. After Cynthia moved, they still spoke on the phone with each other every day. Cynthia’s sister was her best friend.
As I inquired further, Cynthia told me her sister had died five years ago in a car crash. Her sister was coming home from a party when a drunken driver ran through an intersection and hit her car, turning it over. The driver fled the scene but later was apprehended. Cynthia told me repeatedly that her sister’s car caught on fire, burning her to death. No one knew whether her sister was unconscious when the fire consumed her or conscious and unable to escape the horrible death.
Cynthia didn’t find out about her sister’s death until the following day, after she tried calling her sister, just like she did every other normal day. The call went straight to her sister’s voice mail. Cynthia left numerous messages and waited for her sister to return them. Finally, a couple of hours later, her mother received a call from the hospital where her sister had been taken. The upsetting news was revealed. Cynthia reported to me that she could not believe the news and continued trying to call her sister to leave messages. She told me her family chose not to bury her sister because her body had decomposed from the fire.
As Cynthia continued telling me about her sister’s death, she reported feeling a wave of loneliness every day because she could no longer talk to her sister on the phone. At times, Cynthia even believed that her sister was still alive and continued trying to call her. Cynthia and her mother agreed that nothing should be removed from the room her sister grew up in. Cynthia also reported feeling guilty that she and her family did not hold a funeral for her sister. She acknowledged feeling angry that her sister had died and furious at the drunken driver who had killed her.
At this point, my initial thoughts concerning offering cognitive behavioral treatment for Cynthia’s presenting symptom — her fear of driving — were replaced by my belief that she was in much greater need of grief work. Given the way Cynthia described her feelings and talked about her sister and her death, I realized this was not a case of normal grieving. Rather, Cynthia was experiencing symptoms of complicated grief.
What is complicated grief?
To understand what complicated grief is, it is first important to understand “normal” grief and the tasks a grieving person should address to adapt to the loss. J. William Worden is a pioneer in the hospice movement in the United States. He is a founding member of the Association for Death Education and Counseling and has written on topics related to terminal illness, cancer care and bereavement. In the fourth edition of his book Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (2009), he indicates the four tasks a grieving person should address:
1) Accept the loss.
2) Process the pain of grief.
3) Adjust without the deceased.
4) Live effectively in the world by finding a place for the deceased in your emotional life.
In the first task — accept the loss — the mourner should face the reality that the death happened and that the person is not coming back. Some people refuse to believe that the death happened, causing them to live in denial and get stuck in this first task. In the second task — process the pain of grief — people in mourning need to acknowledge and work through their pain. If they fail to do this, they will carry the pain with them throughout their lives, and the pain can manifest into physical symptoms.
In the third task, three areas of adjusting without the deceased need to be addressed: external, internal and spiritual. External adjustment usually develops approximately three to four months after the loss. It involves coming to terms with being alone and assuming responsibility for the different roles previously played by the deceased. This could mean the person takes on the role of being the breadwinner, accountant, gardener, mother, father and so on. With internal adjustment, it is important for the person to adjust to his or her own sense of self. In other words, how has the death affected the person’s self-efficacy? For the mourner, it is important to ask (and answer), “Who am I now?” Spiritual adjustment simply means addressing the adjustments one has made to the world in the absence of the deceased. It involves searching for meaning within these life changes both to make sense of them and to regain a sense of control of life.
The last task is to live effectively in the world by finding a place for the deceased in your emotional life. This means the person in mourning should find ways to remember the deceased without allowing it to get in the way of continuing his or her life.
Complicated mourning has been given many different names, including unresolved grief, chronic grief and delayed grief. Whatever name you choose, complicated grief is, as described by Worden, when a “person is overwhelmed, resorts to maladaptive behavior or remains interminably in the state of grief without progression of the mourning process toward completion.” In other words, something is impeding the mourning process, and a good adaptation to the loss is negatively affected.
The table below shows the diagnostic criteria for complicated grief as proposed by Katherine Shear, Naomi Simon, Melanie Wall and colleagues in a study published in February 2011 in the journal Depression and Anxiety. The table shows the distress that Cynthia was experiencing at the start of her treatment. The diagnostic criteria are strong enough to produce continuing separation distress. In other words, the symptoms presented are associated with impairment, similar to other psychiatric diagnoses. Cynthia was experiencing impairment in her social and occupational life. She remained in a state of grief, with a healthy, normal progression through the mourning process being impeded.
It was clear to me, having completed advanced training in grief counseling and based on the information Cynthia provided in session, that she was experiencing complicated grief. Complicated grief encompasses difficulties in acknowledging the death on a social, emotional or cognitive level. During our initial therapy session, Cynthia and I explored the lack of resolution to her loss and its relationship to her fear of driving. I explained to her the four tasks of grieving and how she had not processed through the grief work.
For instance, in task one, the mourner must face the reality that the death occurred and that the deceased will not come back. There were instances when Cynthia could not emotionally accept her sister’s death. She continued to call her sister, believing that her sister would return her call. For Cynthia, the loss of her sister was debilitating and didn’t improve over time. Her emotions were so painful, long-lasting and severe that she had trouble accepting the loss and resuming her life. She refused to acknowledge the loss in order not to grieve. Denial kept her from admitting the loss.
In task two, the person needs to acknowledge and work through the pain of the loss. Cynthia did not acknowledge her sister’s death and thus did not process the associated pain. This resulted in her pain manifesting into anxiety and fear of driving. She reported in our sessions that her fear of driving started about a year after the death of her sister. Cynthia’s heightened symptoms of trembling, choking, dizziness and fear of dying prevented her from continuing to drive.
In task three, Cynthia had a hard time adjusting without her deceased sister. As mentioned previously, her sister had been her best friend, and they had done almost everything together. Cynthia continued trying to call her sister despite knowing her sister had died because the thought of being alone terrified her. The death caused disruption in Cynthia’s social functioning. She refrained from engaging in activities by herself. In addition, she often avoided going out and interacting with peers because being around friends no longer meant anything to her. She made radical changes to her lifestyle following her sister’s death, including excluding her friends and avoiding many of her former activities. Likewise, Cynthia couldn’t function optimally at work and couldn’t trust anyone in the same way she had trusted her sister. She felt lonely and empty and believed that life without her sister was difficult.
Internally, Cynthia did not know who she was anymore. She felt she had lost part of herself when her sister died. Although she denied suicidal ideation, she mentioned that she wanted to be with her sister and missed her terribly. Cynthia said she did not consider suicide because she kept wishing for her sister to be alive rather than experiencing death herself to see her sister again.
Spiritually, Cynthia could not regain control of her life. Prior to her sister’s death, Cynthia had her life in order. She had many friends, socialized, held a great-paying job and wasn’t afraid to drive. After her sister’s death, she lost that sense of control and could no longer find meaning in the things she once enjoyed.
Task four was difficult for Cynthia to process. She could not find an appropriate place in her emotional life for her sister’s death without it interfering with her ability to live her life effectively.
Interventions used with Cynthia
In this case with Cynthia, I had to use different techniques to help her process through normal grief. I first introduced her to normal grief and complicated grief. I described the model of adaptive coping, the building of a satisfying life and her adjustment to the loss. We also discussed her personal life goals, which were to drive again without fearing she would die, to rebuild her social networks and to be successful in her career like she had been before her sister’s accident. We worked on each of the four tasks of grieving until we both felt she was ready to proceed to the next task.
In the beginning of our treatment, I invited Cynthia to have a supportive person attend the therapy session with her. Cynthia chose her mother, with whom she stated she had a close relationship. The reason I did this was to restore Cynthia’s connection with others, because with complicated grief, individuals often lose that sense of connection. In addition, attending one of our sessions allowed Cynthia’s mother to better understand what Cynthia was going through and helped her to provide support throughout Cynthia’s treatment. I provided her mother with an overview of complicated grief and its treatment.
A couple of sessions later, I asked Cynthia to visualize when she became aware of her sister’s death and to recount the story into a tape recorder. I had her tell the story repeatedly and then listen to tapes of the recitation. This was done to introduce her to imaginal revisiting. It was also a way for her to process the death on an emotional level and integrate her emotions with the reality that her sister has died. I then debriefed with her, having her describe what she felt as she told the story of her sister’s death. I also instructed her to listen to the tape every day between sessions.
Other elements that I used throughout the treatment included a grief monitoring diary. I use this diary with clients whose social and occupational functioning is compromised due to the death. I instructed Cynthia to monitor her grief intensity throughout the day (0 = no grief, while 10 = the most intense grief) and the associated situations. We discussed the diary in sessions, exploring both her positive and negative emotions. Discussing her grief levels helped to bring the treatment into her daily life. When exploring her grief levels, Cynthia often confused her feelings of grief with her feeling of anxiety. I helped her to discriminate between her emotions and to work with them differently. We worked on resolving her feelings of guilt, anger and anxiety.
At the start of our treatment, Cynthia mentioned she felt depressed. She had feelings of hopelessness that she would never recover and regain control of her life. This made it difficult for her to come to terms with the loss of her sister and find fulfillment in her own life. In addition to using imaginal exposure and the grief monitoring diary, I asked Cynthia to think about her personal goals and activities to help reawaken her joy and meaning in life. This was a form of restoration work in which I told her to reward herself with pleasant activities each time that she found an assignment distressing but was willing to try it anyway. The purpose was to help her move toward a goal so she could begin visualizing a satisfying life without her sister.
I also felt it would be helpful for Cynthia to talk about pleasant memories and positive characteristics of her sister. I invited her to bring photographs and other mementos to the sessions. I encouraged her to share those happy memories and to hold imaginary conversations with her sister under my guidance. I often use this empty chair technique in my sessions with clients who are experiencing some form of trauma or grief. This experience proved meaningful for Cynthia and helped her gain the closure she needed.
If I hadn’t inquired about possible losses and deaths during intake, I wouldn’t have known that Cynthia experienced a loss. I would have continued to treat her fear of driving without getting to the core of the problem. Cynthia wouldn’t have processed her grief in a healthy way, and she would have continued living her life with sadness, isolation and anxiety.
Instead, because we focused on the real issue, Cynthia made progress by the end of treatment, no longer meeting the criteria for complicated grief. Although she occasionally experienced moments of sadness, they were neither debilitating nor prolonged. She had stopped feeling guilty and angry and no longer avoided looking at pictures of her sister. She started driving again without the fear that she might die and forged closer relationships with her friends.
Termination with me was an easy process for Cynthia. She expressed gratitude and, although some of the exercises had been hard for her, she was able to acknowledge that they helped her to reduce the pain she had experienced for so many years. She mentioned that she was doing much better and no longer needed counseling services.
Grief is a condition that we all will experience. As counselors, our job is to diagnose and treat mental and emotional disorders. However, some of these disorders may be intertwined with grief. I believe it is important for counselors to pay close attention to what our clients are discussing in session as well as what their presenting symptoms are because there may be other complications that remain unspoken unless we ask. I also think counselors must make it a priority to educate themselves in grief counseling in order to give proper treatment to our clients.
Helen Nieves is a licensed mental health counselor and certified attention deficit consultant specialist who works in her private practice and at an outpatient mental health clinic in New York. She is on the advisory board at the American Institute of Health Care Professionals. Contact her at firstname.lastname@example.org or visit counselingadhd.com.
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