Being Present with the Bereaved

private-griefTo be present to those grieving often brings up feelings of helplessness similar to those experienced when around the dying.  Often this helplessness is experienced as not knowing what to say or do.

People often assign a timetable to grieving and make assumptions as to how long each phase should last.  In fact, everyone has their own experience; the time taken to grieve varies between individuals. Unfortunately, many of the grieving find themselves judged if their grieving doesn’t match some particular schedule.  Grief is not linear and doesn’t follow any predictable trajectory.

Grieving is always a subjective experience. To aid the grieving, there is no necessity for articulation, platitudes or suggestions. It is, rather, simply being there and being present to the grieving individual that is truly therapeutic.  There’s great value in listening to the person and following their lead. In this way, we can demonstrate genuine empathy.

The grieving often find that the hardest part comes after an initial period in which they seem to run on automatic, experience life as surreal, and are surrounded by people. However, once the shock recedes and others go back to their routines, the bereaved are thrust back into their lives — but nothing is the same.  They are left grieving in a world which functions as it always has and are left alone to mourn, a solitary process that often ends in deep feelings of isolation from what has irrevocably changed.

Sometimes grief develops into what is called “complicated grief”.  Complicated grief is associated with self-destructive tendencies and an inability to process grief.  It can be very difficult to identify complicated grief because the process of grieving is different for all of us.  How do we etablish when grief limits our sense of well-being and our ability to function? When can unhealthy grief be distinguished from a healthy grieving process? Even health care professionals who may have experience working with bereavement have trouble answering these questions.

Typically the first year of bereavement is the most difficult.  As one adjust to the loss of the loved one, an incessant array of holidays, seasons and anniversaries present themselves and can trigger anew the magnitude of the loss.  One never goes back to life with the loved one, but, instead, must establish a new “normal”. This adjustment often brings up intense emotions of resistance, anger, isolation, depression, and denial.  These emotions are appropriate as one moves through the pain of loss and must never be judged.  It is only when the grieving becomes “complicated” and self-destructive that we need to address it.  However, complicated grief is difficult to assess and must be approached with great care.

As I have worked with those who mourn, I’ve become aware that it can be very helpful for them to be around those who have similar experiences.  Bereavement and support groups can provide such support.  At times, however, there is great resistance to this support since the grieving often feel that their experience is worse than that of others and is singular in a way that others are incapable of understanding.  Often this resistance is so profound that it leaves the bereaved even more isolated.  I have seen, though, that while those grieving may exhibit resistance to those with similar experiences, they end up finding this support helpful, meaningful, and therapeutic.

While the first year of mourning is the most difficult, later in life certain triggers may remind one of the pain with almost overwhelming intensity.  Grief never really ends — one merely adapts to life anew.  The pain of grief recedes until it presents itself, at times out of nowhere, for a short period of time.  It is important to respect the adaptability and the periodic pain that memory triggers.

Death and bereavement are part of life. We need to experience them with all our feelings and let those in pain know that we support them without judgement.

Being Present with the Dying: Emotionally

black-magic-rose-wallpaper__yvt2Because of deep fears about death and our own mortality, it can be difficult to be authentically present with those who are dying.  When we’re not keenly present, we create an uncomfortable distance between ourselves and the person dying.  Platitudes such as “You never know, maybe you’ll get better” or “Don’t talk like that” only pull us away such that without meaning to, we limit the relationship between ourselves and those leaving us.

Having worked for two decades with those confronting serious illness and death, I have come to realize that the needs of the dying and their caregivers are never predictable.  I have learned to follow their lead in lieu of following an agenda that I deem important.  And while I make suggestions about the end of life, I have learned to respect whatever response I get.  Being fully present to those who are dying requires diligence, as it is imperative to avoid judgment.  At times I have encountered denial, which I have learned to respect while gently suggesting or informing.  At other times, I may end up sitting with someone who wants to talk or rage or sob.  In these instances, I follow their lead and validate their feelings.  It’s also important to be tuned into one’s own discomfort so as not to act on it and work it through at another time.

When working with the dying, it’s useful to ask oneself the question “Whose needs and agenda am I here for, mine or the person dying?”  This may lead to discomfort, discomfort that must gently be set aside so that we can address the needs of the dying.

We all die alone.  Until that moment, we are connected to the people around us, people we love and care about.  If, as caregivers, we allow our discomfort to impose itself and get in the way, we may lose the opportunity to be with those we care about at a time when we are most needed.

Like most people, I become frightened when I think of my own death. When I focus on it, I fear the unknown and anticipate the loss of my ego.  Fortunately, these thoughts and feelings recede during the hectic process of living my life.  But when I’ve been confronted with the death of those in my care or in my personal life, I often must deal with my own issues.  I found, however, that as I worked with patients and loved ones and learned to set aside my own fears and anxieties, that I became less afraid.

I have also found that being fully present and engaged with the dying limits the regret and guilt that so often is a part of bereavement.  By being conscious of our own fears and needs, and by setting them aside as someone experiences the end of life, we experience less of a rupture when the physical bond, our sharing of life, is broken.

Because the experience of dying is solitary, it can be overwhelmingly isolating.  We can, however, foster intimacy by empathizing and being present to whatever the dying person is experiencing or expressing, be it anger, depression, fear, denial, hope, hopelessness, acceptance, peace, etc.  When we achieve this, we can help whomever we are caring for feel less alone.

It is often difficult to avoid acting out our own fears while being fully present to the dying.  While we all die and die differently, most of us deny death in a million different ways.  Without this, we would be overwhelmed with fear and anxiety.  By being attuned to the dying and responding to their needs instead of trying to appease our own needs and feelings, we enrich the relationship with those who are leaving us.  We owe ourselves and the people in our lives an environment in which they can reach the end of their lives in as rich a way as possible.

Being Present with the Dying: Decisions

_brain_surgeDeath’s imminence engenders a plethora of decisions, decisions that for the most part can be made ahead of time.  It’s difficult enough to confront these issues before we are dying and while they remain in the abstract.  Faced with such decisions while on our deathbed only adds to the emotional turmoil.

Some of these decisions can be stipulated in the necessary corresponding documents I wrote about in my last post.  Such decisions include if and when to start or remove nutrition and hydration, balancing levels of pain relief for maximum quality of life, and determining whether one prefers to die at home.  Although wanting to die at home often becomes out of one’s control, planning can help facilitate that likelihood.

NUTRITION AND HYDRATION:  Many of us equate the withholding of nutrition as starving the patient, or withholding of fluids as forcing the patient to die of thirst.  In fact, a patient is often more comfortable when these resources are withheld.  Intravenous feeding (TPN) or the use of a feeding tube are not analogous to eating; artificial hydration is not analogous to quenching thirst.  While artificial hydration and feeding are indeed helpful for getting through various crises, these considerations are irrelevant when the patient is dying.  Withholding these treatment options does not foster discomfort for the patient and may help lessen trauma during the process of dying.  In the final analysis, what is most important is the comfort of the patient, secondary is the comfort and peace of mind of his or her significant others.

PAIN CONTROL:  Because pain is subjective and difficult to quantify, the issue of pain control and pain medication is often fraught with conflicting attitudes, opinions, and feelings.  First, pain tolerance differs for each individual – some of us are more sensitive to pain and discomfort than others.  One must also take into consideration drug tolerance affecting levels of alertness.  Many patients desire a certain level of alertness – at least enough to communicate – and are willing to adjust their pain medication accordingly while others may want to be less aware.  Finding the desired balance for each person is optimal.  To complicate matters further, there are the needs and desires of family and significant others who may wish to maintain communication with the patient at the expense of the patient’s comfort.  It is important to respect the wishes of the patient and have those wishes take precedence over the needs of others, allowing one at the end of life as much control as possible.

DYING AT HOME:  While most of us would rather die at home than in a hospital or nursing home, the end of life is unpredictable and complicated such that dying at home is often out of one’s control.  When it is possible to die at home, there are many things to consider and arrange.  Perhaps the most difficult decisions revolve around whether to continue treatment and sustain life versus letting nature take its course.  The end of life is fraught with unpredictability and the forces of wanting to stay alive often conflict with the desire to avoid the hospital.  Everyone making this decision is working through a unique process and will come to a decision in his or her own way.  It is the role of caregivers to support and encourage the patient in whatever decision he or she makes. The knowledge and support of health care professionals are invaluable in guiding this final process.  Both palliative care teams and hospice programs offer such support and address the many issues involved in keeping a dying patient comfortable.  Both provide holistic guidance to help facilitate and realize the wishes and needs of those nearing the end of life and their caregivers.  Another post will discuss these vital programs.

Being Present with the Dying: Arrangements

neardeathIt is profoundly difficult to be with those who are dying.  We feel at a loss for words or we’re so reminded of our own mortality that we have trouble empathizing and bonding. The more this uncomfortable situation persists, the more we find ourselves lost in platitudes or long silences.  If this discomfort is great enough, we may even find ourselves cut off from the dying and hence miss out on much of the richness that this experience can provide for both those involved.

​Three years ago I left a job where I had spent 20 years visiting the ill and dying in their homes.  Each person died in his or her own way; I learned that very little about the process is predictable. What might be a “good death” to some might be a bad death to someone else.

​Because the subject of death is so uncomfortable and painful, it has become taboo in our culture to discuss it. This leads to avoiding many important decisions that should ideally be made before confronting illness or when death is imminent.  By putting off the subject until being in the midst of serious illness, otherwise clear-headed decisions may become embroiled with emotion and fear, a combination that can lead to traumatic conflict and turmoil.

​Here are a number of concrete decisions that should be done around illness and death:

HEALTH CARE PROXY:  This document names someone and an alternate to act as your voice if you can’t make your wishes known.  This often intimidates people because of the heavy responsibility of deciding someone else’s fate.  In actuality, for a health care proxy to work the way it is meant, the person named the proxy had been told by the one ill what he or she wants.  The person and alternative who will act as proxies are not making decisions but are simply being the voice of the ill person who cannot make his/her wishes known. This document does not need to be notarized (a notary republic) but needs to be witnessed.  Keep copies at home and when in the hospital, a copy should be put in the front of the hospital chart.

LIVING WILL:  This document can accompany a Health Care Proxy.  A living will provides more detail about wishes and decisions the ill person wants made in his or her behalf and can be a written guide for the proxy. Detailed wishes can also be stated in the heath care proxy without having a living will.  This document needs to be notarized.

(DURABLE) POWER OF ATTORNEY (POA):  This is a legal document that allows the person named as the POA to act on the behalf of the incapacitated.  It can be limited to certain powers (such as banking) or be something more general.  This document needs to be notarized.  A copy is given to any entity (such as a bank) that requires proof that the person acting as the POA has such legal status.  The POA is void upon a person’s death.

WILL:  This is a legal document that states what a person wants to have happen with his or her estate (possessions, monies, financial holdings, property) after death.  A trusted person is named to act as an executor whose job it is to manage the estate.  Many people mistakenly think they have no need for a will because they have nothing of value, but a will can help clear up issues concerning possessions with sentimental value and dispel ambiguity about who gets what.  This is a notarized document and is best kept in a secure place at home and possibly with a lawyer.  Even a simple notarized paper stating one’s wishes can go a long way toward preventing ambiguity and conflict after death.

CREMATION AND BURIAL:  Arrangements for burial or cremation can be included in a will.  If cremation is desired and there is no will, it is best insurance to have a cremation document stating that desire.  A document appointing an agent who controls the disposition of remains can be done so that there is no ambiguity or conflict confronting loved ones after death occurs.  Although cremation laws vary from state to state, a document stating one’s wishes will take precedence over the wishes of any survivors. Without family and in absence of documentation, cremation may be legally blocked.  A stand-alone cremation document needs to be notarized.

(DNR) DO NOT RESUSCITATE:  Usually this document is not completed until illness is present.  There is a DNR put in the hospital chart as well as an at home DNR posted in an easily seen place at home.  A DNR states that a person doesn’t want to be resuscitated if the heart stops.  Without a DNR, in most situations a person is legally required to be resuscitated.  An at-home DNR states that no resuscitation is wished if a person’s heart stops at home and medical personnel are called and present.  Once resuscitated and put on a machine such as a ventilator to breath, it is legally very difficult to be taken off the machine and be allowed to die, regardless of the length of time or the futility of survival.  A DNR does not usually need to be notarized but must be signed by a physician and witnessed.

In following posts I will discuss other difficult decisions that are best to consider as well as emotional issues confronted around this frightening time.

Jealousy/Envy and Self-Worth

harrah_jealousy

When good fortune happens to others, are we happy for them or envious? When those we care about get close to others do we feel threatened?  When we find ourselves in the midst of infidelity from our partners and fear the possibility of loss, are we sad and hurt or enraged and green with jealousy?

In monogamous romantic relationships, even a happy and fulfilled one, there is the long-held assumption that we cease to lust after others.  When we find ourselves in a flirtation, we think our relationship is dysfunctional.  Even when one is secure and has solid self-esteem, infidelity betrays one’s trust.  At the same time, such a rupture doesn’t have to signify a lack of intimacy or any particular dysfunction in the primary relationship.  Such a rupture is more to do with shattering the integrity and commitment of a relationship than it is with a lack of lust and love for or from one’s partner.

Envy arises from insecurity about who we are and how we see our lives.  Envy doesn’t resolve when we get what we were envious of, but instead we simply move on to the next thought of deficiency and our envy is set off anew.  Secure people recognize what others have and, in fact, may want the same things but rather than hole up with their envy and jealously, they strive to accomplish their goals.  Insecure people live with their envy and jealousy, which are triggered by one perceived lack after another. Having desires and setting out to achieve them should not be confused with motivation driven by envy.

Despite what one might think, there is no correlation between happiness and securing what is envied. Contentment blossoms with a secure sense of self and the ability to empathize with ourselves as well as others – with what we can control as well as what we cannot.

Each of us is unlike anyone else, absolutely unique.  Comparing one’s self to others is a fruitless exercise that inflates or deflates one’s self-worth.  Healthy self-esteem is not dependent on comparing one’s self to others but rather is built on appreciation and empathy toward oneself.

A patient I have seen for many years views people as part of a hierarchy; people higher up in the hierarchy are physically beautiful, fascinating and wealthy.  She sees these people as happier and always being sought after by others.  At the bottom of the hierarchy, there are the unattractive and boring, “losers.”  And then there are those in the middle, where she sees herself.  She yearns to be with the “beautiful people,” but knows she is stuck in the middle with limited options of moving up in the hierarchy.  This entire construct, based on faulty assumptions, only breeds jealousy and envy and causes incalculable suffering on the part of my patient.  Given that my patient experiences bouts of depression and spikes of low self-esteem, I have tried to break down the hierarchy construct.  I suggest – just as an experiment – looking at life without the construct and envision what it would be like and how she would feel.  Gradually, over a number of years, she has loosened her hierarchical way of looking at the world and has built up her self-esteem and appreciated her own worth.

A couple I worked with had a major rupture when one of the husbands had a brief affair with a much younger man.  He admitted his infidelity only after he was caught and the affair had ended.  The other husband was enraged and distraught and consumed with jealousy and envy.  Devastated and filled with insecurity, the cheated-on husband expressed his jealousy by spewing with anger.  His anger, however, had less to do with a sense of betrayal and more to do with how young and desirable the other man was.  Comparing himself with the other man (only coming up against his own envy and low sense of self-worth) triggered ongoing rage.  He berated the paramour because of his youth and beauty and lashed out at his husband for not being attracted to him even though there was no lack of sex in their relationship.  Jealousy and insecurity from deception and betrayal was compounded with envy of youth and beauty.

Even someone who has a strong sense of self-worth and security is still susceptible to jealousy.  But both envy and jealousy infect one’s equilibrium and destroy a healthy sense of self.  Only when we can be happy for what others have and still pursue our own goals, without our self-esteem being dependent on others, can we find contentment in our lives.

The Blame Game

blame1Blame always causes damage, either to oneself or to others.  To blame others is to defend oneself from uncomfortable feelings and to avoid taking responsibility for one’s actions; blaming oneself reinforces one’s lack of self worth.  Blame breeds resentment and prevents resolution of conflict.

Blame is a defensive response to pain – instead of allowing us to express hurt, it prompts us to act out and attack.  It is always tinged with anger and produces no result.  Blame alienates and pushes away.  Over time, blame destroys relationships.

In my work with couples I have seen blame exacerbate the rupture that brought the couple into treatment in the first place.  Unless both people in a relationship take responsibility in a conflict, they will express their feelings through blame.  This prevents understanding and enflames problems in communication.

Even if the blamed person takes responsibility for her/his partner’s hurt and apologizes, it may seem like the problem is being addressed when, in fact, resentment and guilt are simply buried and end up being acted out in other areas of the relationship.  While blame and subsequent apology may create the impression that the rupture has been dealt with, it in fact has simply been camouflaged until it presents itself in other problematic areas that the couple may or may not be dealing with.  While not always apparent, in any conflict there is shared responsibility in preventing understanding and healing.

Suspicion or discovery of infidelity is one of the most volatile areas that come between couples, leaving the psyche gripped with feelings of insecurity and rejection.  What drives a partner to explode in rage when experiencing the pain of betrayal?  What role does each partner play in a rupture precipitated by infidelity, either real or imagined?  And does responding with rage when infidelity strikes address the problem?

When both people in a couple discover their own responsibility in a rupture, including infidelity, it does not illustrate “blaming the victim”.  In every dyad, there is action and reaction, and I have found that even in the most blatant breaking of trust, the injured party can look at her/his contribution to the breakdown in the relationship.  If blame is the only response to being hurt, after time the blamed member of the couple will start to resent her/his partner.

A couple who had been together for 11 years came to see me after discovery of a workplace flirtation.  The wife had found a romantic-tinged text from her husband’s co-worker and confronted her husband.  He admitted the flirtation had gotten out of hand and, while confused, he said that he did not want to leave the marriage, loved his wife and the life that they had, and wanted to work on the marriage.  The wife was devastated and enraged.  She acted out her pain and devastation with attack and accusation and, as she attacked, her anger only deepened.  As we worked together, many past problems in the relationship came up that had never been addressed.  But the blame and attack from the wife continued unabated until the husband was distraught and resentful.  I tried to focus on the wife’s pain, the husband’s confusion and on working on the past unaddressed problems that contributed to the flirtation and fantasy.  After a couple of months, the wife’s constant blame and accusation and the husband’s growing resentment ruptured the relationship in a more substantial way than the initial out-of-hand flirtation.  The wife refused to look at her role in the ruptures and continued to blame her husband in total for the problems in the relationship.  The conflict deepened and healing was elusive.

A married man I have worked with for many years struggles with tremendous guilt and self-recrimination over his pornography addiction and for his occasional hiring of escorts.  Although his addiction has been a life-long struggle, during his marriage and until recently he has refrained from pornography and sexually acting out.  During his 10 years of marriage, he has had two children.  For a long period of time he has felt neglected by his wife, who has been focusing on the children and has neglected intimacy with him.  When he brings up the lack of sex and suggests working on it, she avoids the topic and lets it drop.  Lately my patient has succumbed to his porn addiction and is worried that he may act out further.  My patient is filled with self-blame about his addiction.  He thinks of his addiction as a weakness and moral failing.  While he has enormous empathy for his wife, and understands why the intimacy has left their relationship, he has no empathy for himself.  Instead of confronting the issue of sex with his wife and not letting the subject drop when he brings it up, he blames himself for needing to fulfill his need for sex though porn.  Because I fear that his self-blame will further isolate him and may develop into resentment towards his wife, I encourage him to persist in bringing up the subject to his wife and to develop empathy towards his addiction disease.

When one is hurt and responds with blame, she/he is unconsciously motivated to hurt the other.  That way, she/he is not suffering alone.  This only further alienates the person causing the pain and breeds resentment and isolation.  To express hurt brings the other towards the one hurting; blame pushes the other away.

Anger: Repression, Suppression, Expression

anger images

Unexpressed anger destroys relationships and when acted out, rarely produces the desirable result.  When turned against oneself, it causes depression and anxiety.

Most people think of anger as a negative emotion and try to expel or suppress it. The result can be disastrous.  Because anger results from a rupture of one’s sense of self and security, efforts to exorcise it only cause chaotic relationships and produce self-inflicted psychic wounds.

We often forget that as people we are profoundly different.  We interpret behavior in terms of our own belief system and in the context of our own definitions of language and expression.  When we “listen”, we tend to interpret and filter the other’s experience as though it were our own.  Instead of conscious listening and inquiry, we assume we are aware of the other’s experience.  We forget that our perspective is ours and ours alone.  We can’t assume we understand what others are saying without careful questioning.  Since we assume our perspectives represent “the truth”, any evidence to the contrary leaves us unsteady and defensive. Depending on our personalities, we may lash out and place blame or we may turn our feelings against the self, leaving us feeling rejected and insecure.

When I work with couples, I often see acted out the dynamics of blame, hurt, insecurity, and misunderstanding.  This invariably destroys trust and reduces mutual empathy.  Each misunderstanding exacerbates the damage such that the slightest wound leads to accusations, blame, and anger.  A button is pushed, the partner reacts, more buttons are pushed, until this pattern defines the way a couple communicates.  As this unconscious reactivity is played out and becomes ingrained in the relationship, it becomes progressively more difficult to reframe; healing the wounds requires greater and greater effort and attention.  We associate this kind of breakdown with couples, but it can come to play in virtually any kind of relationships.

When hurt and angry, we are often compelled to blame and lash out or to internalize and feel insecure and rejected.  Being human, we attribute our feelings to another when in fact they are our own.  Would it not be illuminating to examine these feelings in light of one’s own past? ?  Often we assume the hurt is coming from the others’ insensitivity or lack of caring.  Although this may be in fact the case, most often what hurts us is a rupture from our past that gets activated and leads to misinterpreting the other’s meaning and intent.

Walking down the street, we may simmer with hostility at the perceived obliviousness or self-serving behavior of others.  But if we examine this anger, it is most often the result of feeling helpless to control our own environment.  Impatience is often misplaced anger that, in fact, would be better directed at another object, the actual cause of the frustration.

People become depressed or anxious when they have unexpressed rage that’s turned in on themselves.  All of this provokes feelings of hopelessness and leaves the individual without motivation and control.  While it’s human to be angry and human to try to deny anger, it is also possible to acknowledge anger and explore its origins through the exploration of the self and the understanding of others.

Sex, or especially the lack of it, is often a source of blame and recrimination in couple relationships.  For the therapist, breaking this cycle of mutual blame may feel herculean.  When couples can no longer communicate needs and hurts, sexual intimacy suffers and they lose the ability to empathize with their partner.  One partner may feel rejected and not capable of empathizing with their partner’s problems with intimacy.  As feelings of rejection slowly build, they express themselves as blame, either outwardly or kept to one’s self and expressed passive-aggressively.  It is less threatening to be angry at what one doesn’t get than to express feelings of vulnerability, rejection and need.

I worked with a couple who have had only sporadic sex for many years.  One partner felt rejected and expressed his hurt by verbally attacking his partner and accusing him of not being physical enough.  The anger alienated the partner, who grew increasingly resentful  – the anger expressed directly and passive-aggressively in tern exacerbating the the lack of intimacy.  The angry rejected partner’s incessant blaming pushed the other away, whereas had he expressed his hurt and described his feelings of rejection, he would have drawn his partner towards him.  In session, I had to continually reframe the “blaming partner’s” anger as an expression of deep insecurity and of feelings of rejection and of hurt.  As the couple was able to access their underlying feelings — fear of intimacy in one partner and fear of rejection in the other — both were able to work through their resentment.  As resentment waned, each member of the couple began to be present for the other and to gradually empathize with the other’s feelings and needs.

I once spent four years working with a patient who continually railed against the world and everyone in it.  In session, he raged constantly and complained bitterly about the stupidity and insensitivity that surrounded him.  He had very painful memories of continual childhood emotional abuse.  I encouraged him to express his anger but as I began to explore the origins of his rage, he would turn it toward me.  He wanted to express his anger but was unwilling to probe more deeply to his hurt and feelings of worthlessness.  Whatever interpretation or intervention I put forth, or no matter how much validation and empathy I provided, he just wanted to express his rage and have it heard.  But having it heard over two 2-year periods did nothing to alleviate his existential discomfort and never drew him to examine his pain.  He never got past his anger and left treatment much as he started.

While we need to let out our anger, if we don’t explore its source, it will continue to feed itself and inhibit growth and deeper understanding.  Blame inhibits understanding and repressing anger causes misdirected rage and depression.  Anger is an emotion that must be acknowledged but whose acknowledgment must also lead to understanding and empathy.