A Buddhist Approach to Grief Counseling

Grief theorists, in keeping with Western culture’s emphasis on autonomy and individuation as signposts of psychological health, have long held that disengaging from the deceased is necessary for the successful resolution of grief (Marwit & Klass, 1995).   For example, according to the psychoanalytic view of Freud (1917), grief work entails decathecting, or detaching libidinal energy from the deceased.  Furthermore, the attachment theory of Bowlby (1969) posits that the bereaved individual attempts to maintain a bond to the deceased until he or she realizes the impossibility of doing so, and eventually “lets go” of his or her relationship to the deceased.

The predominant beliefs in the importance of disengaging and letting go in resolving grief have been gradually giving way to the concept that continued attachment to the deceased loved one is a healthy and necessary task of the grief process (Silverman & Klass, 1996).  The work of Worden (1981, 1992, 2002) can be seen as a bridge between the majority view of theorists beginning with Freud and the more contemporary view of the importance of continuing bonds. Worden originally described one of the major tasks of mourning as “withdrawing emotional energy from the deceased and reinvesting it in another relationship” (1981, p. 13), in keeping with the goal of decathexis described by Freud.  Significantly, in subsequent editions of his work (1992, 2002), Worden acknowledged that the bereaved do not in actuality decathect from the deceased.  Accordingly, Worden now describes this task as “emotionally relocating the deceased and moving on with life” and suggests that finding a place for the deceased in the life of the bereaved “will enable the mourner to be connected with the deceased but in a way that will not preclude him or her from going on with life” (2002, p. 35).

My approach to grief counseling is strength-based and solution focused.  Narrative therapy, a relatively new model of cognitive therapy (Carr, 1998), is in accord with this focus.  Narrative therapy has been found to be useful for helping clients access continued attachment and spiritual beliefs about death as a means of making meaning and finding the strength to emotionally relocate the deceased and move on with life.

Grief as a Holistic and Spiritual Process

Worden (2002) has identified four tasks of grief: (1) to accept the reality of the loss; (2) to work through the pain of grief; (3) to adjust to an environment without the deceased; and (4) to emotionally relocate the deceased and move on with life.   Worden’s formulation recognizes that grief impacts the bereaved in the physical, behavioral, cognitive, emotional and spiritual domains (Worden, 2002; Attig 1996).  Similarly, Marrone (1995) has identified the following phases in the grief process:  (1) cognitive restructuring, in which the bereaved reorganizes and restructures his or her thoughts and concepts to assimilate a loss; (2) emotional expression of the experience of the loss; (3) psychological reintegration of new coping behaviors and cognitive strategies for adjusting to life without the deceased; and (4) psychospiritual transformation, “which involves a profound, growth-oriented spiritual/existential transformation that fundamentally changes our central assumptions, beliefs and attitudes about life, death, love, compassion or God” (p. 498).

The fourth phase or task identified by both Worden (2002) and Marrone (1995) as described above provides the ground for working to transform and maintain the bereaved’s relationship with the deceased loved one.  As observed by Silverman and Klass (1996), “we need to consider bereavement as a cognitive as well as emotional process that takes place in a social context of which the deceased is a part….People are changed by the experience; they do not get over it, and part of the change is a transformed but continuing relationship with the deceased” (p. 19).  Cognitive interventions are useful for accessing and working with this transformative process, and as discussed below, narrative therapy provides a powerful cognitive container for the transformative work of grief.

Spiritual belief in continued attachment as a source of strength.

Whereas Freud and his followers may have seen continued attachment to the deceased as a form of pathological grief, the experience of continued bonds to the deceased is now viewed as a strength, resource and form of resiliency in the normal grief process (Benore & Park, 2004; Angell, Dennis & Dumain,1998).    Coping with loss has been called “a spiritual process that includes locating our {loved ones] in time and place, and transporting our recreated ‘experiences’ to the here-and-now” (Angell, Dennis & Dumain, 1998, p. 618).  Benore and Park (2004) have found that religious and spiritual beliefs in an afterlife and continued attachment to the deceased enable one to adapt more easily to the death of a loved one:

“The bereaved who strongly believe in [continued attachment] do not need to reconcile a loss of the person, but rather a change in the relationship.  Beliefs that the deceased person and the resulting relationship continue may eliminate the        most distressing aspects of death, whereas those who do not believe in [continued  attachment] must deal with the difficult issues of permanent loss, the void in their life and relationship network, and the sense of isolation (p. 12).

Grief and Spiritual Transformation

As one gets in touch on a deep level with his or her own suffering and resiliency in the face of that suffering, he or she can begin to get a panoramic view of the human condition and tap into his or her spiritual strength. Religious and spiritual beliefs have been observed to be one way in which individuals create meaning and a sense of order and purpose to the human condition, life and death, as well as creating an ongoing relationship with the deceased (Golsworthy & Coyne, 1999; Calhoun & Tedeschi 2000). “Because religious beliefs are central to many people’s global meaning systems, and because death is a central arena for the enactment of religious beliefs, these beliefs are likely to be a central part of the process of coping and adjustment following bereavement for many people” including beliefs in continued attachment to the deceased (Benore & Park, 2004, p.4).

The strength-based approach I use with my grieving clients, through the use of techniques of narrative and solution-focused therapy, is informed by my Buddhist practice.  In particular, I come to each session with my clients with the ground that each human being possesses inherent wisdom, or Buddha Nature, and that this wisdom can be called upon to access the individual’s strengths and resilience in times of suffering.  As Levine (1982) notes, grief fully experienced allows us to “plumb the depths” of our souls and to “touch something essential in [our] being….[W]hat is often called tragedy holds the seeds of grace” (pp. 85-86). Those “seeds of grace” are the basic goodness or Buddha Nature possessed by all, and it is my job as collaborator or partner in the journey of grief to support my clients in getting in touch with the strengths that they possess but which may be obscured by the intensity of their feelings of helplessness and loss.  Through narrative therapy, including the use of literary and other creative forms of expression, clients are able to create some space around that intensity, which in turn gives them some perspective and hope for change and transformation.

The broader perspective that can be reached through narrative therapy techniques can put the client in touch with both the uniqueness and universality of grief and suffering.  Paradoxically, contemplating the universal truth of suffering can open us to acceptance and peace.  As His Holiness the Dalai Lama (1998) observes, “if we can transform our attitude towards suffering, adopt an attitude that allows us greater tolerance of it, then this can do much to help counteract feelings of mental unhappiness, dissatisfaction, and discontent” (p. 140).  The Dalai Lama (1998) suggests that the most effective practice to help one tolerate suffering is to contemplate and understand that “suffering is the underlying nature” of existence as human beings:  “If your basic outlook accepts that suffering is a natural part of your existence, this will undoubtedly make you more tolerant towards the adversities of life” (pp. 141-142). Through allowing ourselves to experience and express our suffering, we can see that there is a way out of that suffering, through working with it as a fact of life, and finding a meaningful way to grow, transforming hopelessness into hope and possibility.  Narrative and solution-focused therapy can foster the realization that grief is not necessarily pathological, but an integral component of the human condition.  Through experiencing our own unique grief, we can tap into its universality, lessening our hopelessness and isolation, and deepening our connection with others and the human condition.  This is the transpersonal and transformative work of healing grief.

References

Angell, G.B., Dennis, B.G. & Dumain, L.E. (1998). Spirituality, resilience and narrative:  Coping with parental death.  Families in Society:  The Journal of Contemporary Human Services, 615-629.

Attig, T.  (1996).  How we grieve: Relearning the world. New York:  Oxford University Press.

Benore, E.R. and Park, C. L. (2004).  Death specific religious beliefs and bereavement:  Belief in an afterlife and continued attachment.  The International Journal for the Psychology of Religion 14(1), 1-22.

Bowlby, J. (1969). Attachment and loss: Attachment (vol. 1). New York:  Basic Books.

Calhoun, L.G. & Tedeschi, R.G. (2000). Posttraumatic growth: The positive lessons of loss. In Neimeyer, R.A. (Ed.), Meaning reconstruction and the experience of loss (pp. 157-172). Washington, D.C.: American Psychological Association.

Carr, A. (1998). Michael White’s narrative therapy.  Contemporary Family Therapy, 20(4), 485-503.

Dalai Lama, H.H. & Cutler, H. (1998). The art of happiness:  A handbook for living.

New York:  Riverhead Books.

Freud, S. (1917). Mourning and melancholia. Standard edition of the complete works of Sigmund Freud (vol. 14). London:  Hogarth Press.

Golsworthy, R. & Coyle, A. (1999). Spiritual beliefs and the search for meaning among older adults following partner loss.  Mortality, 4(1), 21-39.]

Klass, D. (1993). The inner representation of the dead child and the worldviews of bereaved parents. Omega, 26(4), 255-272.

Levine, S.  (1982). Who dies? An investigation of conscious living and conscious dying. Garden City, NY:  Anchor Press.

Marrone, R. (1999). Dying, mourning, and spirituality: A psychological perspective. Death Studies, 23, 495-519.

Marwit, S. & Klass, D. (1995).  Grief and the role of the inner representation of the deceased. Omega, 30(4), 283-296.

Silverman, P.R. & Klass, D. (1996).  What’s the problem? In Klass, D., Silverman, P.R. & Nickman, S.L. (Eds.), Continuing bonds:  New understandings of grief (pp. 3-27). Philadelphia: Taylor & Francis.

Worden, J.W. (2002, 1992, 1981). Grief counseling and grief therapy:  A handbook for the mental health practitioner. New York:  Springer Publishing Company, Inc.

Treating Depression in the Elderly

Contrary to popular belief, depression is not a “normal” part of the aging process, but a treatable mental health condition. Symptoms of depression include feelings of worthlessness, hopelessness, helplessness, guilt, isolation and unrealistically negative beliefs about oneself. These feelings not only affect the depressed person, but also their family members, loved ones and caregivers.

Depression is unlikely to go away by itself, and the guidance of a professional counselor, in addition to a physician, is often warranted. In fact, psychotherapy has been found to very likely help the depressed senior live a happier, more fulfilling life and decrease the risk of suicide.

There are a number of things a loved one or caregiver can do to help alleviate a depressed senior’s depression. These include:

1. Make sure the depressed person sleeps and eats regularly.
2. Reinforce rewarding experiences and activities, including exercise.
3. Explore spiritual or religious beliefs as a source of personal comfort and support.
4. Allow the depressed person to tell his or her story, called “life review”, through techniques such as guided journaling, letter writing, autobiography or collage.

A counselor or psychotherapist trained in narrative therapy can be particularly helpful for helping seniors find meaning and a sense of integrity and ease their feelings of depression.  Narrative therapy is particularly helpful in helping depressed clients reconcile the inevitable losses incurred over a lifetime and find meaning in those losses in the context of their lives through the telling of the story of their lives. The role of the narrative therapist is to bear witness to the complexity and rich nuances of the evolving story and collaborate with the client in to make sense of his or her losses and find healing and growth through the process of reconciling those losses and acknowledging the contributions they have made in their lives.

Children and Grief: A Story of Trauma, Abuse and Healing

In my therapy work with grieving children and adolescents, it is important for me to keep in mind that the child’s age and stage of development at the time of the loved one’s death will strongly influence the ways in which the child reacts and adapts to the loss. An understanding of the child’s emotional and cognitive development will enable me to determine how best to communicate about death with the particular child, to understand and empathize with the child’s experience and guide the child through the grieving and healing process with appropriate interventions.

For example, I successfully worked with a grieving twelve-year old girl, who I will call “Abby.” I worked with Abby both individually and in a small group with other grieving pre-teens at a hospice-based children’s grief support group. Abby’s maternal grandfather died suddenly and violently two years ago while cleaning his gun.  There is some uncertainty as to whether the death was accidental or a suicide.    Abby is an only child, who lives with her mother.   Although Abby did not speak with me about it, her mother has reported that Abby’s father physically abused Abby when she was four or five years old and he has been court ordered to not have contact with her. Abby has not seen her father (who is divorced from her mother) since she was six years old.  She had a very close relationship with her grandfather, and spent every Saturday with him, doing special things together.  Abby reports that since her grandfather’s death, she spends her Saturdays alone, mostly sleeping.

The Interdependence of Grief and Development

Childhood grief and development are interdependent:  The early death of a parent or other loved one affects a child’s development, and the child’s development affects how he or she will grieve and reconstruct his or her relationship with the deceased.  Furthermore, children re-experience their grief as they reach each milestone in their development.  .

Capacity to Grieve and Understand Death’s Finality

A child’s ability to understand the meaning and finality of death corresponds to his or her cognitive development.  For example, a three to five year old believes that the deceased person has gone away and will return at some point.  Thus, it is common for a child of this age to constantly ask questions such as “Where’s Daddy?”  and “When is Mommy coming home?” A child of five to approximately nine years of age  believes that death can be avoided.  Furthermore, a child in this egocentric phase also believes that his or her parent died because either the parent was bad or the child was bad, and that if the child is good, the parent can return.  This is thus seen as one of the most vulnerable and difficult developmental stages for adjusting to a parent’s death

In working with Abby’s grief over her grandfather’s death, I always kept in mind that she was dealing with her loss both from her current cognitive developmental stage, and from the earlier stages she was in when her father abused and then left her.  Thus, she was likely relating to her grandfather’s death emotionally from that earlier stage, and may believe that she is somehow be responsible for his death. The child at this stage needs someone who can clarify what the child is thinking and feeling, and can reassure and build self-esteem by praising the child’s accomplishments.   This is something that I tried to do each time I met with Abby.

Although Abby is able to grasp and verbalize abstract concepts about death, her grief process was still informed by early developmental issues of safety and trust, as well as the magical thinking of the child in latency.  Abby’s grandfather’s sudden and violent death, coupled with her father’s abuse and abandonment, seems to have made it unsafe for Abby to trust and truly connect with her peers at a life stage when peers and feeling accepted are so important to social and emotional development.

Developmentally, even in more “normal” circumstances, 12-year olds yearn to belong, but may feel different and isolated, as the brain and body go through a dramatic growth spurt instigated by a surge of hormones. Physically, a 12 year old girl is starting to become a woman, and may experience self-consciousness and awkwardness that may lead to withdrawal.  Emotionally, she may experience a strange and seemingly uncontrollable roller coaster of highs and lows exacerbated by pubertal hormonal changes, as well as grief over the impending loss of her childhood.  Cognitively, in moving from concrete to abstract thought, an introspective and intelligent 12-year old like Abby is increasingly aware that others may not share her feelings, thoughts and values.  A grieving pre-teen, like Abby, may also feel different because so few of her peers have experienced the loss of a loved one.  This recognition can lead to the first taste of existential alienation, causing further withdrawal.  Those who are more firmly in the formal operational stage of abstract reasoning can have a more panoramic view about these differences, and develop true compassion and empathy for others.  The child not quite out of concrete operational thought, especially one dealing with profound grief like Abby, may have a difficult time getting to that stage, and may regress to more egocentric behaviors, like those I have witnessed in Abby’s case.

Tasks of Children’s Mourning

Worden (1996) has identified four tasks of mourning:  (1) accepting the reality of the loss, (2) experiencing the pain and emotional aspects of the loss, (3) adjusting to an environment without the deceased, and (4) relocating the dead person in one’s life.  The satisfactory completion of these tasks depends on both the child’s stage of development at the time of the death and his or her adaptability and ability to attend to any unfinished tasks at later stages of development.

Accepting the Reality of the Loss

A child can accept the reality of losing a loved one when he or she understands, through the achievement of formal operational thinking, “the nature of abstractions such as finality and irreversibility” (Worden, 1996, p 13, citing Piaget, 1954).  Some grasp of such abstractions is possible during the concrete operational stage of cognitive development, and is only fully understood at the formal operational stage.  Thus, if a loved one dies before formal operational cognition has been achieved, the child will experience a deeper level of grief when he or she attains that cognitive stage and fully and deeply comprehends the finality and irreversibility of the loss.

This was clearly the case for Abby.  Abby has an understanding of the abstraction of death’s finality.  She has been grappling in our sessions with giving spiritual meaning to the finality of death.  My job was to empower Abby’s cognitive work by normalizing and validating her process and the private thoughts she has chosen to share with me, while at the same time providing a safe space for her emotional process.  Furthermore, as Abby was then a pre-teen on the cusp of profound developmental challenges, I needed to stay aware that as she comes to terms with the meaning of her grandfather’s death, her new cognitive abilities also opens her to a new level of understanding – and pain – about the loss of her father.

Experiencing the Pain and Emotional Aspects of the Loss

The pain and emotions of grief can be frightening for a child to experience. Awareness of the child’s capacity based on his or her stage of emotional development to cope with strong emotions is important. It is also important to assess the child’s coping and defense mechanisms, and their effect on how the child experiences the pain of the loss.

In Abby’s case, the abuse and abandonment by her father early in her life has left deep developmental holes and she has split off from her emotions, which has complicated her grieving process over the death of her grandfather.  Journaling in a group setting proved to be an effective means for Abby and the other group members to deal with their feelings, as well as allowing them to connect with the others and feel less isolated, empowered by the realization that they have all experienced a loss, and they are not so different, after all.

Adjusting to an Environment without the Deceased

This task is an ongoing process through progressive stages of development as well as important transitions throughout one’s lifetime.  The child– as well as the adult he or she will become –  re-experiences his or her grief at each stage of development as a result of his or her growing cognitive abilities, and also as he or she comprehends the vacuum left by the dead loved one, who is not there to nurture and support the child’s growth and achievements. An intervention I used with Abby was the creation of a memory box for her grandfather, in which she has placed pictorial depictions of their relationship.  We also did an art therapy project together when Abby returned from summer vacation.  This was primarily a non-verbal exercise in which Abby was able to “tell” her grandfather through the medium of collage about her summer activities and experience her emotions of loss and sadness on a somatic level.  My job in this process was to simply sit beside her and be an empathetic witness.  In joining with Abby in this way, we established a good degree of contact and trust.

Relocating the Deceased in One’s Life

As the child grows and changes, his or her relationship with the deceased parent or other loved one also changes (Christ, 2000).  Thus, according to Worden (1996), another ongoing task is to find new ways to memorialize the deceased loved one with the attainment of each developmental milestone:  Children need to “find a new and appropriate place for the dead in their emotional lives – one that enables them to go on living effectively in the world.”  The above-described art therapy projects have been helpful with Abby in this regard.  The narrative therapy intervention of letter writing was also helpful at this stage, having Abby write a letter to her grandfather.  This process helped Abby clarify her feelings and create a safe container for them, allowing her to relocate her grandfather and live an effective life.