Individual Therapy
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Dr.Gelcer deals with a variety of problems, including
Depression, Anxiety Disorder, Phobia, Addiction, Burnout, Post Traumatic Stress,
Gifted Children and Adults, Attention Deficit Disorder (ADD/HD) and Learning
Disabilities (LD), Eating Disorder, Body Dysmorphic Dysorder (BDD), Bereavement
and Loss. She is the author of articles on Family Therapy; Gifted Children;
Bereavement and Loss; and Training and supervision of professionals and students.
She is also the chief author and conceptualizer of the book “Milan Family
Therapy”, which was translated to Japanese. Before opening her Private Practice
in 1991, Dr. Gelcer was the Senior psychologist of the Child and Family Studies
Centre in the Clarke Institute of Psychiatry, for over 13 years. During these
years, she was also the Founder and Director of the Toronto Family Therapy
Training Program, the Gifted Children’s Team and the Learning Disabilities
Clinic. For further information, see
Toronto psychologist Esther Gelcer
ESTHER GELCER, PH.D., [at time of original publication was] Chief Psychologist, Child and Family Studies Centre, Clarke Institute of Psychiatry, Toronto, Ontario.
Mourning is a process
of social disengagement. In our modern society, however, the influence of social
and religious institutions on the process of mourning has significantly
diminished and been partially replaced by mental health clinics. Given the
latter's penchant for the intrapsychic view, the perspective on mourning has
become reduced to the individual. These trends are clearly reflected in a review
of current literature and research on mourning. This paper proposes an
interactional, systemic view of mourning through the analysis of two different
families. Findings indicate that despite contextual differences between these
two families, some basic commonalities render generalizations possible: (a) The
selection of the identified patient is not coincidental to the stage of the
family life cycle and to the role of the deceased member in the system. (b)
Although death affects each individual differently, depending upon his or her
relationship with the deceased, it continues to influence all family relations
with equal powers. (c) Nonresolution of mourning permits a ghost to become an
integral member of the family system. Examination of the treatment process
demonstrates that a systemic approach is effective, even when individuals are
interviewed alone.
Three important elements of modern family life affect one's adjustment to dying
and death. First, because of our current emphasis on health, adults and children
may live for many years before a death in the immediate family occurs. This gap
in life experience creates a crisis similar to most other family pathology.
According to Fleck, "The absence of shared tragedy and mourning early in life
has wrought certain difficulties for families and individuals in facing death
and gaining reassurance in the continuity of individual and family life after
the loss of a loved one" (10, p.108).
The second element concerns the need to adjust to the phenomenon of dying.
Because of improved medical services, death nowadays is not sudden but is
expected and often occurs after a prolonged period of illness. This process
requires a different adjustment than that for sudden death or chronic illness.
Adjustment through anticipatory grief would normally be expected to result in
gradual emotional disengagement by the various members of the family
commensurate to the dying member's capacity for involvement with others. More
often, for those inexperienced with death, there seems to be rather an increased
emotional involvement with the dying member, and pathological family processes
result resembling those of coping with chronic illness or with rearing a
defective child.
The third element concerns the role of mourning in maintaining social and
individual adjustment, especially the role of institutions in facilitating
mourning for the preservation of equilibrium and social continuity (32, 35).
Historical and anthropological studies indicate that every society, or culture,
has had mechanisms for dealing with mourning. Usually these are governed by
religious beliefs, which also dictate certain practices. These regulations
emanate from an understanding of individual and interpersonal needs of mourners
and at the same time are geared toward the preservation of social stability and
growth (35). Our individualistic society has abandoned, or forgotten, many
traditional social customs and religious rites. The role of religious and
sociocultural institutions in bereavement has been diminishing along the same
lines as in many other aspects of family life (e.g., marriage and parenthood).
Our society presently offers little sociocultural support in cases of death.
Consequently, it is perhaps not surprising that, of the institutions active in
educating and in helping people deal with death and dying, mental health clinics
are becoming prevalent. When individuals turn to these clinics for help, they
are usually treated alone. Psychotherapy for unresolved grief reaction is still,
by and large, based on Freudian psychoanalytic assumptions (13). Very little
work has been accomplished based on systemic understanding and directed toward
working with whole social systems. On the other hand, as the review of
literature will indicate, studies of individual differences in relation to
mourning are in abundance.
The main thrust of this paper is to demonstrate that "the work of mourning is
best learned as a shared family experience" (10, pp.108-109); that is,
regardless of social and cultural evolutions, death does not affect isolated
individuals in any society and at any time, nor even isolated families. Death
has a powerful impact on the beliefs that structure organizations, large and
small, because it has implications for continuity, integrity, and change.
Two case studies will demonstrate, respectively, complications arising out of
our inexperience with death and from anticipatory grief reaction. In both cases
religion or sociocultural support was bypassed or intentionally ignored. Family
malfunctioning eventually became apparent only a few years following an
experience of death in each family. And although each presented an adolescent,
individually, as suffering from behavioral disturbances, family pathology was
clearly evident in the group as a whole.
More specifically, the struggles of these adolescents to begin adult life
evidenced a parallel to their parents' attempts to establish new marital
relations. The difficulties in each family were perpetuated by the omnipresence
of a dead marital partner/parent. Until this dead person was psychologically
buried and mourned, the role of a ghost colored all triangular relations and
played havoc with each family member and the groups' accomplishments of their
normal life cycle tasks.
Treatment focused at first on unraveling the connections between the
adolescents' behavioral problems and their families' tendencies to avoid
mourning. Once established, the thrust of the process of change was focused on
working with the parents on a monthly basis, allowing for time and for
sociocultural reintegration of each family unit. This technique was primarily
fashioned after the Milan team's (39) approach and incorporated features of
structural family therapy tactics (28).
Literature Review
Studies of individual differences in mourning indicate that major discrepancies
exist in individual reactions, depending not only upon the relative structural
order or the label affixed to a social relationship or status, but more upon the
intrinsic nature of a particular relationship that has been disturbed by death.
For example, variations of such relationships include parent-child,
child-parent, siblings, widow/widower, ages of the dead as compared with ages of
survivors, etc. Individual reactions have been studied based on one or another
classification of subjects. Thus, for example, it has been found that adults go
through clearly delineated stages of mourning, the completion or disruption of
which leads respectively either to resolution or complications (12, 25).
Children, on the other hand, are far more limited than adults in their ability
to conceptualize death (30, 2, 26), and this ability varies according to their
age or cognitive level (37, 17). Children's expressions of grief therefore vary
accordingly (14) but are also a clear function of the nature of their
relationship with the dead (29, 14, 4), the circumstances of the death, and, in
the case of a deceased parent, the sex of the parent and the ability of the
surviving parent to provide a supportive environment for successful mourning
(14). Helping children to cope with grief therefore seems to require a
specialized approach. For example, because of children's difficulties in
understanding death and verbalizing their grief, Leviton (22) among others,
urgently points to the need for education about death, whereas Bernstein (5)
suggests a bibliotherapeutic approach, and Berman (4) tailors a preventive
mental health approach to facilitate mourning that takes into account the
child's cognitive and emotional ability to comprehend death.
The literature also abundantly documents the problems children have as adults
when they have not successfully mourned. These problems include such reactions
as depression, difficulties with gender identity, various somatic complaints,
and even psychosis. Adult problems related to unresolved mourning also vary, but
whereas these reactions also seem to be related to the nature of the
relationship with the dead person, support systems available, circumstances of
death, etc., adults are generally taken to have better coping skills than
children.
Anticipatory grief is given special attention in the literature because of its
effects on the mourning process. This reaction, experienced generally upon
forewarning of loss, confounds grief by virtue of the protracted period of
dying. Again, studies have focused primarily on individual adult's reactions to
the prolonged illness of a spouse or of a child. Ball (3), for example, found
that reactions to sudden death were overall more intense than to prolonged
illness of a spouse for survivors below 45 years old, whereas sudden death was
less significant for older survivors. Parkes (31), on the other hand, found that
anticipatory grief increased the chances for good adjustment in young widows and
widowers. Glick et al. (15) advance the notion that anticipatory grief provides
a chance to give up (false) hope and to understand the cause of death.
Although some links between anticipatory grief and mourning have been
established, results are inconclusive and operational definitions are muddled
(13).
The arguments about the effects of anticipatory grief have not yet been extended
to studies of children. Knowledge of developmental psychology, however,
indicates that anticipations are cognitively complex functions of which young
children are mostly incapable (34). So much more true for anticipation of death.
Whereas researchers and clinicians seem to have taken the easy (but
unproductive) route of studying one unit of the family structure at a
time�usually the older the better�rather than tackling the whole system, studies
of children's reactions to death perhaps highlight the importance of the family
and larger social systems for providing education and support during the
mourning process. Fulton and Gottesman (13) argue that "the difficulty with the
traditional psychoanalytic perspectives of grief is that they are based on the
assumptions about human reactions to loss that fail to give due consideration to
either the socio-psychological, or the socio-cultural aspects of the phenonema"
(3, p.50). They criticize demographic research in this area as guided by two
basic assumptions: (a) that all subjects in a particular state of mourning
experience comparable volumes of grief, and (b) that the mourning process, once
begun, continues in an irreversible path of dissipating grief. They emphasize
again that "grief is not a private matter" (13, p.51). Others have highlighted
the contextual significance of mourning by finding that the expression of grief
is contingent on the psychological significance of persons in the family (36)
and upon that family's capacity to deal with, or to deny, death (40).
Assuming these psychosocial considerations and given the dwindling role of
active cultural and religious mechanisms, psychotherapy seems to have become the
primary mode of helping mourners. In family therapy, for example, analysis of
the sociocultural context in which mourning is unresolved usually reveals that a
close relationship exists between the behavior of the identified patient and the
role of the deceased member in the family life cycle. One is a living monument
to the loss of the other. Similarly, as long as the deceased member's role is
maintained alive in the family, other members' roles are rendered dead or
inactive; progress in the accomplishment of family life cycle tasks is arrested.
Caplan (9) considers that the stoic family member who is credited with being
"courageous" and "strong" for not crying over a lost loved one is headed for
trouble. Yet, today, to be "superman" is still more acceptable than to give in
to expressions of pain. Grief applies to everyday situations, affecting and
being affected by those people who survive. The reciprocal interplay between
mourners and their social support systems ideally leads to maturation and to
learning to give up what is obsolete, to assume new roles and to take on new
life tasks. The ill effects of bypassing mourning, however, evolve into family
and social pathology. On the other hand, reactions to death are like reactions
to crises or illness. They can be viewed as having their own mobilizing effects
on the individual and on the family.
Caplan (9) suggests minimizing interventions in order to modify as little as
possible the impact of hazardous life situations on the family and on its
members' way of dealing with those situations through their own efforts. Along
the same lines, MacGregor's (27) Multiple Impact Therapy (MIT) deals with the
process of mourning within a family context and on a brief intervention basis.
This technique is interesting in that it considers the limitations of individual
members in a family as well as implies a thorough understanding of the whole
system. The MIT method basically involves helping the natural love object, or
the spouse, to be more satisfying than, for example, the heretofore exploited
child. They help the widowed mother "to seek the adult satisfactions of
continuing growth in preference to encumbering her child by 'living for him'"
(27, p.160). Based on Bowen's astute systemic observation that emotional
closeness or distance between the parents directly affects the treatment results
of children (8), the MIT project's attitude is one of keen attention to the
parents. This is based on the thinking that in times of stress, illness, or
death in a family, the parents need attention. Therefore, the MIT team would
communicate to parents its belief that they and the family system as a whole
would derive direct benefits from doing something constructive for themselves
and their children.
The MIT approach is strikingly similar to that which is practiced by other
experienced family therapists such as the Milan team (38). The latter, however,
focus on the paradoxical nature of unresolved crises in families. These
therapists struggle to tailor paradoxical prescriptions suitable to each family
in its context. In our examples of unresolved grief, the striking paradox that
emerges is that the dead are regarded as living and the living are viewed as
dead. Ritualized prescriptions can accordingly incorporate a paradoxical
injunction in such a manner as to bury the dead or revive the living. This is no
substitute for religious rites, of course. If applied accurately, however, it
can have a powerful impact on the evolution of change while preserving family
unity.
Recent developments in family therapy, especially the latest method developed by
Selvini-Palazzoli and Prata,1 clearly emphasize not only that the parents are
the pivotal point of the family system, but also that clinical interventions
with this holon are tantamount to affecting the nodal point of the system. In
addition, although the actual treatment techniques of The Milan team differ from
the MIT project, there are significant similarities. All are guided primarily by
three therapeutic principles: team approach to therapy, brief intervention
model, and relatively long intervals between sessions.
These principles, together with strategic-systemic reasoning, also guided the
work with the families presented here. At that time I had already visited
Selvini-Palazzoli and Prata in Milan and was influenced by their new work. The
treatment of the families, therefore, combined the influences of past experience
with similar problems, together with the application of new approaches,
including some principles of structural family therapy (28). The two cases, in
sequence, show the evolution of the ideas and the work.
Case Presentation
Family A
Melissa was 13 years old. Her mother, a famous literary personality, died
mysteriously from a "freak accident" at home when Melissa was 6 years old and
her sister, Heather, was 2 years old. The father, an executive in a large firm,
gave up his work for a year in order to tend to his young daughters. By the end
of that year he fell in love with, and married, a young previously unmarried
woman, who one year later bore him a son, Jerry. This woman was proud to be
chosen to succeed the famous deceased wife. Although she knew that she could
never live up to the dead woman's fame, she was confident of surpassing her in
her own capacity to love and care for her husband, his children, and their son.
She was an immaculate housekeeper. Her husband reciprocated by acknowledging his
love for her�emotions he said he hadn't experienced in his previous marriage�and
by shifting his Bohemian life-style to one oriented toward home and family. All
three children grew up doing well at school and having harmonious relations at
home. Because of the girls' youth when their mother died, they were considered
to have forgotten about her or never really to have known her. Like Jerry, they
addressed the new wife as mother and expected to receive the love and affection
that was showered on Jerry by both parents. Heather succeeded better than
Melissa in this, as she emulated her (step-) mother's behavior, including
spoiling the father.
Early in her adolescence, Melissa was taken to a therapist because she was
described as defiant, lazy, skipping days at school, having failed a class in
the previous year, and, in the (step-) mother's words, "endangering the peace at
home." "Heather loves her so much and may begin to imitate her." Melissa was
diagnosed as severely depressed and borderline psychotic; the family was
referred for family therapy.
Melissa's appearance was striking. She looked much older than her stated age,
except for a baby-like, naïve, sad look in her eyes. She was tall, fully
developed, and well dressed. In the presence of her family she was more
withdrawn and depressed than when she was seen alone. But even in individual
sessions she spoke inaudibly, if at all. At home she was reported to maintain a
similar silence while she continued to do as she wished: coming home later and
later every night, getting up late, skipping school, and avoiding all family
activities and chores. Her father was full of rage as he reported that he was
impotent to discipline the girl. She behaved and looked like the "zombie" her
(biological) mother looked like, according to the father, except that the mother
produced intellectual works of fame, whereas this one "will be unalphabetic" Her
stepmother (Melissa now refused to call her "mother") expressed a wish to help
Melissa but more out of protection of her husband ("he smokes and drinks too
much when she upsets him") than out of compassion for the teenager. She said
that she found it difficult to mother Melissa when the child refused to call her
"mother."
It soon became apparent that the work of mourning the dead mother was not
resolved, if at all begun. At the same time, the new marriage was not yet
acknowledged. This was expressed in the family's system of attitudes and
beliefs, which included two mother-wife figures. The one that was presumably
part of the past was still present in the lives of all family members and
provoked intense reactions. The new wife-mother's role therefore was a
countermeasure to the intrusive ghost of the dead wife-mother. Both were
maintained at all costs. The competition between the two wife-mothers produced a
situation in which alternatives existed for different parts of the family; for
example, a "bad" wife could be idealized as a "good" mother, and vice versa. But
at this point of the family's history, the living wife-mother felt she was
losing the battle for her role because it was not recognized by the whole
family. Who can fight a ghost? Resolution of the past, and integration of the
present reality was necessary.
The couple were invited for therapy sessions without the children in order to
help them cooperate better with each other as a married couple and in taking
care of the children. This move also differentiated the present from the past
and the parental issues from those of the younger generation. The reaction to
the invitation was mixed. Mother: "We have never had a honeymoon. Ever since the
day we were married I have been treated as the 'best housekeeper' for this man
and his children." Father: "I suffered enough in my previous marriage. Her death
was a relief. This woman I love. She is an excellent wife. We don't need marital
therapy." At the same time both parents agreed that neither of the younger two
children needed treatment and Melissa's individual treatment was not helping
anyone much.
This agreement between them, to remain ambivalent about treatment, confirmed the
fact that mourning work was premature at this point. Therefore, therapy
continued to focus on the functions of this couple at home and outside. The
parents' ambivalence, however, was directly expressed in the children's behavior
at home. When the parents cooperated (not only at home, but also in playing
tennis, going out more, etc.), Melissa and her father became closer. He
disciplined Melissa and was able to differentiate her from his dead wife. But
the mention of the dead wife's name was taboo, at home and in therapy (unless it
was used derogatorily). The change in the father-daughter relationship became
threatening to the new wife, who felt that, if her husband succeeded better than
she with Melissa, her own work with the girl would be superfluous. In spite of
all she had done, she was not the real mother, whereas he was the real father!
As the wife's negative reactions to Melissa intensified, Heather aligned herself
with her sister and father. Melissa began taking drugs, and Heather formed a
secret coalition with her. As this symmetrical escalation proceeded, the husband
was caught in the middle. He was now faced with two alternatives: the possible
loss of his (second) wife or of his two daughters; (mother: "I told you she
would corrupt Heather!"). The father chose a third alternative: Melissa was sent
to see a psychoanalyst who found her uncooperative and referred her for
treatment in a private institution out of the country.
The maternal grandparents, who in earlier years served to preserve their
daughter's memory by introducing Melissa to her mother's works, now became
disillusioned with their hopes for the girl and made a substantial financial
contribution for her institutionalization. Both Mr. and Mrs. A felt it was right
that these grandparents should be "punished" in this manner for their intrusions
into the couple's life and heaved a sigh of relief that they could now live in
harmony with their "perfect" son and daughter (one from each marriage). They
considered this to be a better solution to the problem, since it was "Melissa's
problem to begin with." They couldn't see that mourning, seven years later, was
called for. So they stopped coming for treatment.
But as Melissa cooperated fully and quietly with her removal from home, Jerry's
and Heather's social, academic and disciplinary problems intensified. These
reactions both surprised and dismayed the parents, especially the mother. She
telephoned asking for an individual session and explained that she was now
feeling "an absolute and utter failure." She could not help her children alone.
Her husband resumed drinking, she thought, because "he is now mourning the loss
of his daughter." As she introduced the issue of mourning, the couple were
invited back for therapy; that is when mourning work was accomplished, at first
indirectly and involving one member of the couple at a time, but gradually more
directly. Although only the couple participated in treatment, the effects of the
work seemed to touch the whole family, including the maternal and paternal
grandparents.
What convinced me that mourning work was called for, despite the parents'
denial, was that the ghost of the dead wife was brought up at the most
unexpected times and in a surprising fashion. For example, in Melissa's absence,
her stepmother began tidying and reorganizing her room. She then moved into
Melissa's room a large oil painting, a portrait of the dead wife, which was
apparently considered a great piece of art and had hung in the entrance to the
family's home. Mr. A considered this move "a waste of an art work," an intrusion
on Melissa's privacy in her absence, and a contravention of his authority, since
he wasn't consulted ahead of time. Heather also reacted negatively, feeling left
out of memorabilia of her mother; and even little Jerry complained that "there
are too many changes at home." The maternal grandparents soon heard of this move
and expressed their own wish to possess their daughter's portrait.
It became clear that this ghost lived for seven years because it had many allies
in the family, while her replacement was moved in swiftly and singlehandedly by
the father in order "not to change anything in the lives of the young girls." It
was this realization that prompted me to emphasize the many drastic and negative
changes that had befallen the family: Their love for each other was jeopardized
by a ghost they would all rather bury; a promising daughter was removed to an
institution; another was perhaps heading in the same direction; a son�who "has
nothing to do with it at all"�was also beginning to fall behind; and now, a
loved second wife was feeling useless and on her way out.
The solution was intuitive and simple. The couple were to build a "new home" for
themselves. Children and grandparents must have no part in this decision.
Therefore, Mr. and Mrs. A announced to the children that while they were away at
summer camp, the parents would be working hard to renovate the home or look for
a new one. The couple were then asked to go through the whole house, room by
room, and check each and every piece of furniture; whatever both liked would
remain, whereas anything that either one of them objected to (this would be
mostly the wife, because she claimed her wedding gifts "were still in their
original packages in the basement") was to be sold or placed in the basement.
Only after the cleaning of the old was completed and "empty spots" perceived
could they break open the packages of their wedding gifts and arrange the new
order.
The wife was eager to perform the task, but the husband acquiesced reluctantly,
feeling pressured to preserve his wife's sanity. Both agreed that they would
rather build the new marriage than mourn the old. But upon the husband's first
excursion to the basement, loaded with "articles unwanted" by his wife, he did
not emerge again for the rest of the day. His wife continued rearranging the
upstairs, unaware of the passing time, but eventually she became concerned about
her husband's absence and went to the basement herself, carrying more rejected
articles. She was astonished to find him knee deep in the books, diary, and
photo albums of his previous wife. He claimed he was "making space for things,"
but she was upset. She had discovered that the ghost had its own quarters and
that they occupied a substantial part of their home.
Both realized then that they were trying to build a new and growing relationship
upon monumental ruins of the past. They suggested a reciprocal division of
labor�he clean up the basement while she rearrange the upstairs. This atmosphere
of trust and cooperation allowed the couple to make sensible decisions and to
unite against oppositions from others. They donated most of the dead wife's
works to libraries, sold some of the art work, and bought new works selected by
both. In the absence of their children, they paced their housework with common
holidays and with the development of their individual talents (the wife began
pottery classes and the husband began writing short stories). When the children
returned, including Melissa who gradually rejoined the family, they were faced
with a congruent, cooperative, and enterprising couple.
Family B
Larry was 13 years old. He was referred for treatment by his mother's cousin who
was in the helping professions and who explained that she could speak better
English than Larry's immigrant mother. But a conversation with Larry's mother
revealed not only that the latter was fluent in English�although with a heavy
accent�but also that she had taken Larry to an ethnic psychiatrist three years
previously when his father was dying of a prolonged and rapidly deteriorating
illness. At that time she presented Larry's problems as "absent-minded and
falling behind in school." The psychiatrist's diagnosis: "transient situational
reaction." Recommendations: individual therapy for Larry with additional
treatment for his mother. Shortly thereafter, the father died, so neither Larry
nor his mother followed the recommendations. Three years later they returned to
the same psychiatrist, escorted by the cousin, who complained that Larry was
getting worse. He was lying, shoplifting, daydreaming, and failing at school.
This time the diagnosis changed to "borderline psychotic reaction," as Larry
presented behaviors colored by feelings of omnipotence, unrealistic fears of
murderers and drunk people, and beliefs in magic. The family were referred to
our Centre for family therapy.
Mother; her common-law husband, Peter; Larry; and his younger brother, Marco, 7
years old, were invited for a family assessment. All came except Peter. A slip
of the tongue in the first session, made by Larry's younger brother, Marco,
indicated the confusion in this family about their adult roles. I began the
sessions by asking the ages of the family members present. Marco said, "But my
father is not here today. Whose age do you want? My real father's or the one who
is not here or only my mother's?"
All three adults did not vary much in age: 32 to 35 years. But Marco,
unprovoked, proceeded to calculate, with great difficulty, what these adults'
ages were at the time of his father's death, three years past. Despite the fact
that Peter only recently joined the family and was absent from the first
session, for Marco time had stood still. Events were relevant only in relation
to the time of his father's death.
The mother immediately took over, informing us that Marco "didn't know anything
because he was only a baby then"; (he was 4 years old when his father died). The
real problem, she said, was Larry, because now she was ready to marry Peter, but
Larry was objecting to the marriage:"He doesn't like Peter, he won't listen to
him and won't call him 'father,' unlike Marco."She was afraid that Marco would
soon begin to emulate his brother and that this would increase the opposition to
the new marriage. She vehemently protected her common-law husband's absence from
the session, claiming he was "working hard to support the family."
The team, having gauged this confusion in the family system, decided to support
Peter's absence and to inquire about the father's death. The mother's insistence
on telling the story in detail and her apparent pleading with the children for
forgiveness and compassion indicated further the unresolved grief and delayed
mourning.
Shortly after they were married the couple had immigrated to Canada. The
husband, a truck driver, often complained of fatigue, but he was known to be a
loving man who was eager to succeed. Six years later he fell off his truck,
suffering some fractures, and never recovered fully. During this period he
spoiled Larry a great deal and told his wife that they should have another child
soon. Shortly after Marco's birth the father became disabled and unemployed. The
wife sought full-time employment in order to provide for the family, and Larry,
then at the beginning of elementary school, cooperated by baby-sitting for his
brother and caring for his ailing father. Both children recalled that period in
their lives, but mother compulsively continued her story.
When she was told of her husband's imminent death, she sent her children to her
parents overseas. She said she began mourning him prior to his death. She had
cried for him all that summer while she worked and visited him in the hospital.
The day prior to his death she was planning to go on a picnic because she felt
that she had cried enough by then. Her husband agreed that she needed to get
away a little, but he also told her of a dream in which he was reunited with the
children. She read his message as requesting family closeness, canceled the
picnic, and stayed by his side until he died later that day. She then telephoned
her parents announcing his death and asking them not to divulge the news to the
children. Since she expected them back at the end of the summer, she preferred
to tell them herself. Nevertheless, Larry clearly recalled."I was so confused!
Everyone was wearing black! I asked my grandma�she said her sister died. I asked
my grandpa�he said his brother died. But I didn't see any funeral!"
The paternal uncle took photographs of the funeral from which the mother
prepared an album to show to her children when they returned. But they had not
yet seen it at the time of assessment. Instead, when the children returned home
and were eager to see their father, their mother sat them down and said, "Your
father died. That's it. There are only the three of us now." Larry and his
mother cried while he told her: "You must get a new husband now, more, quick!"
His mother responded, "No, you will be the man in our family, Larry."
She refused to wear black for a whole year (as required by her ethnic custom),
as she claimed to have suffered and mourned her husband enough. In addition, she
discovered after his death that his family had known all along of his terminal
condition and that was the reason behind their hitherto unexplained objection to
the marriage. Angered by this discovery and by her misfortune, she refused to
practice any religious rites. This prompted her younger sister, whom she had
nurtured and loved dearly, to sever all ties with her. Having severed ties with
the husband's brother, the family was left without any support.
Larry's problems began with psychosomatic complaints and went on to shoplifting,
stealing, showing phobic reactions, and attracting attention at school by being
the class clown and a failure. The union with Peter brought relief to the family
budget and a welcome support for Larry and Marco, but the honeymoon did not last
long.
Although Peter appeared for some of the family sessions, his presence and
absence soon came to represent his tenuous position in the family and his own
depression about unresolved ties with his own ex-wife and children. Separated
five years ago, he was not allowed to see or have any contact with his own two
children, the youngest of whom was just born at the time of the separation.
Furthermore his ex-wife vengefully refused to divorce him, so he was forced to
wait two or more years (in total, seven years) before he would be eligible to
marry again. Peter was also showing phobic reactions. For example, he wouldn't
drive a car, thus placing his common-law wife in the role of his chauffeur. He
worked seven days a week and was always too tired to do anything but watch TV.
According to the team's assessment, the family were told that they were "trying
too hard and too fast to become a family again. In these efforts you seem to
become so confused that you behave as if the dead father were alive and the
living father were dead."But since the children were considered too young to
sort out this confusion right now, only the couple were invited for succeeding
sessions. Peter again dropped out temporarily but indirectly made his presence
known through phone messages. Nevertheless, the team conceptualized the mother's
appearance for sessions as her being not alone. She was appearing, without
Peter, as a "representative" of the past marriage.
Four sessions with the mother alone focused at first on helping her structure
and monitor the children's behavior according to the principles of the past
marriage, as the only surviving parent. In the third session she appeared
dressed in a black dress (in mid-summer): "Larry bought it for me at Christmas
with money he received from Peter." The message could not be ignored. We
reviewed her mourning rites. To our surprise, she informed us that recently she
happened to show the children the burial album of their father for the first
time. She cried a great deal during this session, realizing the connection
between her unresolved grief and her dress, the connections among Larry, Peter,
and her deceased husband. What could she do now?
We said that although we could help the surviving family, we could not intervene
with the dead. "Perhaps the church would have an answer." Since we recognized
that this period was particularly difficult for her, we offered extra sessions
in addition to the monthly routine. She didn't utilize these. She returned for
the fourth session angry with her sister and with the latter's lack of support.
She also talked of her parents' refusal to acknowledge her widowhood.
Indirectly, however, she also indicated some progress. Whereas in past years she
visited the grave every weekend, taking the children (and later also Peter),
this year she went alone and only in order to plant flowers. She did not intend
to return to the grave for the remainder of the year. Sensing her need for
broader support, but recognizing her problems in getting this from her family of
origin, we reiterated our previous prescription, adding that perhaps there were
still some rites she had overlooked that the church would indicate and help her
with. "Our team is limited in regard to religion," we said.
She did not return to the following sessions. Instead, it was Peter who called
in the winter, saying that he might "leave her if she doesn't change." The
couple were invited back, and this time Peter reported that he was feeling
alienated from the family: "Perhaps I should have some sessions alone with you,
like my wife had." She agreed. She pointed out that Larry was progressing well
at school, that he had a girlfriend, and that "perhaps Peter is jealous because
he isn't having as much fun as Larry." Our focus and our next step was to work
with "the living couple."They cooperated.
During the couple's sessions we realized their deadlock. Peter wanted new
children in this marriage, but she had had a tubectomy (instructed by her dying
husband, after Marco's birth, to have no more children). She, on the other hand,
accused Peter of stalling his divorce proceedings, although she knew his
ex-wife's role in that. Consequently, she refused to consider allowing Peter's
children in her home, and Peter did not fulfill his promise to be a father to
her own children. The deadlock was soon felt by the children. Marco's teachers
complained of his deterioration at school, and Larry threatened to leave home.
In the meantime, Larry sought a part-time job helping a truck driver. A crisis
occurred when Larry returned home from a truck excursion at 3:00 A.M. He claimed
they had had mechanical failure. His mother didn't believe him, and Peter got
into a fist-fight with him.
At this point, the team advised the whole family to return to family therapy. It
was reasoned that the mourning work by the mother and her children was completed
and that the focus should now be on reinforcing the present family structure.
Peter was commended for showing how much he cared for Larry. Instead of
emphasizing his impotence in parenting his own children, his wishes to parent
Larry and Marco were encouraged. Larry dramatically heaved a sigh of relief and
begged his mother to "stay out and let 'us men' tackle it." They did so to the
best of their abilities.
Discussion
The scope of this paper does not permit comparison of these two cases with more
similar cases, with individual treatment of similar problems, or with similar
treatment of different family problems. Inferences can be drawn from comparison
with the reader's experiences or with cases reported in the literature. The
paper is an attempt to provide as detailed a description as possible of each
family process in its unique context, sacrificing breadth for depth of
presentation. In doing so, the difficult task is to highlight the unique
features of each case in terms of problem presentation and treatment process, at
the same time underlining their common denominator.
To summarize, Family A was Anglo-Saxon, Canadian born, and upper middle-class,
from a well-established background. The family encountered a sudden, unexpected
death of a mother who, while alive, was considered distant from her children
(they were cared for by a nanny) and incompetent as a wife. Nevertheless, she
left a legacy of professional accomplishment and fame. The surviving husband
remarried relatively soon after her death. The new marriage brought a competent
mother and wife into the home and subsequently produced another child in the
family. Problems began to be noticed only seven years later. The identified
patient was a girl.
Family B, in contrast, was from a lower middle-class, Greek-immigrant
background. In this family, a father, not a mother, had died. Although his death
was considered unexpected by the children, both parents knew of its inevitable
occurrence, and the children were subjected to abnormal hardships in the
process. Anticipatory grief was reported by the mother. Although the children's
developmental tasks were compromised in the face of their father's prolonged
terminal illness, they became very attached to him as they nursed him at home.
In this family, the mother reported a loving, close, and cooperative marital
relationship. Her anticipatory grief, however, mixed with sociocultural factors,
clearly influenced all family members. In addition, immigration and
acculturation pressures, followed by the father's inevitable unemployment,
contributed to the general mood of depression and to the unstructuring of roles
in the family. Reactions of this nuclear family following the death of the
father were in marked contrast to the extended family's reactions and to those
of their ethnic/religious group. Whereas all others mourned him and followed the
rites fully, the mother thought that she and the children had suffered enough
and refused to participate in Greek Orthodox rituals. Instead, the nuclear
family, who bypassed religious rites, traveled every weekend to visit the
father's grave. For them he was a recreational object. Eventually, when the
maternal aunt introduced Peter to her sister three years later, only an informal
marriage was accepted. Problems in the family were noticed earlier on, but
unattended to because of socioeconomic pressures. The identified patient was a
boy.
The differences in treatment varied somewhat according to each context and in
accordance with my experience. The length and intensity of treatment also
varied. Whereas both families visited our Centre over a period of approximately
two years, Family A was seen for the first year on a weekly basis, receiving a
combination of individual sessions for Melissa, followed by family sessions.
Only in the second year were the parents seen alone on a monthly basis. Family B
received more intense work by the team, although there were fewer contacts. Seen
on a monthly basis, Family B received three family assessment sessions, then
four individual sessions for the mother alone, followed by two sessions for the
couple alone and the final two sessions for the whole family.
Despite the many differences between the families, the commonalities may point
to some wider generalizations. In both cases, the children were unable to grasp
the death of their parent, yet they were subjected to the same rules of conduct
as adults. Paradoxically, their development was arrested at their level of
maturity at their parents' death. Both families lost a parent of the same gender
as the surviving children. The implications for gender disturbance in
adolescence were indeed among the problems that were of concern upon admission.
Academic underachievement is not uncommon in depressed, and in these cases
grieving, children. "Death is not easily tolerable, for it can breed shame" (6,
p.19). An adolescent who lost a father stated: "A child might lie about her
parents being alive. I used to lie all the time. ... I felt ashamed and
embarrassed because I was different from everyone else. If I said he was dead,
they would all feel sorry for me. I couldn't stand that and would rather lie"
(6, p.19). Similarly for stealing, clowning, and, as a last resort, avoidance
and denial through use of drugs. Perhaps one other commonality warrants our
attention: namely, the period of their lives in which problems became
pronounced. Adolescence is a period of beginning adulthood. Hand in hand with
identity formation comes the creation of new relationships. Much has already
been written about unresolved childhood problems revisiting the adolescent upon
facing new beginnings (18).
We could continue to analyze the psychodynamic factors that contributed to these
children's problems, but we would then be subject to the same criticism we
earlier applied to individual therapists of similar cases. That is, the
individualistic approach in these instances serves to isolate the individual
from his main source of support (or confusion), the family system. Such
isolation or centering, in the Piagetian sense, exaggerates and distorts
reality. On the other hand, decentering, which is exemplified by viewing the
individual's problems within the family context, brings to focus a more
realistic and relational approach (34).
From this perspective, adolescence can be viewed as a trying time for the family
system. Roles are subjected to the test of change, as new functions are invoked
and the family structure is shaken up to prepare for branching off. Perhaps it
is not by accident, therefore, that the point at which these families mobilized
themselves in search of treatment came when the parents also experienced
problems in beginning new relationships, built upon unresolved pasts. Was the
request for help and the cooperation in treatment provoked by the children's
problems or by the parents' problems? The answer to this question lies in our
present understanding of systems. The family functions as one synchronized
whole. Ackerman, among the forefathers of family therapy, stated: "Conflict
between the minds of family members and conflict within the mind of any one
member stand in reciprocal relation to one another" (1, p.75). From this
viewpoint, it is clear that in both cases the surviving parents' unresolved
conflict about their dead spouses was expressed through denial of mourning and
was reciprocated by the children's refusal to deny. On the other hand, the
children's behavior functioned to preserve the unresolved mourning. Their
conflict about beginning new lives for themselves thus paralelled that of the
couples and perhaps served as a starting point for the couples' work toward
resolving this conflict in their marriage. It is this resolution that helped
free the couples from marital knots and facilitated the actualization of their
parental roles.
Do all families have to go through similar mourning processes? In our particular
examples, both families lost a parent at the "wrong time" in their life cycles.
According to Hertz, "Those deaths or serious illnesses in which an individual is
in the prime of life are the most disruptive to the family" (16, p.225). At this
early phase of the family life, a mother or a father has the greatest
responsibilities for the family. Their death therefore leaves a structural gap
that can be difficult, perhaps impossible, to fill and may indeed interfere with
accomplishing family life cycle tasks. In an attempt to compensate for this gap,
both families independently added a superfluous role to their systems, that of
the ghost. This role's primary function was to disqualify the new marital
partner's role, rendering him or her impotent in the face of current life tasks.
For the children, also, it was a constant reminder of the need to fill the
gap�because a ghost is not a real parent.
To some extent, one sees these dynamics perpetuated in most second marriages,
when a new marital partner is brought in only as a substitute for the ex-partner
but is also seen as qualified to provide his or her own contributions to the
system. This game of partner-substitution, however, has some retroactive
functions as well. It disqualifies and qualifies the ex-partner's role
simultaneously. When all is added up, we find ourselves with a family system
that works toward minimal change over a maximum amount of time. The struggle to
preserve sameness at the expense of innovations within times of change is
perhaps comparable to a ship's crew that continues to practice sailing out of
the water.
Despite the various contextual differences in the lives of these families, they
both resisted�at different points in the process of treatment�the therapist's
touching the wound (1). They argued that mourning was not called for at such a
late date or for "such a mother who wasn't really mothering" (Family A), or
"after so much suffering"(Family B), etc. They would rather have us help them
get on with current tasks, than unravel a traumatic past that left some lacunae
in their life experience. At most, they were prepared to have us treat the
identified patient alone. They were especially concerned not to disturb the
newly acquired marital relationship. The turning point in the treatment of both
families occurred when the parents realized the deadlock, so to speak, in their
marital relations. The harder they tried to redefine a new beginning for the
family, the more the system sank into entropy. Stated another way, new
beginnings were confused with past endings, and death was confused with living.
There is indeed a fine line between supporting new initiatives in clients' lives
and helping resolve painful problems. Although this principle applies to all
forms of therapy, in family therapy two essential variables must be considered.
One is the length of time between sessions. As the Milan team observed,
interventions that affect a change in one member of the family require a certain
time span before change reactions of other members become evident. "Case by
case, session by session, it is the task of the team to decide upon the length
of the interval, which may vary anywhere from two weeks to several months" (38,
p.15). In these two cases, the average interval was about one month, although at
different points in the process the intervals varied greatly, from three months
to one week. The rationale for these decisions rested on monitoring both the
innovative and the conservative forces of the systems. It was assumed that these
family systems had their own mobilizing forces enabling them to institute marked
changes in their lives. Similarly for the conservative forces. My role was to
coordinate my input into each system with its own output.
The second variable relates to the first�children best express the family
system's tendencies for change and growth. Leaving the children out of the
treatment sessions, therefore, perhaps contributed most to the parents' ability
to deal with their own mourning of past marriages. On the other hand, focusing
on the children's problems during these marital sessions served to encourage
innovation and growth. These parents were capable of helping their children by
themselves. Hence the interplay between probing and support.
Summary
In Hertz's words:
Societal, familial, and intrapsychic processes all operate to promote the
isolation of dying. Our society, in keeping
with its massive denial of death, has created 'death specialists' for dealing
with all aspects of the dying. ... With all of
these individuals handling death, the family has gotten increasingly distant
from the dying person. [16, p.223]
This paper critically reviewed the individualistic approach to mourning and
death, contrasting this approach with systemic presentations of family problems
and treatment. The two cases that were presented portrayed the
interrelationships between reactions to death and beginning a new life within a
family constellation. Individuals' resolve to avoid grief and deny death had
negative implications for the whole family and arrested its growth. Based on
these assumptions, family therapy was the treatment of choice and proved
effective in both cases.
Given that these results were of an exploratory nature, perhaps future work with
similar family problems could be more carefully monitored. Certainly, further
research in this area would serve to refocus the mourning process back on to the
family and perhaps on to the wider sociocultural support systems.
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Fam Proc 22:501-516, 1983
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