Grief and the Attitude of Gratitude

With one of my very long-term patients, I’ve set a termination date; it’s still a year off but has already brought up a lot of new feelings and issues regarding the end of her treatment, grief and gratitude foremost among them.  With Thanksgiving upon us, I thought now might be a good time to discuss those feelings.

I began seeing this woman (I’ll call her Diane) many years ago when she was in her late teens. She sought treatment because of a recurrent auditory hallucination (buzzing in her ears), visual hallucinations of spiders and other small objects in her peripheral vision, extreme insomnia,  symptoms of depression that verged on immobility, drug abuse, and a compulsion to cut herself with razor blades.  In short, she was in enormous pain and constantly on the verge of psychological chaos.  In our early sessions together, she was very difficult to reach.  She often came in and did headstands on my couch.  She would put on accents and pretend to be different characters; she was very good at it, quite funny, and used her humor to keep both of us at a distance from her pain.

And yet, I got her.  Every therapist knows this fact:  you resonate with some clients better than others; I had a deep and immediate link with Diane. From our very first session, I intuitively understood what she was feeling behind the jokes and impersonations; I talked about those emotions in ways that made her feel understood. At the same time, she had an uncanny intuition about me, too; she often made very perceptive observations as to my mood and state of mind.  We “clicked”, as you might say, from Day One. Years later, she told me I was only the therapist she’d consulted who didn’t seem afraid of her and didn’t bring up medication, which always felt as if the therapist were saying he couldn’t tolerate the depth of her emotional difficulties.

She was one of the most difficult patients I’ve ever worked with, not only because she was so disturbed but also because she was extremely angry and hostile.  My job in those early years was to contain a lot of that hatred, to give back understanding rather than hostility.  She trusted me enough to wait for me to grow:  it took me years to evolve out of the theories I’d learned in school into a deeper understanding of disintegration issues and basic shame.

She’s now married with children and a successful career.  When I look back on my own career, I’m most proud of my work with Diane and a few other patients like her. She has often told me that, if it hadn’t been for our work together, she’d probably be a psychotic mess today like her brother, or more likely dead as a result of self-destructive behavior. We both feel our work together has been a great success.

Even so, whenever she refuses to respect her limits, if she continues striving to be Ideal Diane, she can slip into states of disintegration that may take days to recover from.  She no longer uses illegal drugs, doesn’t cut herself or have hallucinations; but unless she exercises care for her state of mind during the day, silencing the music and mental chatter, she’ll have trouble sleeping. She no longer worries about collapse, but she’s still an anxious person.  She can become grandiose in public situations if she’s not on guard, indulging in some kind of narcissistic behavior that will make her feel humiliated afterward. Basic shame is a fact of life.

In our most recent session, we talked about her sadness that our work was drawing to a close. The impending end of 2010 had brought home the fact that 2011 would be our last year together.  It would be a huge loss, she told me, no longer to have our sessions.  We talked about her grieving process in that regard, but also about mourning the person she would never become:  Ideal Diane was unattainable, of course, but she wouldn’t ever resemble a “normal” person, either, one who might have come from a “good-enough” family background.  There are limits to what psychotherapy can accomplish, even one that lasts a very long time and feels deeply meaningful to both client  and therapist.  Diane knows she’ll carry the scars of her childhood for life.

At the same time, she felt deeply grateful to me for what we’d done together. Grateful that I’d stuck with her all those years and tolerated her hatred.  Grateful that I hadn’t terminated her much earlier because she was so difficult.  I had literally saved her life, she said.  We both felt deeply moved by the session; I felt what a loss it would be for me, as well, no longer to have our sessions.  You don’t get many opportunities in life to know someone as profoundly as I know Diane.  I’ve spent more “quality” time with her than I have with most people, and been more emotionally intimate with her in a very real sense than I have with all but my closest friends and relations.  I feel grateful to Diane, too.

Finding Your Own Way:

The ability to feel profound grief and gratitude, I believe, are the hallmarks of mental health.  I reject all those self-books that teach you 100 ways to achieve happiness, or how to “conquer” this or that affliction.  Can you grieve for the damage that you’ll never completely transcend but at the same time feel grateful for the actual good in your life?

Not for the first and probably not for the last time, I’ll bring up It’s a Wonderful Life.  As always, I’ll be watching it during the holiday season and I recommend that you watch it, too.  It’s a moving study in grief and gratitude.  When George stands weeping with his family as the townspeople of Bedford Falls file through his front door, bringing money to save him from prison, those are tears of gratitude in his eyes — there is so much goodness in his life! — but it’s not a happily-ever-after kind of ending.  For me, at least, it’s bittersweet, with a mixture of feelings. George never does get to travel the world and have adventures, as he’s always longed to do.  He’ll always grieve for what he’s missed, always regret what he’ll never have the chance to do.  He’ll also love and feel deeply grateful to his wife, family and friends. One doesn’t erase the other.

That’s as good as it ever gets for anyone.  Over this Thanksgiving holiday, appreciate what’s good about your life, as so many people try to do at this time of year.  Give thanks where it’s due.  But also mourn for what can never be.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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10 comments

    Great therapists can help people to change their lives, to accept who they are and to mourn for who they will never be and to come to terms with the yearning for that which they had longed for but never received. It sounds like Diane was a lucky lady. I enjoyed reading your post. It reminded me of my own therapist. Life changing.

    Thanks, Christine. To have had a great therapist who helped you truly to grow and develop is a wonderful thing. Rare, in my experience.

    i just recently lost my therapist two days before thanksgiving. she didn’t die but will be counseling children in the same agency in another nearby location. within two weeks of her announcing to me that she would no longer be my therapist we had one session the next day and two weeks later we had our last session together. i am no longer allowed to have any contact with her. during our therapy together i would send her emails & call her on the phone. there were no limitations but i also respect boundaries. i felt for some time before she even knew it that she would be leaving me. her new job came on suddenly. we developed a very close & intimate therapeutic relationship which started back in 2008 just shortly after i returned to a women’s therapy group in which i had been absent from due to a battle with cancer. she started co-facilitating the group the same time as my return. there was an immediate connection. i was seeing the group leader as my therapist until that just wasn’t working any longer. he wouldn’t let me end therapy with him without a final session. this new therapist volunteered to oversee a private session with the three of us. i wanted her there to protect me from him. i had so much rage. when she volunteered she also said that she would very much like to be my new therapist. i was overjoyed. we did some very intense work together & was under the impression that our therapy would continue for an endless amount of time. to have it so abruptly end has been devastating. the amount of pain & grief i feel is overwhelming. i start seeing another therapist twice a week beginning this week but no one can replace “her”…i finally found someone i learned to trust & was beginning to express my emotions to. we had great sessions together. she frustrated the hell out of me. she pushed me forward. she made me feel i could do anything i set my mind..heart & soul on. how does one get past this grief? i write..i write..i write..i know my new therapist but she can not replace “her” & i do not want her to. this is all so maddening. namaste!

    The grief will surely take a while to get through. You’re right, your new therapist can’t replace the old one you trusted, but maybe over time you’ll develop a sense of trust in the new one. I’m sorry you’re having such a rough time, Marge.

    I too am really pleased to have “met” you on Twitter which has led me here.. I think this is one of the most authentic essays on the profound human relationship between a client and their therapist, and really brings home how it is a two way street..
    And I totally agree with your observation that the ability to grieve for what we will never have, and be grateful for all we do is a maker of mental health… as I think back over my own clients through the years it was often the inability to do this which brought them to me, and the ability to which signalled the end of our relationship.. thank you for making me aware of that!

    One of the great joys of writing this blog has been connecting not only with people who relate to what I’m saying, but with other therapists, too, who find that the ways I think and work resonate with their own ways. Thanks, Liz.

    I absolutely LOVE “It’s a Wonderful Life”:) I agree, we must learn to embrace the lessons from our pain (and that’s a large spectrum to work with) and learn to walk with them in a healthy manner. Great post!

    Thanks a lot, Joseph. I’m now going to actually watch It’s a Wonderful Life for the first time in my life.
    Meanwhile, in the last 2 days, reading your site and your kind responses and also thinking about all that I’ve read made me thinking about something: what if the very attitude of “big changes aren’t possible,” “you can only change that much,” “don’t expect to be a really different person” actually impedes your actual change potential?
    Don’t get me wrong: I see a lot of wisdom in the stories that you bring. I really feel it must be true. Other psychotherapists who are also your readers and post here tend to agree with you as well. And it’s probably for the first time in my life that I can actually hear and read what mental health professionals have to say about what kind of change you could reasonably expect. Add to this Martin Seligman’s apparently empirically based What You Can Change and What You Can’t, which I read recently, and which suggests that at the very best you can only expect mid/moderate relief from most of your psychological problems and only marginal relief from some of them.
    On the other hand, I can’t help but seeing on my mental computer screen numerous other statements that state that you indeed can learn to be very much comfortable in your own skin; love and accept yourself as you are, unconditionally (!); be comfortable with who you are; having a silent mind; let go of the image of perfection, the perfect you, that you have in your mind; accept and love others unconditionally, and so on. Yes, many of these statements incorporate some spiritual attitudes and practices like meditation, prayer, gratitude, seeing yourself as part of the whole, not separate from other human beings, and so on. And for the most part, they aren’t stated by mental health professionals. But some of those people claim that they have indeed reached such a profound change. Add to this just another article that I’ve recently found here (Thanks!), “Willpower—It’s in Your Head”, which basically shows that your own mindsets about willpower determine how much of it you will actually be able to exert.
    And so I’ve been kind of questioning all that subject recently. On one hand, knowing that I will probably not be able to change as much as I want has already brought me a feeling of great great relief. I’ve actually become more inclined to work more on accepting and dealing with what I’ve got than to keep hoping to be someone very different one day. It also kind of goes hand in hand with the spiritual attitude of abandoning any hope for fruition, i.e., making peace with who you are now and with your today’s life situation first before you can embrace any kind of change. On the other hand, what’s the right balance? Isn’t there the danger of actually believing too little in the possibility of change, of having too low expectations? Is it possible that spiritual practices bring something that psychotherapy doesn’t? Why would some apparently trustworthy people claim they have undergone such profound changes? Are they basically liars?
    I don’t expect some profound and elaborate answer on this. Just your two cents as a well-experienced therapist and some words of wisdom, maybe your outlook on some of the specific questions that I’ve asked. It seems to me that this might be important to talk a bit about it as it is such a recurrent theme on your website.
    Thanks!

    To me, it’s not so complicated. Put aside the global issue of what’s possible and focus on what you can do right now. To me, genuine change and growth are all about the choices we make every day, right now — do we “go with” our defenses, or do we try to face the more painful truth, accept our limits, opt for what’s possible rather than the ideal? It’s what I try to do and I’m still growing. I’ll never be Ideal Joe, but then, it’s always getting a little better, bit by bit.

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