Working with pathological grief

“My patient’s mother passed away last month after a prolonged illness which had consumed his life for the past 5 years. His father, severely mentally ill, abused and raped the mother until she ran away with her children. The patient has been consumed all his life with his mother’s suffering, wanting to understand it. After his mother’s death, he became manic, couldn’t sleep, and talked nonstop, and so he entered therapy. He reports feeling trapped in a cage, wanting to break free, so he ended his brief troubled marriage. He believes he has suppressed his real self, and was always asked to suppress his anger by his mother.
At first in our work, he cried over his mother’s death, claiming she had been his best friend. Now he is moving out of his mother’s home. And he has come late to all of his recent sessions.
When I ask about his sadness he says he feels relief because the last months were bad for her. Since he put his life on hold the past five years for her, he says, he feels relieved that he is free of this responsibility. While his sense of feeling free must be legitimate, I felt he was warding off his sadness. He also talks over me. How is grief when there is prolonged illness, and how should I intervene?” Excellent questions! 
In a case like this of complicated grief, the patient struggles not just with grief, but relief, guilt over the relief, and anger toward a mother who abandoned him, and love. What a mix!
You believe he needs to feel his grief. I have a hypothesis that he has to face a lot of different feelings. You encourage him to feel his grief. In response, he comes later and later to your sessions. Perhaps he is becoming angry with you. Who knows? We can’t without exploration. So let’s look at some ways to explore his resistance.
When he comes late, I might say, “I notice you were late today. That’s often a response to how you are feeling about the therapy. What feelings are you having about the therapy and how it is going?” As he becomes more comfortable describing his feelings “about the therapy”, you can then ask about feelings he is having toward you. Perhaps describing his “irritation” with you will improve the alliance and improve his attendance. Take home point: any time a patient comes late or misses a session, explore feelings about the therapy. These forms of acting out are ways to avoid mixed feelings toward the therapist. If we don’t explore those feelings quickly, the patient may terminate prematurely.
Next, how do we focus? Wherever he starts. 
If he is reluctant to look at his grief, ask him what feelings he would like you to help him with. If he says he had to suppress his anger because his mother asked him to, ask, “Would you like to explore those feelings of anger now so you wouldn’t have to be depressed?” Notice we don’t start exploring the anger. We start by asking if he WANTS to explore those feelings. Since he is coming late, we are dealing with resistance. So if we ask if he WANTS to explore, we will find out about his resistance and get it out into the open where we can begin to explore and understand it.
If he says he feels relief over his mother’s death, ask him to tell you about his relief, what his relief tells him, what is he learning about himself from this experience of relief, what does this relief tell him about his feelings over caring for his mother? If the relief is part of complex feelings, anxiety will rise. Then you can ask, “I wonder what other feelings are coming up that make you anxious.”
If no anxiety rises, his relief will be a split off feeling, indicating that splitting is in operation—not an unlikely possibility with a man who just had a manic episode! Let’s suppose you have explored his “relief” and no anxiety arises, then you ask, “It sounds like you are pleased with this relief and it doesn’t seem to be a problem for you. So I wonder what problem you would like me to help you with.”
When he talks over you, note that this is often a sign of anxiety and ask if he is feeling anxious. Or you might ask, “I notice you were talking over me, was there a reaction you were having to what I said?” Always interrupt the racing speech. It is a way to talk over feelings rising within him. Since he recently had a manic episode, most likely, the talking over you is an indication of a very low capacity to tolerate mixed feelings. Thus, the graded format may very well be necessary.
Now for the manic episode. I know today that manic episodes are often understood purely as medical events. However, we often find that manic episodes are a defense against grief and loss. In this case, since the manic episode was triggered by his mother’s death, we should at least hold that hypothesis in mind. If this hypothesis is correct, the patient is severely fragile. When the mixed feelings toward mother rise, his anxiety will move quickly into cognitive/perceptual disruption. He may be able to use higher level defenses initially, but as feelings and anxiety rise, his defenses will shift to rapid speech, thought disorder (rapid shifting of topics), splitting, projection, projective identification, and manic denial.
This, if he turns out to be severely fragile, explore feelings very gradually and just build his capacity. Do not even think of going to unlockings with this patient. Just build his capacity to recognize and cognize about his feelings. For instance, when he says that he feels only relief, this is splitting. So remind him of his mixed feelings and see if you can increase his ability to tolerate and intellectualize about them: “I’m sure you do feel relief, since caring for her was so difficult. At the same time you feel relief, you must also feel some sadness. After all, you really loved her too. I wonder what that is like to notice this relief, sadness, and love for her at the same time?” As his feeling tolerance grows, his anxiety will shift into the striated muscles, and his defenses will shift into isolation of affect.
But, given his manic episode, I would approach him as a fragile patient and explore gradually to find out what levels of feeling and anxiety he can actually tolerate. Then we will know what level of feeling to work at so we can build his capacity.






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