Complicated Grief: A therapist question about the loss of a client’s daughter, possible suicide

Dear Dr. Neimeyer,

I have been working intermittently for many years with a woman named Pam who was divorced when her adult children were adolescents, as a result of the father’s unpredictable and violent behavior and alcoholism. Likewise, two of her four children have had long histories of drug and alcohol use, despite her funding their efforts at recovery in several treatment programs. Pam herself reports drinking a “glass or two” of wine each evening, but this seems not to have interfered with either her work as a manager or her volunteer activities in helping disadvantaged children from chaotic homes, an activity that seems to have special meaning her her because of the chaos of her marriage.

Two months ago, however, tragedy struck, when her oldest daughter, Lucy, died from apparent kidney failure as a result of her long history of anorexia and a bout of heavy drinking when she was attending a friend’s wedding in another state. Unsurprisingly, Pam plunged into a guilty and abject grief, which I believe is complicated by her codependent, symbiotic relationship with her daughter for a lifetime. Pam believes her daughter’s death was an accident, but Lucy also had made a serious suicide attempt some years before, and at this point the family is awaiting the autopsy report.

Here is my question. Although I am accompanying her as I would another bereaved parent, aware that the process of reconstructing her life will be a slow and arduous one, it seems that there may be other considerations of which I should be aware due to the elements of addiction and the extreme degree of symbiosis that characterized the relationship. Do you have some thoughts I might consider as I accompany her?

A few final comments: I have worked closely with her psychiatrist, and we have connected her with other bereaved parents whose children have similarly died. She is open to the suggestion of creating some structure to “contain her grief”, which she has found helpful…but has some days filled only with tears, which is understandable. She returned to work for a few days this week, and found that helpful. And she is going to volunteer to work with some young girls in a local school with her expressed hope that this would give her a sense of purpose. As I write this, Bob, I’m aware there may be little else to do other than accompany her in these ways, but I have continued to feel uncertain, that I may need to understand better the huge significance of her loss through a different lens. But then again, she has never been open to my invitations to differentiate from her children, so maybe she will move through her grief just as she has moved through her life, as so many do; so supporting her is all I may be able to do.

I would appreciate just a brief response, and of course, no rush at all. Thank you so much.

Lisa

Dear Lisa,

First, thanks for relating Pam’s history, loss and current conundrum with such care. Just as you imply, complicated histories can predispose people toward complicated grief, except when they don’t. That is, it is often helpful to entertain two possibilities in relation to our most complex clients, two hypotheses that are (intentionally) in some contradiction to one another. The first might be that who people are will shape how they grieve, with the corollary that who they are is a function of the relational patterns they have lived out across a lifetime. Clearly, this would lead us to be concerned with Peg’s likelihood that she will struggle with a symbiotic relationship with Lucy in death as she did in life, marked by long-term guilt, inability to “move on,” preoccupation with the unfinished business of their relationship and the circumstances of her daughter’s life, etc. This is the classic territory of complicated grief, with the bond made more sticky by the long previous history they had as mother and daughter, the death of the latter serving as the final proof of the mother’s “failure.” Of course, a fair amount of this would be expected in this case in any circumstance, but the question would be whether you would observe any movement across the months toward to lightening of this load, the establishment of self-compassion, and so on. An essentially unchanging pattern or worsening one across time would reinforce this concern.

The second hypothesis might be that Pam’s grief for her daughter, while painful, might actually turn out to be adaptive, and the one things she could do “successfully” for her daughter, without the daughter’s own addiction undoing it. In this possible scenario Pam might be able to mourn, memorialize and metabolize the loss, meaning to take it in in an adaptive way. This might look across the months like a capacity to experience brief, but gradually lengthening periods of purpose or even pleasure, to remember her daughter fondly without collapsing over into rage or guilt, etc. Of course this would not likely emerge quickly, but the trend line should become apparent over time.

But what to do clinically? Basically, I would do just what you are doing, providing support for appropriate expressions of loss with others (including the therapist), but also help her “make sense” of her life with Lucy and its implications in some adaptive way. For example, the latter might entail serious periodic engagement with questions like, “What lessons might be found in your life with Lucy for how you might adaptively mourn her now?” “What might be the patterns to watch out for?” “What were Lucy’s brightest moments, and how can you help keep memories of these times alive?” “When did you feel most loving and effective with her as a mother, and how might you extend these forms of relating to her in life to how you might relate to her memory in death?” “What of a constructive sort did the complicated history with Lucy teach you about how to help other struggling young people now and in the future?” In other words, winnowing some lessons from this life and loss and implementing them concretely as she moves forward might make a critical contribution to the goal of helping Pam consolidate the second of the possible futures outlined above, rather than the first. There are many specific tools that could assist with this, many of which are described and illustrated in the Techniques of Grief Therapy volumes referenced on my website, and perhaps already on your bookshelves or in your own clinical toolbox. Another book entitled Working with the Bereaved by Simon Rubin and his colleagues might also be useful in this regard.

I hope these thoughts are helpful, Lisa, as you continue this important work.

–Dr. Neimeyer

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