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The Mystery “Talking Cure” For Grief: a brief history

As soon as anyone concentrates his attention to a certain degree, he begins to select from the material before him; one point will be fixed in his mind with particular clearness and some other will be correspondingly disregarded, and in making this selection, he will be following his expectations and inclinations. This, however, is precisely what must not be done. In making the selection, if he follows his expectations he is in danger of never finding anything but what he already knows.”  - Freud (1912b/ 1928, p. 112)

Cicely Mary Strode Saunders was born in Barnet, Hertfordshire, in 1918, the eldest of three children, in a well-off but unhappy family. Her demanding father was an estate agent, and they lived in some comfort in a large house with lawns and tennis courts. Her mother was cold and withdrawn. Like Kubler-Ross, her father disapproved of her desire to be a nurse, and so instead she went to St Anne’s College, Oxford, where she read politics, philosophy, and economics, intending to become a secretary to an MP. After the Second World War outbreak she abandoned her course and defied her parents’ advice, enrolling as a student nurse at St Thomas’ Hospital in 1944, where she was recognized as gifted. A year later, during her work as an almoner, at Archway Hospital, she cared for a dying 40 year old Polish Jewish immigrant named David Tasma. 

David felt that his life had been wasted. He had no relatives in England and only a handful of friends. In a brief and intense relationship, they discussed the idea that she might find a home for dying people to find peace in their final days. He left her £500, then a substantial sum, and the wish of "can I be a window in your home?" A window is now dedicated to him at St. Christopher’s; it is plain and has a view of the car park.”

Dame Cecily Saunders, the founder of the hospice movement writes in a 1966 paper, The Care of the Dying, “a patient being admitted to St Joseph’s used the phrase: ‘It was all pain’ and this ‘” total pain”’ calls us to analyze, to assess and to anticipate’ the whole life and experience of death. The evolution of hospice care has been extraordinary since these early days; however, it remains committed to helping people cope with dying and navigate the pain of loss. 

What kinds of pain? She writes, 

“total pain is the physical symptoms, mental distress, social problems, and emotional difficulties. It also reflects a willingness to acknowledge the patient's spiritual suffering and see this as a physical problem. Crucially, it was tied to a sense of narrative and biography, emphasizing the importance of listening to the patient’s story and understanding the experience of suffering in a rounded way.” 

So what Cecily was saying is that when we see someone in pain, we may not see the total story. We may not understand where the pain is coming from. When I think of a person's grief story, I naturally think of the endings that person might have experienced but locating the pain there might not be the total story. What if we don’t just grieve endings but also beginnings - meaning, we can grieve how life may not seem to start over after loss, rather, the same pain keeps mysteriously repeating over and over again. 

THE MYSTERY CURE FOR MELANCHOLIA

Come along with me to solve a mystery - the mystery cure for complicated grief. Meet a family with authority, trusted theory thieves. They have left behind curious clues to find and we need not travel far. Just look inside right where you are, the clue is the letter ‘r’.     

This story about grief is told through the lens of a family. In a way, it is the modern grief family and we will begin our story with their most famous daughter. 

Against her father's wishes, Elizabeth Kubler-Ross became a doctor and not a secretary. She worked as a medical professional in the military and then left Switzerland to work in America as a professor in the Psychiatry department at the University of Colorado. Seeing how the medical profession had become inhumane and less bonded with their patients, she decided to teach her students a real lesson. She invited terminally ill patients to come to her class and be interviewed by her medical students. She made the point that the sufferer had as much to teach as they had to learn, and as you can imagine, this changed the conversation about grief. Let’s not skip over this. End-of-life care such as Skilled Nursing, Palliative Care, Critical Care departments, and hospice care providers are indebted to this work of patient-centered care. It is hard to imagine our world of patient autonomy without Dr. Ross’ work. She gave the dying a voice in their treatment that had not been given before. 

As a result of this pioneering research, she wrote her seminal work On Death and Dying where she presented 5 stages of grief: Denial, Anger, Depression, Bargaining, and Acceptance. These stages have become a global model for grieving. Now in the therapist's office, her model was being tested for its real results. When some read the stages of grief, they felt that if they passed through the stages into acceptance they would feel better and move on, but for many grievers - that is not what happened. Mourners got stuck in their grief. Like a dying person stuck in their bed, grief can feel restraining instead of releasing and it can illuminate patterns that have formed in our life. 

For my daughter, I mean, Doctor Ross, depression was part of the normal grief process. The depression stage in grief doesn’t start as a clinical illness but it manifests as a deep sorrow, however, when a depressive position is resisted, it splits off and becomes more complicated (persecutory) in our grieving. The resistance to death was not only externalized by anger, but it needed to be internalized into a stage of depression so that the fear of death could be faced and a new identity or sense of self could be created. This resoluteness in grief is captured in a poem by Rabindranath Tagore placed in the preface of Dr. Ross’ book: “Let me not pray to be sheltered from dangers but to be fearless in facing them. Let me beg not for the stilling of my pain but for the heart to conquer it.” 

There is a point when the dying person realizes he or she will not be rescued but rather must take on the courage to be, and conquer the fear which is to accept it by faith. This is an ancient paradox of accepting fear as a friend, rather than a foe. Authorities have used our fears for manipulation and coercion, most particularly religious authorities, but who knew there was a forgotten wisdom to allow fear to be a sacred spiritual guide? Fear can help the human heart identify their needs in grief which is to encounter a new form of love we have yet to encounter. Dr. Ross doesn’t talk too much about love. Most doctors don’t. But one of Dr. Ross’ patients mentions a loving encounter with a visitor,

“He was here the other day. Yes, he sent me a beautiful bouquet. But from him, I got my faith. It’s my faith now. And it’s faith, it isn’t a theory of someone else, meaning I don’t understand God’s way and many things that happen, but I believe that God is greater than I am, and when I look at the young people dying, and their parents, and everyone says what a waste and that, I can see. I say, ‘God is love,’ and I mean it now. It isn’t words, I mean it. And if he is in love, then he knows that this moment of this person’s life is their best moment.” (pg. 70)

For years Dr. Ross’ answer to becoming unstuck was to insist mourners participate in an act of faith which is to accept death and grief as a part of life so we can move on. Interestingly she later changed her message, perhaps because many of her colleagues did not like her stages and the assumption that grief took on a linear path towards getting over it. I mean, what if grief remains with us even if we aren’t consciously invested in its pain? Dr. Ross joined David Kessler to correct some myths about her stages in a book called On Grief and Grieving where she updated the stages to include guilt and shock (maybe her feelings when her book was so misunderstood) but she included in the afterword of the book: 

“the reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same nor would you want to.”(pg. 230) 

What does it mean to rebuild oneself ‘around’ a loss? Does our sense of self over our loss to hide it in some way? Does the loss become front and center and take over our identity? What does it mean to change in grief? If you love a good mystery to solve this is where the fun begins. We will rebuild the narrative by looking back to ancient history for the first letter ‘r’ in grief work. When we find the first ‘r’ we find where this mystery puzzle began to unfold. But let us pause for a moment and consider what may have happened at this point in the story or any story. You see once Doctor Ross constructed the stages she told a story about grief. Stories are dangerous things. It is very difficult to construct a story without splitting the narrative between a hero and villain, what is good or bad, even right or wrong. Grief plays by the same rules. If we are stuck in feeling the one we grieve is ‘all bad’ or ‘all good’ with no blend of human imperfections then we lose something within our experience of love.

The first ‘r’ repression was not discovered but integrated into therapy by the Father of the modern grief family- Dr. Sigmund Freud. It was a term used and expounded upon in the 1840s by Ludwig Feuerbach to describe how a society's internal conflicts can be repressed by religion. His particular critique was the Christian religion. Interestingly, Freud associated religious repression with the ‘father complex.” Father Freud writes after developing his method over many years, 

“psychoanalysis teaches us with quite special insistence that the god of each of them is formed in the likeness of his father, that his relation to God depends on his relation to his father in the flesh and oscillates and changes along with that relation, and that at bottom God is nothing other than an exalted father.” (1) 

This father complex ( also known as superego), or internal voice of ‘the law’ denies one pleasure and speaks of the limits of reality. I think it is important to acknowledge that Freud also repressed his religious belief because of unresolved conflict with his father along with an attempt to maintain scientific credibility. But a closer look into history shows us there were other really good reasons for Father Frued’s defenses and repression which we will take up later on in the book. It is also important to note that not all gods are Zeus-like fathers. It is also fair to say, some individuals have gods more like their mother. A god that promises a future reality that is a fulfillment of one's dreams which can make us whole and complete where we can get what we wish for. 

But if the family gives space for the Father to be disciplinarian, he is the one who denies the children free association and his moral voice is appropriately internalized.  But this demanding, unrelenting voice of the superego was not characterized as a moral voice, it was just a stronger voice that demanded authority. The Father’s ideal role for teaching in the home not only religious values but all matters of morality can become an attempt to control all manners of conflicts within the family instead of working them through.  

Dr. Freud insisted that his patients not filter their thoughts and feelings, rather, allowed them to let their thoughts and feelings speak through free association. But even if we fill up a session with all our words and stories something can still seem hidden. Like the epitaph on a tombstone that says, “Gone but Not Forgotten”, Father Freud noticed there was a phenomenon of “Forgotten but Not Gone” in the psyche which he called repression. Repression is a mechanism that allows the mind to consciously deny what it knows to be true because the patient is strangely inhibited or prohibited from freely associating with themselves. To put it plainly, the mind refuses to know what it knows about the trauma of life until a later experience ruptures our reality and pulls us backward to an earlier life memory.

When it comes to modern mental health, there is an emphasis on what is normal or maladaptive behavior or healthy or unhealthy emotional coping. For Dr. Frued, or as he will be referred to here, Father Freud, his concern was with what is real or unreal in the mind of the subject. This may sound unimportant, or even insensitive, but this split is the beginning of a new model of the mind. Notice he was not exploring what was real or not real in the subject but was exploring the ‘unreal’ or the fantasy structure in the mind that gets woven into our ideals where we miss something in real of life. In his theory, the trauma was often in accepting life as it is, when the mind can create a too-much-ness that must be integrated. An experience can be very good or very bad and how we experience this too-much-ness on either side is within our fantasy as a way to mark it in memory. Trauma is a Greek word for wound and in a subjective or emotional sense, the wound is quite invisible and thus it becomes unspeakable for the patient. In other words, the wound is repressed but can be seen by the third eye in the counseling office. 

The third eye Freud identified in the counseling office was the symptom. The symptom most identified with grief is often depression but Freud was interested in anxiety. Not to analyze grief, as it were, but an attempt to analyze what was lost  (or hiding) in the subject, which to him was an unintegrated memory. Anxiety also spoke of a too-much-ness in desire, which he called libido, and this anxiety is what makes grief sexy. The symptom always tells the truth when our words and even actions can hide the truth in some way. The symptom is speaking the unspeakable of the unconscious and comes most alive in our dreams. If you think about it, why are our dreams hiding truth from us? That’s right. We are in our bed at night watching these movies we have made in our head and we won’t even disclose the truth of what they mean to ourselves. What?!  

The symptom would be speaking the unspeakable in the patient’s grief and also would slip out in how something was heard/misheard or said/mis-spoke. He termed this parapraxis. The unconscious was also speaking through the characters in the stories told by the patient as they borrowed from the conflicts of others rather than facing their inner conflicts. The patient talking about these other things was talking about themselves but they were not aware of those associations. 

Another clue for the mystery cure for grief is in the symbolic structure of the counseling session itself. Dr. Freud used another ‘r’ word and created a technique called reality testing which was his exploring the conflict between what feels real and unreal to the subject and to unpack the trauma of human relationships. Because the patient could not see their projections - or put off their inner conflicts with others - Father Freud made projection visible by how he and the patient sat in the counseling office. Father Freud, and modern analysts, have patients lie down on a couch. This image has been depicted in movies and television for decades but the reason for this technique is rarely explained. Father Freud would sit at the head of the couch so that the patient would be looking in the same direction as the analyst - like they were both watching a movie together. 

Father Freud's choice of not looking face to face was more intimate in that the words meant so much more than the stories themselves. Not what words were used, but how they were used - even misused. Their words became a map of the meaning or signification of the symptom. Once Father Freud enters the world of the patient's words it becomes clear how the patient is attempting to speak the unspeakable by what words are said and omitted, and in particular words that are misspoken. This gentle listening to the wounds in their words is how the analysis can reconstruct the trauma and therefore can reconstruct reality through the reconstruction of one's relationship to a listening cure. We can get caught up on meaning or answers, which strokes the ego validating intelligence, alone. To me, the wound in our words of grief is less about our relationship to answers and more about our relationship to mystery and the non-answers in life. The meaning is most pungent in the ways the absence of meaning takes meaningful form. To cope with this absence we can be looking for a type of mother when our grief is looking for a mirror. This search for comfort strangely seems more like an unconscious search for conflict as loving support just can’t do enough to make us happy and feel nourished. The mourner can be protesting how they feel unseen and invisible, yet, when the caring person sees their life falling apart they refuse the mirror and demand a mother. 

In everyday life, it actually might be rare to see people face to face even when we are talking to their eyes. We look at someone and see what we want to see in them and make judgments instead of creating the space of their subjectivity to speak about their experience of their world and even their experience of us.  When we talk to another person we are projecting on them our needs and wishes through association. If they are a person of authority we try to read what they think or feel about us which interestingly gets linked or associated with other authority figures in our past. We can not control this because it is how our minds are structured when making meaning with words. 

This is also another key to the mystery cure for grief which is how Father Freud centralized the unconscious in counseling ensuring counseling remains compassionate. We are asking people to reconstruct their painful associations with the world which were likely taught to them by their parents (or lack thereof) and this is very precarious. A patient's defense to discovering these unconscious associations is sustained by a loyalty to love. Reality testing loss has a triangular effect. No matter what is lost by Freud’s patient - use of a hand, side of the face, death of a parent or child - the patient has a third person in mind, often the parent. This means the patient, the thing lost, and a third is always present in the counseling room and slowly the counselor begins to symbolize this third person. 

This notion that we can be unconsciously grieving for an audience creates meaningful associations to uncover how we suffer. Freud’s use of the Oedipus complex, which will be taken up later in the book, speaks of how our individual needs may be caught up in the flaws we perceive in our parents. As we come to terms with the humanity of our parents, the conflicts of grief are more associated and located within rather than in them. So we get it, the symptom is the third eye in the counseling office to show us the unconscious - blah, blah, blah. What about the mystery cure for grief and when does Father Freud tackle this idea of mourning?

Freud authored a paper in 1917 called Melancholia and Mourning where he addressed this very issue of what makes mourners stuck in their grief and this is when he introduced the idea of Melancholia in grief which is understood today as clinical manic depression. Mourning is a natural process of coming to terms with a loss in our world. Melancholia is when the loss is split off in the subject and internalized as a sense of lack. A bereaved person may speak of their loved one in idealistic terms as if the goodness in the relationship is only in the deceased and now the bereaved person must hold all the badness of the relationship keeping them stuck in a false sense of themselves. Modern ideas of reminiscing or continuing a bond with the deceased speaking only of the good of a relationship usually means the mourner remains in the imagination of love rather than working through the conflicts of love which can’t be addressed directly and need symbolic representation and thus the symptom of melancholia speaks this unspeakable story in modern mourning. And we wonder why grieving gets complicated and so many mourners feel depressed. 

Father Freud's psychoanalysis was less about helping his patients ‘let go’ of what was haunting them as if the pain was primarily linked to a regressive state from childhood and more about  ‘letting it out’ because something was speaking in the here and now of their life. Freud resisted naming the ‘it’ (known as the id - in German is literally ‘it’ - in classical ego psychology) as a deeper essence within us. Freud argued that the ‘it’ - perhaps the wound within - is often hiding in everything we do. He invited his patients to ‘let out’ (hypercathaxis) their free associations so that he could catch the subtleties of their language understanding the ‘it’ would slip through almost unnoticeably in what was wished for. Stories of loss are so linked with stories of love that we can not separate the two - even if what we have lost can feel so benign. Like losing our hair, keys, or losing a presidential election. In Freud’s paper about mourning, he interestingly didn’t discuss the literal death a person mourned. In his paper, he used the example of a symbolic death of  ‘a woman who had been jilted on the altar.’ For Father Freud, grief was an invitation to explore this symbolic world often in our dreams where there should not be limits but yet our mind creates them. When within our mind there becomes an impasse between limit and loss, a lack can form and feed self-reproach. He writes, 

“In Mourning it is the world which has become poor and empty; in melancholia it is the ego (the self). The melancholic mourner represents his ego as worthless, incapable of any achievement, and morally despicable, he reproaches himself, vilifies himself and expects to be cast out and punished. This delusion of inferiority is completed by sleeplessness and refusal to take nourishment …. Moreover, self-reproaches derive from the pros and cons of the conflict of love that has led to the loss of love.”  (1914, pg. 246)

Father Freud explored the trauma in the loss of love throughout his career, finding helpful insights into human sexuality and the way we deal with limits within our loving relationships. Father Freud taught us that feeling stuck in mourning may not only be an encounter with painful endings but also a resistance to healthy beginnings. Maybe we have felt stuck for a very long time repeating the same conflict just with a different face. Maybe there are repeated patterns, and loops of behavior, that prevent us from creating a new story with our life. 

This is the key to going to the unknown of grief because the temptation is to find the ‘it’ or core meaning, deep within the story; however, Father Freud discovered that the ‘it’ is always hiding in plain sight and slips through within human relation not in what we say to each other but in how the patient tries to tell a story to make the the suffering story complete and coherent when it is split. 

Freud found an unlikely pupil who would help reorient psychoanalysis back to science in the creation of what she called object relations theory. It’s here where we find the mother of psychoanalysis - Melanie Klein. Mother Melanie, also from Vienna, Austria, was about fourteen when she began to dream of being a doctor and with her mother’s help learned enough Greek and Latin to secure a path to medical school. But her dream was cut short by an early marriage at 17 years old which subsequently led to three children. It was during the First World War that she returned to her interest in Freud and began studying psychoanalysis independently. Her husband's work moved them to Budapest where she was analyzed by one of Freud's dear pupils, Sandor Ferenczi who encouraged her to work with children. After the war in 1921, she was invited to Berlin by Dr. Karl Abraham where her ideas blossomed and her career was established. 

After her training, her scary German accent prohibited her from finding many clients, so she started treating her children. Freud did not treat children, believing they were not able to fully participate in the internal dynamics of the unconscious transference relationship. But Mother Melanie observed how children play with objects and use them to tell stories about the conflicts in their inner life of love and naturally created a relationship to the symbolic. She developed what would be called object relations theory by carefully witnessing how children relate or play with objects like a toy, a sibling, or even their mother’s breasts. Klein makes many beautiful and important discoveries but one most critical is what she calls projective identification. Projection is what Freud calls this ability to project onto someone else what we have repressed about ourselves. This is a fundamental Freudian psychoanalytic insight to understand whereby it is human nature to blame or praise others when our unconscious desire might be the opposite. 

Now this blame game causes a lot of war within families, but for Klein, she wanted to look closer to interpret the unconscious anxiety in the child. Children are taught, “I’m rubber and you’re glue, what you say bounces off of me and onto you.” What if a trusted caregiver does project onto the child something they don’t like about themselves and the child identifies with the projection? It would be great if the child thought of a parent's criticism, “oh, yes, dad’s just feeling insecure today.” Or, “Mom just doesn’t think she is beautiful today.” But the child often thinks, “I am not good enough.” A child can feel trapped in this identification which was a projection from their primary caregiver who needs something and yet they have told their child they need it. 

But this phenomenon tends to happen most when the child engages in infantile rage, acting out in screams and fights with the parent. Instead of engaging with the child's needs, the parent can neglect them. But if the parent engages the rage, understanding how the child needs to experience all of their emotions in a facilitated environment, otherwise, these things will discharge in an environment that may irreparably harm others and themselves. As we grow, and conflicts become more complex and less spoken in adult relationships, we can fantasize about what others are feeling instead of integrating our inner conflicts. In this fantasy, we can project our self-hate on the other and they begin to hate us. We taught them to be afraid of us. We condition them to hurt us by our sense of hurt. Parenting takes on this impulse by children to engage in projective identification and not be bamboozled by it. The ‘good- enough’ parent sees this manipulation and creates a space for limits and loss without agreeing with the child on their sense of lack. 

Another insight from Mother Melanie is how children are taught the psychological technique of ‘splitting’ by the nature of survival. Splitting is the infantile early development of the super-ego. Our parents teach us that this is hot and this is cold. This is safe and this is unsafe. This is good and this is bad. But more fundamentally - this breast will feed me this breast won’t. This breast is good and this breast is bad. Coping with the limits of love are threshold of growth. But often when a child is testing the limits, it is not based on their fantasy sense of reality, rather, there is some unconscious wish for repair of security and care from the parent. Object relations theory teaches us how rebelling against limits (as children or adults) often hides through symbolization, some kind of loss about the primary caregiver. Entering the world of a child's words is often entering the world of words of the parents and detecting their ‘voice’.  

“Thus, the phenomenon which was recognized by Freud, broadly speaking, as the voices and the influence of the actual parents established in the ego is, according to my findings, a complex object-world, which is felt by the individual, in deep layers of the unconscious, to be concretely inside himself, and for which I and some of my colleagues, therefore, use the term ‘internalized objects’ and ‘inner world’. The inner world of innumerable objects taken into the ego, corresponding partly to the multitude of varying aspects, good and bad, in which the parents (and other people) appear to the child’s unconscious mind through all the real people who are continually becoming internalized in variety of situations provided by the multitude of ever-changing external experiences as well as phantasied ones. If, in our patients, analysis diminishes the anxieties of destructive and persecuting internal parents, it follows that hate and thus in turn anxieties decrease, and the patients are enabled to revise their relation to their parents - whether they be dead or alive - and to rehabilitate them to some extent even if they have grounds for actual grievances.”  (pp. 362-369)

For Mother Melanie, the mourner, no matter how old, can enter these repeated patterns of childhood persecution. This means the mourner is not only searching for the comfort of a primary caregiver but may be searching for a conflict to deal with feeling neglected and their needs unwitnessed. The mourner, through grief work, learns that these re-enactments in the here-and-now are projections from their past that have been internalized, and there's work to be done to see the world more ambivalently.   

In her book Love, Guilt, and Reparations Mother Melanie shares a case study about a young boy named Fritz and proceeds to illustrate this process of entertaining the machine gun-like questions from the anxious child testing limits. Mother Melanie entertains his questions about existence and sex, his ‘interest’ in poop and urine, and the discovery of real things in the world like the sun, garden, electric cars, and even a train. After the onslaught of questions, the child notices his parents (and therapist) do not have the answer and begins to explore this with ambivalence, which is to say, the parent has what he wants and sometimes doesn’t. She writes, 

“When the reality principle gets the upper hand in this struggle and maintains the necessity to limit the boundlessness of one's omnipotence-feeling, a parallel need arises to discover mitigation of this painful compulsion in the detraction from parental compulsion. If however, the pleasure principle conquerors, it finds in parental perfection a support that it tries to defend.” (2)

It’s funny how sometimes the parent is really smart and kind of dupes their kid into thinking they do have all the answers which is not true. When Fritz went to school, this re-enactment continued, but now with his friends. It was Fritz's playmates who started teaching him about truth and lies and he was conflicted inside. At first, he didn’t want to admit their unkindness hurt him, rather, he defended them until his brother said they couldn’t be trusted. And Melanie shared, 

“Aggressive tendencies now appeared quite openly; he spoke about shooting them dead with his toy revolver, about shooting them in the eye; and showed his death wishes in his remarks and in his play.” (3)

Oh yes, ‘normal’ children have destructive tendencies, even criminal tendencies. But like Fritz, this splitting is repressed and so he returns to his playmates as friends and ambivalently accepts that they are just kids. The therapy allowed for this expressed aggression to exist and thus the child became unstuck in the need to act out this sense of loss. Mother Melanie expanded reality testing to what she called reparation which was to explore how our primary caregiver or friends may not be what we have hoped but also might not have been what we had feared. Reparation paradoxically begins to accept that our primary caregiver is like us - full of wishes and lack - and often we are trying to fill in the story of love without all the right details.  Sometimes a child's belief/projection that their parents think they are bad, can become a self-fulfilling prophecy which creates guilt and a paranoid schizoid position. It’s when the psychotic core of good or bad is further split in two rather than integrated as good and bad within the subject.  

Mother Melanie's last paper published three years after her death is titled The Sense of Loneliness in which she mirrors the end of life with the beginning of life. Since we begin life usually in a clinic in need of a caregiver, any subsequent illness is a return to the clinic where we find we continue our dependence upon a primary caregiver, and the longing for a mother persists.  

However gratifying it is in later life to express thoughts and feelings to a congenial person (counselor), there remains an unsatisfied longing for an understanding without word ultimately for the earliest relation with the mother. This longing contributes to the sense of loneliness and derives from the depressive feeling of an irretrievable loss. I have heard patients express the painfulness of integration in terms of feeling lonely and deserted, through being completely alone with what to them was a bad part of the self. The process becomes all the more painful when a harsh super-ego has engendered a very strong repression of destructive impulses and tries to maintain it. ” 

For Mother Melanie, the mourner has a lifelong journey to experience the losses in life as limits and not punishments or a sense of withholding, rather use this empathy to give voice to the exiled experience. Similar to Kubler-Ross’ acceptance, Mother Melanie invites mourners to embrace what she called the depressive position which is to experience the lack within as less punitive or persecutory and more universal. Loneliness and loneliness are a trauma that all of us will encounter no matter our socio-economic position. When faced with the possible meaninglessness of our sufferings, it is easier for the sufferer to find meaning in a belief they are being punished rather than absorb the possibility that their suffering is quite normal and therefore, quite meaningless. The anger towards this predicament can point outward or inward and surface old traumas of desertion and forgottenness to remind us how mourning is not only about endings but beginnings whereby we are repeating behavior patterns we are not aware we are repeating.    

The Modern grief care story goes beyond the daughter, father, and mother to who I think of as the son of the modern grief family and he was attached to ‘mother’ Melanie’s hip. John Bowlby also studied mourning through the lens of beginnings, not endings. Before the 5 stages of grief, Dr. Bowlby created the four stages of grieving to describe the separation from a caregiver. 1) shock/numbness, 2) yearning/searching, 3) disorganization-despair, and 4) reorganization. Dr. Bowlby explored the idea of ‘separation anxiety’ when he wrote, 

“my view is that the principal trauma, which is potentially present in the life of a young child, is loss of a mother, or loss of her love.” (4)

Consider this analogy. As a child transition to school, their teacher (now mostly female) becomes a new type of mother and their pencils and crayons become their new objects to tell stories of what feels missing in their young world. As they grow older, perhaps their coaches become new fathers and even give them balls to play with. These balls become what Donald Winnicott called ‘transitional objects’ which beyond mother breasts, are our first ‘not me’ objects we connect to who are not enmeshed with mother. For example, the ball becomes a symbolic object with profound internalized relations. But some kids struggle to pick up sports, so they choose an instrument or other object of meaning and these objects mediate conflicts that were unspoken at home with primary caregivers.  

When Dr. Bowlby offered this idea of attachment to his classical psychoanalyst friends they rejected him and he was kicked out of their cohort. Jerks. How could these psychoanalysts be so brutal with their ideology and exile a dear friend? They were jerks, but like many jerks, they thought something essential was being threatened. Attachment seemed to be going in the opposite direction from individuation and the formation of a healthy ego/self. Now let's be clear, these psychoanalytic therapists likely would have been a bit insecure of Bowlby's claim on therapy because they weren’t even called therapists - they were analysts. They were to analyze at a distance as their clients' internal movies/ thoughts and feelings were objects of study and didn’t even look them in the eye. 

But the work of object relatedness was to reveal how this distance just wasn’t always therapeutic. Children need a bond, a nearness, a parental figure to attach to. Since psychoanalysis often is a guided quest into our childhood aggression and regressions, patients transfer a need for the security and support of a parental figure. Bowlby's theory about attachment ultimately invited the therapist to be vulnerable so that the patient can transfer this need of a caregiver upon them and over time can experience their inner world of needs. But it takes discipline for the therapist to see themselves as a symbol of an unsettled attachment. 

Modern therapists understand that assuming this position of attached caregiver, knowing they can’t fulfill a primary caregiver role, is very fragile and can cause psychological harm if not facilitated skillfully. Sometimes patients can form a co-dependent relationship with their therapist as a surrogate parental figure and the patient never learns to face the world with their own courage. This is also why many therapists wish to be your mentor, guru, or coach, because it is too uncomfortable working around the profound transferences within the relationship. But if therapists are symbolic, they are taught to re-enact the symbolic inner conflict the patient is seeking to have with a caregiver, which means exploring their destructive impulses and ambivalent feelings, so they can become a healthy individual through an encounter with the conflicts and limits of love.

Brother Bowlby’s attachment theory helped psychoanalysts lean in further and build better alliances with their patients so they understood the unconscious power of a transference relationship and need for a secure bond. Dr. Bowlby argued that emotional individuation is always the goal, but the healthiest place to start was to allow this projection of primary caregiver to animate the story of what the inner child feels is lacking within themselves. Bowlby's attachment theory is now adopted broadly by psychotherapists who are taught to model a caregiver role to not only patients but also parents to help the family attach for the sake of healthy differentiation over the discovery of their child's deeper capacities for resilience through vulnerability. Dr. Bowlby and broadly psychoanalysis, maintains that the lost object in therapy is often the lost attachment with one's mother.

Bowlby’s theory of forming an early attachment with mother has also undergone great scrutiny as it functions with one major assumption; the mother ought to celebrate her primary role of nurturing a child within the family system. Some cultures do not give the mother the primary responsibility to raise the children, rather the father or even ‘the village’ (extended family or hired caregivers) raises them. The village, which is a cross-cultural phenomenon for the survival of the poor in society, has become more popular in western culture, however, most psychologists agree that without the establishment of a secure bond with a mother/primary caregiver figure, development is critically disturbed. Within this model of development, grieving was part of growing and affirmed as the cost of feeling attached and healthily separated. John Bowlby brought to our attention how even Freud later noted that children and infants grieve and its effect even though not pathological, is heart-shaping: 

 “Despite his early recognition of the role played by grief and mourning in mental illness, to which reference is made in subsequent papers, it seems that it was only toward the end of his life that Freud came within reach of appreciating the reality and significance of grief and mourning occurring in infancy and early childhood. In the final pages of Inhibitions, Symptoms, and Anxiety, having by this time a clearer grasp of the place of the child's attachment to his mother and of separation anxiety, Freud takes a fresh look at the problem of mourning. Before this re-examination, he tells us, he had been clear that "the affective reactions to a separation … are pain and mourning, not anxiety" (1926, p. 131). 

Bowlby searched for Freud's overall view of grief and mourning, knowing that in bereavement in particular, a child is searching for a primary caregiver. But so are adults. Mourners can unconsciously reach back in the past to anchor their sense of love, to feel like they belong to a larger story. But in mourning, we are often uprooted from a caring world. We don’t recognize this new path forward, so we go where it is familiar - we go backward and can get lost searching for ghosts. Bowlby believed the stage in which the mourner was most likely to be stuck was in the yearning or searching stage. 

But who has that much time to explore with a patient all this content of lost stories in family, work, religion, history, etc? Don’t we have patients who just need cognitive and behavioral guidance? To think and do more positive things for their family and themselves. Well . . . the ‘r’ list keeps growing as other grief experts keep using the alliteration. Dr. Robert Neimeyer teaches the idea of reconstructing the meaning of the loss through narrative therapy and keeping journals of one's grief experiences. Dr. Alan Wolfelt says to reconcile internal grief with external mourning through more journaling exercises. Dr. Richard Schwartz teaches how one should re-script the grief narrative in some way to serve the inner needs of the traumatized person. As it turns out, the best grief therapy still honors holding a deep story of suffering for patients needing more therapy rather than less to understand what it is that still feels lost to make the story more nuanced and the patient enjoys the sense of incompletion so they may remain curious to their own choices in the meaning of their life.

It was the French Psychoanalyst, Jaques Lacan, (aka French Freud) who took the old Freudian garden of the unconscious seriously and went to work pulling the weeds. He began to re-language the unconscious through the frames of the imaginary, symbolic, and the real to make restitution with the past. What is fascinating to me is this framing had been the history of psychoanalytic work up to this point. The lost story of the repressed unconscious was still stuck in finding what feels hidden rather than missing, perhaps stolen in the subject. It creates a tremendous amount of therapeutic activity to keep going through this content in hopes we recover something that had been lost in the past. Lacan believed the tradition of healthy therapy should take the storytelling of narcissistic musings seriously but be willing to wound it if necessary with a discipline of seeing ‘the real’ coming out in the here and now of therapy. 

Of course ‘the real’ is metaphoric as well because finding it was not seen but rather a part of the discourse. It was speaking through the symptoms of what the patient was (un)doing to cope with the truth. Therapy can get lost in addressing unmet needs when in truth its power is in confronting desire in engagement with what Donald Winnicott called the ‘False Self’. One can know when grief needs therapy and not counseling when there is an obsession with grieving the right way or good way or after a trauma there is a voice of righteous rage that becomes persecutory. Health mourning becomes less about making us be good and more about making us more true - which is to have a more ambivalent relation to what we want out of love.

Dr. Winnicott writes in his paper Maturational Process, “On the basis of this, one could say the False Self deceives the analyst if the latter fails to notice that, regarded as a whole functioning person, the False Self, however set up, lacks something, and that something is the central element of creative originality.” (pg. 152) In other words, while grieving the lost object of love which feels be missing in one’s life Winnicott notices that mourning becomes unstuck only when the mourner becomes aware that what is missing is not outside of themselves, rather it is their true self which has become missing from their own story.

(1) Freud, S. 2001 (orig. 1913). Totem and Taboo: Some Points of Agreement between the Mental Lives of Savages and Neurotics (trans. James Strachey). Oxford: Routledge Classics.

(2) Klein, M Love Guilt and Reparation, Love, Guilt and Reparation: And Other Works 1921-1945 (The Writings of Melanie Klein, Volume 1; pg. 16

(3) Klein, M Love, Guilt, and Reparation, Love, Guilt and Reparation: And Other Works 1921-1945 (The Writings of Melanie Klein, Volume 1; pg.1 7

(4) John Bowlby, Grief and Mourning in Infancy and Early Childhood, Psycho-anyltic study of a child, 1960., pg 13.