6. Chronicity, Grief, and Loss - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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6. Chronicity, Grief, and Loss

Therapist Resources > Therapy Books > Opening the Can of Worms-Cple

Opening the Can of Worms, Complications in Couples and Couple Therapy
by Ronald Mah

The diagnosis of bipolar illness or any chronic illness is a significant life crisis for the family.  More often than not the family and the patient are unprepared for the physical and mental changes, the uncertain periods of crisis alternating with periods of stability, the financial cost, and the uncertainty of the future.  Interpersonal relationships become unstable and confusing.  Adjusting to the demands of bipolar illness on the family takes time, energy and infinite patience (Hyde, 2001, page 110).  Some individuals may be able to lower their emotional reactivity through a variety of processes including psychotherapy, meditation, spiritual change, physical activities, and so on.  However, many other individuals may remain sensitized to various triggers and vulnerable to intense emotional responses, while being relatively successful in managing their behavioral responses.  For individuals with bipolar disorder, PTSD, and personality disorders, behavioral functionality may improve despite inability or limited ability to lower expressed emotion.  Behavioral improvement should lead to relationship and other improved functioning.  This occurs with the acquisition of better coping skills, redefinition of relationships, knowledge and awareness of the challenges, information about the growth/change process, and acceptance and integration of productive interventions.  Support may include the use of other professionals and services and participation in appropriate family and community gatherings and interactions.  However, since these positive changes are not previously comfortable or normal for the challenged individual and the partner or family members, they often are emotionally, mentally and physically draining.  Experimenting, developing, and then maintaining these new responses and processes can be exhausting.  The therapist needs to warn and prepare the couple to stay sensitive and vigilant about recurrent fluctuations in the stability and growth of the relationship.

Even when the issues may be well addressed and the relationship stabilized, the individual and partner may also go through complicated grief and loss processes.  "Mental and physical functioning, loss of dreams, loss of one's identity and roles, and the loss of control of one's body due to side effects of medications all confront the patient and the family.  Grief work is important and takes time and energy to process.  The family and the patient experience a complicated mourning that can become what is known as 'chronic sorrow'  There is a terror to the process that can dominate and overwhelm both the patient and family" (Hyde, 2001, page 110).  The individual, couple, and family may need to accept they are not the same as others in being somehow "normal."  "These redefinitions of family and patient can lead to health and reasonable functioning or they may lead to isolation and fear of rejection."  Loss and grief may have been a part of the couple's relationship for a long time.  The loss and grief is not only acute or isolated to a specific outbreak, but chronic loss and grief from enduring emotional and relationship distress.  While Cole and Molly initiated couple therapy after a heated argument, they had lost or been gradually losing for years the "happily ever after" romantic marriage dream.  The acute feelings of loss they experienced in the midst of the latest battle merely threatened to confirm the chronic loss of intimacy suffered over years.  With problems arising in the relationship, loss of hope, expectations, dreams, and other couple's ideals along with functional losses such as income, independence, and access may have created grieving processes.  The partners suffer from not understanding or being confused about what has disrupted the explicit and implicit relationship or marital contract.  They intuitively feel the breach of the "happily ever after" contract, but may be unaware of their grieving process.  The therapist needs to assess for accumulated and ongoing loss and grief for one or both partners.

There are differences in grief processes that are important for the therapist to assess for.  Anticipatory grief comes from anxiety about the unknown and what everything may be about.  With this last fight and therapy as a last hope, Molly may be anticipating a final dagger in the heart of the relationship.  Individuals' vivid imagination can cause such significant distress, that partners may feel relief to get a diagnosis or authoritative interpretation from the therapist.  The urgency of anticipation provides an opportunity to emphasize the critical need for an accurate diagnosis and description of the developmental and predictable course of a challenge or disorder.  Acute grief occurs when the individual or couple experiences a clear onset of an issue or challenge.  Depending on needs and circumstances, professional intervention or help with medical treatment, legal advice, financial assistance, or security may be initiated along with acute grief to protect and stabilize oneself and the couple or family.  Painful and conflicting feelings including resentment and shame may surface with acute grief.  "Chronic grief is reflected in the never-ending battle to address the bipolar illness.  Grief about the loss of relationships, employment, lifetime of compliance with medication and reliance on many other rituals of survival remind the patient and family of the nature of this illness.  Finally, many patients and families experience complicated grief.  Because of the difficulty of dealing with a complex mental disorder, grief is often exacerbated by the nature of the illness.  Personality traits of the patient and the family members confuse the clinical picture.  Grief is accumulated and compounds the treatment process"(Hyde, 2001, page 116).

The therapist may find that a partner such as Cole is in chronic grief without being fully conscious of it.  Personal and cultural models to be stoic and to minimize intimacy may have caused Cole to deny or hide his loss.  His loss may be personal but may also be about Molly as his wife.  Much of grief may have to do with the loss of the image of the person one holds the partner to be.  Subsequently, there is also a loss of the couple one is supposed to be in.  In addition, there is also the loss of whoever one is supposed to be from being not in the relationship one has thought one had chosen.  As a result, all losses are personally based.  As discussed earlier, it may be effective for the therapist to separate the person of the partner from the illness or issue.  Cole for example, if he holds Molly and Molly's emotional reactivity as the same, then his frustration and anger increases from seeing her emotionally charged words ("ranting") and "hot and cold" behavior as Molly being a "ranter" and an "volatile crazy woman."  On the other side, Molly sees Cole and his difficulty being emotionally connected as "cold disconnected Cole."  The therapist can conceptualize and model addressing bipolar disorder, the PTSD, addiction, or the personality disorder as distinguished from the person of the partner.  As a result, the disorder, challenge, issue, or set of behaviors becomes the enemy identified as the object of animosity and the target for removal or management.  This helps free the partner from being the adversary.  Rather than ranting volatile Molly or emotionally disconnected Cole being each other's enemy, Molly struggles against his emotional disconnection while Cole deals with her emotional reactivity.  In fact, the challenged partner and the other partner can join in alliances against their respective "problems."  This may help mitigate against the sense of losing the partner one thought he or she had.  Looking through and beneath the negative behavior, the partners may find the ones they originally were attracted to.  Cole and Molly can join together to work against the disconnection and reactivity that harm them- that threatens their mutually valued relationship.

Susan McDaniel and her colleagues suggest the therapist adopt the following attitudes toward chronic illness:

a) respect defenses, remove blame and accept unacceptable feelings;
b) maintain communication;
c) reinforce family identity;
d) elicit the family illness history and meaning;
e) provide psychoeducation and support;
f) increase the family's sense of agency; and
g) maintain an empathic presence with the family.

These attitudes reflect a hopeful and respectful stance on the part of the therapist (Hyde, 2001, page 117).  Several of these recommendations further serve to distinguish the disorder from the person.  Problem behaviors become identified as necessary defensive attempts to manage and survive extraordinary stress and deep issues.  Since they cannot normally be eliminated, they can however, once accepted as permanent parts of individual and couple's psyches to be managed.  Cole's emotional disconnect may be identified as evolving from his adaptation to his insecure attachment with his emotionally stunted father.  Cole had a formative loss of intimacy with his father in childhood.  Molly's emotional reactivity may be seen as responsive to unfettered emotional drama from a chaotic childhood.  Molly still grieves her long lost childhood sanctuary.  While the defenses may be problematic within the couple's relationship, they originally served in childhood to prevent even greater disruption and destruction emotionally, psychologically, or spiritually.  The therapist helps the couple accept their historical habitual attempts as essential to earlier survival.  They also need to accept that they are relatively stuck with their emotional, psychological, and spiritual needs and desires.  Of course, Cole should desire intimacy.  Of course, Molly is triggered by fears of emotional instability.  These needs and desires are a part of them.  This is critical for getting away from blame and shame.  Assigning blame implies the partner makes willing choices that dismisses or disregards moral boundaries.  Failure to resist problematic feelings and behaviors is deemed unacceptable and out of sync with simple expectations.  Individuals often blame themselves for their emotional volatility and impulsive behaviors acquired for psychic survival during childhood or from times of great vulnerability.  In adult relationships, self-blame/shame often is amplified with anger and blame from the partner.  The therapist needs to lead the partners in examining the family illness and other history, including family-of-origin can through a psychoeducational process to identify relevant compelling forces and triggers.  Realization that immature choices were compelled frees adults to make new functional choices.  Cole and Molly need to see that their respective choices are not as volitional as they thought.  They are chronic responses to long-term grief and loss.  The process of this therapeutic exploration also coordinate with McDaniel's other recommendations as they enhance deeper communication, facilitates mutual empathy, and empowers the couple to make change.

3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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