Abstract
This paper explores an existential-analytical approach to grief accompaniment within the context of recovery following a severe traumatic brain injury (TBI). A brief literature review of the relevant literature initially provides a scholarly context for the discussion within the wider framework of rehabilitation psychotherapy. Then a recent case study from the author’s psychotherapy practice is introduced and used to illustrate existential-analytical grief accompaniment. The focus of discussion is initially placed upon the development of the personal capacities associated with the 1st Fundamental Motivation – the ability to endure and accept the facticity and consequences of the TBI. Following this, the pre-requisites for a personal grief processing – relationship, time and closeness – are explored and situated within the 2nd Fundamental Motivation of existential-analytical theory. Finally, the grieving process itself is then touched upon and illustrated through the relevant parts of the accompaniment process. Grieving or turning-towards loss includes development of an attitude of letting be, an inner dialogue in relation to the values that have been lost, and finally a reorienting toward the world and new values.
Grieving and Traumatic Brain Injury: Existential-Analytical Understanding and Accompaniment
For the past seven years I have worked as a psychologist in an outpatient rehabilitation firm in Vancouver, Canada. My work has mostly involved conducting psychological assessments and psychotherapy with individuals who have suffered orthopedic or brain injuries and have encountered psychological difficulties in their rehabilitation. The typical course of recovery for many of my clients has involved lengthy hospital stays, stints in rehabilitation facilities, and persistent cognitive, physical, and emotional challenges following their injuries. My outpatient psychotherapeutic work with these clients typically begins within a few months of their release from hospital, and involves assisting them as they seek to transition back into the community and seek to rebuild their lives. While there are some similarities between clients with orthopedic and pain-related problems and those with traumatic brain injury (TBI), this paper will focus on accompanying clients with TBIs through their multifaceted and at times lengthy process of grieving.
Psychotherapeutic work with clients with traumatic brain injuries (TBI) is a relatively challenging and complex endeavour (Klonoff, 2010; cf. Zasler, Katz, Zafonte, 2013). Part of the complexity of such work is due to the fact that clients frequently present with numerous physical co-occurring conditions, such as orthopedic limitations, persistent pain and fatigue (Horn, Siebert, Patel, & Zasler, 2013). Additionally, clients with TBIs also present with significant cognitive challenges, including limited cognitive insight into their limitations, problems with short-term memory, reduced processing speed and capacity for multi-tasking, problems with receptive and expressive language, distractibility and problems with sustained attention, and difficulty in learning new tasks (Eslinger, Zappala, Chakara, & Barrett, 2013; Kreutzer, Mills, & Harwitz, 2016). In short, psychotherapeutic work with such clients has both similarities as working with other client groups, as well as some unique challenges related to the nature of their injuries.
TBI clients who are referred for psychotherapy often present with one or more psychological disorders, including depressive disorders, anxiety disorders, trauma and stressor-related disorders, problems with substance use, and psychosis (McAlister, 2013). While there is a significant literature on these various disorders in the context of TBI, the focus of this paper will be on the process of grief and adjustment in the context of recovery from TBI. In my experience, it is not uncommon for clients to be referred for any number of the conditions noted above, but relatively few health professionals and even psychologists seem to be attuned to the fact that TBIs are associated with significant losses, and that the acceptance and grieving associated with TBI may be a significant challenge for survivors (Coetzer, 2003). Moreover, it has been my experience that relatively few clinicians, including psychologists, have a nuanced understanding of the distinction between common psychological disorders following TBI – especially depression – and grief and adjustment following TBI. Therefore, a phenomenological exploration of one particular case may serve as an example of common human reactions to the significant losses associated with TBI. A correct understanding and diagnosis of such issues has profound implications for how we, as clinicians, intervene with our clients.
Losses after a TBI
If we look a little more closely at the losses associated with TBI, we might rightly ask ourselves what kinds of losses TBI survivors sustain in their injury. I use the term ‘TBI survivor’ deliberately here, because clients have frequently survived a horrific accident which has significantly and permanently altered their personal, familial, and occupational lives (Kreutzer, et al., 2016). Their losses include cognitive and physical functioning, functional capacities (e.g., ability to walk, run, use of various limbs), the loss of meaningful activities (e.g., jobs, volunteer work), and the loss of relationships (e.g., work colleagues, friends).
One of the main challenges from a psychological perspective is that the losses sustained by TBI clients are complex. In contrast to bereavement-related losses, TBI-associated losses are often confusing and ambiguous for clients and their families. The first complicating factor is the recovery itself, and clients and their families might rightly ask themselves whether the loss they are grieving is indeed a loss or a function that will return over time. They might ask themselves, for example, whether their cognitive limitations, such as problems with short-term memory or attention, are temporary or permanent impairments. The challenge for clients and their healthcare providers is that the recovery from TBIs is difficult to predict within the first few years, and so the answer to the question of the permanency of a loss might not be answerable for clients (McAllister, 2013).
One of the most challenging questions for TBI clients and their families is, to what extent, clients have lost parts of themselves, or to what extent they can expect to return to pre-accident functioning (Coetzer, 2003). This loss is frequently associated with the personality change associated with TBIs, and is actually a more complex issue than can be addressed at this point. However, clients and their families do frequently reference the fact that TBI clients are fundamentally different than who they were prior to their injury.
Case Study
As we move to explore existential-analytical accompaniment following a TBI, a case study will serve as a guide. The following anonymized case is in some ways quite typical for the clients of kinds that I frequently see in psychotherapy. I have amended some details of the case in order to preserve client anonymity.
Sally is a 64-year-old woman who was referred to me by her family doctor for ‘depression’ following a traumatic brain injury. Approximately one year ago Sally was involved in a life-threatening motor vehicle accident. As Sally was riding her motorcycle in a rural community, she suddenly encountered a deer on the highway. She attempted to swerve, lost control of her bike, and impacted a tree. Although Sally was wearing a helmet, she sustained a severe traumatic brain injury, which included an immediate loss of consciousness at the scene of the accident, a 1-week coma in hospital, and significant cognitive and functional limitations since the accident.
Sally went through months of intensive rehabilitation to rebuild her functional and cognitive capacities as much as possible. When she arrived for psychotherapy, Sally had regained many of her functions. She spoke normally, with the exception of some occasional word-finding problems. She was able to walk and engage in most physical activities (e.g., household chores, light physical exercise) with relative ease. Apart from persistent headaches, she was relatively pain free. Sally basically looked like she did prior to the accident.
In spite of the fact that she had made a very good physical recovery from this severe accident, Sally was struggling cognitively and emotionally. Her cognitive challenges were numerous. She had always prided herself in her intelligence, in her ability to solve problems, and now Sally was faced with many cognitive limitations, including slow cognitive processing, a poor short-term memory, and challenges with executive functioning. She required the help of family and friends to plan her daily activities and needed a detailed journal to remember even basic things, such as appointments or taking her daily medication. Most challenging for Sally was what she called her “swiss cheese brain”. She would frequently begin an activity, then become distracted by a thought or a phone call, and move on to other activities, never remembering to return to her initial activity. Sally’s home was littered with unfinished projects. In addition to her cognitive challenges, Sally also faced more general physical limitations. Two of the most difficult of these limitations were low energy levels and frequent and sudden experiences of fatigue. Her daily routine included a 2-hour nap in the afternoon, after which she would awake with enough energy to continue for the rest of the day. However, most nights Sally would go to bed around 8 pm, and then typically sleep 12 hours.
Emotionally, Sally also faced many challenges. Initially she felt confused about her situation. What had happened to her and what was this new reality that she was now facing? She often struggled to follow her doctors’ explanations of her injury and of its consequences. As a result of this lack of understanding, Sally would frequently engage in activities that would exacerbate her symptoms; she would plan day-long trips with her partner or make decisions to visit her daughter for week-long visits. Not understanding her limitations and her inability to pace her levels of activity led to increased headaches, feelings of frustration and irritability about her limitations, and eventually ‘depressive’ symptoms, for which she was now seeking my help. Fundamentally, Sally was wondering whether her life, as she now faced it, was worth living. How could life possibly be good when so much of what she valued – her intelligence, her stamina, her capacity for problem-solving – had been taken from her? She would often say: “I know that I’m supposed to feel grateful that I survived this accident, but all I can feel is frustrated and irritable about what I have lost. I am not sure that this kind of life is worth living”.
Fundamental Motivation 1 – Endurance and Acceptance of a Traumatic Injury
As psychotherapists we can likely consider a variety of areas where we may begin therapeutically. However, given that the focus of this paper is on grieving following a TBI, it makes sense to concentrate on areas that are relevant to Sally’s losses. One of the first things that stood out to me with Sally was the fact that she was feeling frustrated and irritable about her life at this point. Irritability and frustration are common experiences for individuals with TBIs and are frequently related to the fact that they seek to accomplish goals in life which push them beyond the limits of their capacities (Coetzer, 2003). This, too, was the experience for Sally, who struggled with starting household chores or woodworking projects, but would then abandon these because she became distracted or was unable to finish them due to fatigue. Coming upon such unfinished projects throughout her home on a regular basis evoked frustration, anger and confusion for Sally. She could not understand why she could not complete the projects. She remembered back to her life prior to the accident when she was very productive and often used her practical skills at fixing and maintaining homes to the benefit of friends and family. Feelings of frustration (inability to accomplish goals and desires in everyday life) and irritability are often indicative of the fact that clients struggle to adjust to, endure and find acceptance of a new reality. And this is the place where we then want to begin.
In Existential Analysis (EA, Längle, 2003), the most fundamental human ability is the ability to be in a given situation. We are here, thrown into a given reality, and we are typically not asked if we like or want this reality. This is the case for all of us – we are born into a world without our consent, nobody asked us if we wanted to be born, and yet here we find ourselves. We are born with a certain body shape, genetic endowment, intelligence, financial situation, cultural or religious location, and we have really no say about this facticity of our existence. We are thrown into it, as Heidegger (1962) rightly says. The same is also the case for Sally, who through a tragic accident, found herself in a situation that she neither expected, wanted, or even fully understood. One moment she was riding her motorcycle along a country road, enjoying the sun and the feeling of the ride, and the next she found herself awakening in hospital as she was coming out of a coma. She felt confused, shocked, and only gradually and over months and years began to understand what really had happened to her and the extent of the consequences of her injuries. She was asked to ‘say yes’ to a reality that was alien and confusing to her, and naturally she found herself railing against such radical and unwanted change.
What is required of us all when we face such a situation? Certainly we may initially and spontaneously react to such situations automatically and naturally with what EA has termed coping reactions (Längle, 1997/2009). These are natural, spontaneous, and largely unconscious protective reactions that help us to overcome and deal with a situation for some time but ultimately lead us into being fixed and feeling stuck. In short, coping reactions initially are helpful but often cease to be so over time. Sally’s responses to the TBI illustrate several coping reactions. These include her initial avoidance and minimization of the injury, overlooking or resisting her functional limitations, engaging in activities that would increase her symptoms (e.g., too much housework or exercise), and struggling to accept the reality of her cognitive limitations (e.g., refusing to use a journal or day planner).
While understandable, all of these spontaneous coping reactions were ultimately problematic because they led to further suffering and fixation, including experiences of tension, frustration and irritability. They exacerbated Sally’s symptoms because she frequently overstepped her boundaries and struggled to pace her levels of activity. The main challenge, however, from an existential perspective was that there is no personal or decided working through of a situation, no development and movement, and they did not permit the possibility of a personal, emotionally-integrative engagement with loss (Längle, 2011). We cannot begin to grieve a loss that we deny, minimize or seek to overcome through frenetic activity. The resulting psychological problems – irritability, frustration, restlessness, tension – can in this context be understood as consequences of an initial inability to ‘say yes’ to a new reality, a partially unconscious protest against the fact that Sally’s life had changed radically and she was now attempting to catch up to herself.
What is required instead is a personal and decided activity (Längle, 1997/2009). This activity, which may initially only be the development of an attitude or a letting be, is required to allow for a personal and decided engagement with loss. In Existential Analysis (Längle, 1997/2009), we see two potential levels of personal or decided activity, namely endurance of an unwanted reality or its acceptance. I want to elaborate briefly on both of these, and highlight how they emerged in Sally’s recovery. The transition from fighting against an obdurate reality like a TBI can be seen as a pre-requisite to engage with the losses in a personal and decided manner, a manner that ultimately enables Sally to grieve what she has lost.
Endurance
How can I bring in my personal or deciding being when I have the feeling that “I simply cannot”? This is the struggle that emerged for Sally. Gradually Sally awoke to the realization that she could not live her life like she could before. No matter how much she wished it to be different, Sally came to realize that her brain simply could not function like it used to. Through dozens of examples every day, from the moment she awoke in the morning to the moment she fell asleep, Sally was reminded again and again that her functional capacities had changed. No matter how much she would like to function how she used to, she simply could not accomplish this. In such situations, the most basic human ability, and it is indeed an ability and action rather than a reaction, is the ability to allow something to be as it is.
In Existential Analysis (Längle, 1997/2009), this ability requires two specific activities – endurance (which means having the strength to stay in a given situation) and acceptance (which is the ability to allow myself and my situation to be as it is). Both endurance and acceptance are forms of ‘letting be’. Endurance can perhaps be best depicted through a standing or bracing against. Endurance means that we assess and determine what stands in our way, that we bring some strength and activity into action in order to create some room for ourselves. We test our inner ground to see if there is sufficient support in order to stand up for ourselves, and we ultimately come to a decision that we will take our place and not give way. We will be faithful to my own Dasein, our own being. This is quite similar to what Frankl spoke of as the defiant power of the human spirit – die Trotzmacht des Geistes (Frankl, 1984).
Endurance was the easiest place to begin for Sally. She understood herself as a ‘fighter’ and was able to point out with relative ease the many circumstances that she had been able to endure in the past. She had endured bullying in school, had survived years of debilitating depression, which included lengthy admissions into psychiatric hospitals, and had fought against sexism in the workplace that told her that she could not, as a woman, take on mechanical or practical work. Through these various struggles, Sally had gained an increasing confidence that she could overcome circumstances in which the odds were stacked against her. Initially, we drew upon these experiences to re-awaken in Sally the memory that she had indeed been successfully in enduring these situations. She repeatedly reminded me with a smile and a twinkle in her eye that she knew how to be stubborn, and this was what was initially required of her.
Acceptance
A second level of decided and personal activity is also possible. In my clinical experience, this is a step that often takes place after some time, some working through of the situation, and represents a more advanced dealing with a situation – acceptance. We ask ourselves – what do we mean with acceptance? It is a term that is easily misunderstood because it is frequently confused with valuing, with resignation, with giving up, or with martyrdom. However, in Existential Analysis (Längle, 1997/2009) acceptance is neither of these.
The bodily posture of acceptance is perhaps best seen as a welcoming, an opening of the arms (Längle, 1997/2009). It means that we do not push away whatever is unwanted, but rather we allow it to be part of life. It is more than the bracing against, but rather it is an allowing, an agreeing, a giving space to the unwanted reality. This means that the being of the unwanted reality is no longer so threatening, but we have found a way to be alongside it. We no longer brace ourselves against the reality, but give it permission to be. We have learned that there is enough space for both of us. In this way there is a first consent, a first ‘yes’, to the reality of the situation. We can say ‘yes’ to the situation because we have learned we can allow it to be and it allows us to be also. We bring it into the reality of our lived experience. Acceptance is therefore more relaxed, more settled than endurance.
Acceptance for Sally was a more difficult accomplishment. Initially, it seemed that she might be able to find an ‘inner yes’ to her new situation with relative equanimity. She had lived with a persistent depression prior to her TBI, and emerged out of the inpatient rehabilitation with a certain naiveté about her condition. However, as Sally began to realize, again and again and again that she had far more limitations that she initially understood, acceptance became more challenging. Through repeated experiments, Sally began to realize that she would not be able to return to her beloved job as a mechanic for medical equipment (e.g., wheel chairs, walkers, assistive equipment, etc.), a job that gave her meaning and an outlet for her mechanical gifts. She also realized increasingly that she was more dependent on her partner for reminders about daily activities and for assistance in planning and executing these daily activities.
Sally’s journey toward acceptance was long and marked by fits and starts, by moments when she was able to say ‘yes’ to her limitations and experienced herself as being at peace with her losses, and times when she would suddenly realize yet another consequence of her limitations and become frustrated, angry, or overstep her limitations. This kind of journey is not unusual for TBI clients (Coetzer, 2003), especially when we consider the fact that insight into their limitations is affected by the TBI itself, and that the recovery process is unpredictable. One of the most challenging realizations for Sally was that, contrary to what she had been told through thorough neuropsychological testing, that she would not be able to return to her work.
Fundamental Motivation 2 – Grieving the Loss of a Life Values
The realization that she was unable to continue in her job and Sally’s increasing acceptance of this fact, were critical in moving Sally into the next phase of her recovery. The initial weeks after receiving the word from her work supervisor, alongside her occupational therapist, were very difficult for Sally. She was exhausted from trying to accomplish a job that she was not able to do. She spoke about times of confusion, disorientation and feeling overwhelmed. These moments were particularly poignant when she spoke about feeling disoriented when driving to and from work. Several times she made crucial mistakes in driving and there were a few near-misses in traffic. I reflected back to Sally that I was concerned about her safety at this point, as well as the safety of others on the road, and encouraged Sally to take a break from driving in order to rest and regain some orientation at home. What followed for Sally was a deep encounter with loss, a time of intense grieving for her beloved work, and then a re-engagement with the question of how she might live her life in the absence of paid employment.
The framework and methods of Existential Analysis (Längle, 1984/2009) were of great assistance to me as I accompanied Sally into turning towards her loss. The questions that emerged for her changed from those concerned with the facticity of the situation (“Can I still do my job?”) to ones that concerned her feelings about the loss. The questions had less to do with endurance or acceptance of this unwanted situation, but more with her relationship to life itself, with its feelings and relationships. In this experiential dimension of life, Sally became aware that she had a choice now about what to do. She could, as other clients have done, throw herself into new activities and simply seek to replace her work with other activity. And eventually she did this. However, before this began, Sally began to turn towards what she had lost and allowed herself to feel the gravity of this loss.
The physical posture associated with this turning-towards is a repositioning of one’s body and facing where life is hurting right now. Rather than turning away through avoiding or distracting oneself from the pain, we turn towards it. This requires that my attention, my focus, is on where my life is hurting. Turning-towards is an emotionally open movement; we are prepared to be there not only cognitively and with our attention, but on an emotional level, with our feelings. Turning-towards leads to inner movement, we are filled up emotionally, we establish relationship, and are present to life. We also reveal ourselves to others, who can now step into relationship with us. And so during this time of sadness, of the flowing of many tears, of looking at the joy and meaning of Sally’s beloved work, the therapy gained increasing intimacy. Speaking in session slowed down and a deepening of the therapeutic relationship took place over time. I tried, as best I could, to protect and hold a space in which we could look together at what was now lost. At varying times in our sessions, there was a temptation or an impulse to move forward more quickly. At times this impulse came from Sally and at other times it came from others – such as her partner or other members of the rehabilitation team – who were interested in seeing Sally return to some other kind of function. But Sally, too, had the wisdom to not want to move too quickly. She withdrew from some of these relationships for a while, gained time and closeness with herself, and I tried to encourage others to allow her the time to grieve, and sought to accompany her in turning-towards her loss.
What is required so that we are able to turn towards that which we have lost? We have already determined that it requires a certain kind of stability, of being able to acknowledge the facticity of the loss, and a certain courage to face the loss and accept it, integrate it as a reality into my life. Now when it comes to the emotional engagement with loss, three other pre-requisites are needed (Längle, 1984/2009): relationship, time, and closeness. I will elaborate on these and connect them to Sally’s grieving journey, before attending to the grieving process itself.
Relationship
All human activity takes place within relationship; in fact, as human beings we cannot not have relationship. As Heidegger (1962) noted, there is a basic relatedness that exists fundamentally in life. All Dasein is da-sein, is being-in. We are inescapable related to a time, a context, to relationships that precede and embed us. But we can intensify this relationship by stepping into them more personally and therefore increase our felt presence in relationships. Being in relationship means that we allow the other to take his/her place, to recognize this other Being, and to allow this being to become part of our being. We open ourselves to the other, give their Being a home in ours, and therefore step into relationship. Relationship therefore means that I have a feeling for myself and a feeling for the other. It means being present with one’s emotionality. Relationship leads to a protected space in which I and the other can be touched. Relationship therefore creates the ground of turning towards, because it offers protection and support. It is the stage on which this turning towards can take place. The general principle in Existential Analysis (Längle, 1984/2009) is that the more I stand in relationship, the easier it is to step into relationship and to live out an engagement with my emotions. Relationship gives protection in which turning-towards can happen, a ground on which contact can occur, and a horizon of understanding in which relationship is bedded. Turning-towards thus requires relationship, relationship both to oneself and to the other.
The grieving of Sally’s various losses, and most poignantly of the loss of her job, took place within a well-developed therapeutic relationship, as well as within the context of other relationships. By the time Sally and learned that she was no longer capable of remaining at her job, our therapeutic relationship was on solid footing. Sally regularly spoke of the fact that she genuinely enjoyed our therapeutic encounters and that she found them to be at varying times inspiring, comforting, grounding and challenging. I, too, was genuinely appreciative of the work that we were able to accomplish together, finding joy in the accompaniment of someone who was facing a life-changing situation with emotional openness and authenticity. I often found myself looking forward to the therapeutic encounters, knowing that I would frequently not only learn something new about Sally (who often would prepare herself well for our sessions through reflection and dialogue), but also learn something new about brain injury or grief or even myself. And thus, as it became clear that our therapeutic work was entering into the area of grief, we had a solid relational foundation upon which to enter into such an encounter.
Sally’s life outside of therapy also prepared her well for the intensity of a therapeutic relationship focused around grief. Although she had been raised in a challenging family background, and had encountered abuse and discrimination at various points in her life, Sally was well embedded within positive and life-giving relationships at the time of her accident. She was close in particular to her partner, as well as to her daughter, son-in-law, grandchildren and numerous friends. One of the challenges that Sally faced as she turned towards her losses was the fact that some of her friends and family members, as well as some other healthcare providers, had relatively little understanding about the importance of grieving in Sally’s context. At varying times, she experienced herself feeling misunderstood, rushed or pressured, and frustrated with the fact that life seemed to be moving at a faster pace than she was prepared to move. This was likely exacerbated by the fact that Sally’s cognitive processing skills were already slower as a result of the TBI (cf. Eslinger et al., 2013), but in particular during this time of her life Sally experienced the need for silence, for reflection, and for sadness. At times she found herself having to assert and protect such spaces in her life, but found that our therapeutic pacing was in synch with her own perceived need.
Time
The slower pace of life for Sally in general and during her grieving in particular, is a fitting transition into the second pre-requisite for the existential movement of turning towards loss. Life, of course, itself takes place within time, and our felt experience of life, our feelings, emerge only there where we devote sufficient time for them (Längle, 1984/2009). Such slowing down, taking the time for feelings to come and to be felt, is intensified through the therapeutic relationship. Therapeutically this requires a focus on the present on what we are feeling right here and now, because it is only at this point and place, in this hour, that our life is happening. Taking time therefore already has the seed of turning towards, because turning towards requires time. We must stay, and only where we devote time, is turning-towards possible. It cannot occur under time pressure. Taking time means that we devote the most valuable thing we have – a portion of our lives – towards which is valuable. It is thus an indication of our values. We give time – the time of our lives – towards those things which are valuable to us. Relationships live from the time that we have for one another. Time is therefore a thermometer of the vitality of relationships. When we are in love, for example, we often spend much time with each other. The existential meaning of time is that we live for whatever we take time. The development of emotions also take time. They do not happen as quickly as thoughts, but require time for me to step into relationship, to be moved and to resonate in us.
The protection of our therapeutic space, of the intentional taking-time for sadness and tears, required us to slow down the pace of our sessions. Sally and I were both aware of this necessity, and so sessions often began with an initial sitting down, with a first looking at each other, a sigh and a breath, and then with wordless tears. At times very few words needed to be said. Sally would typically catch me up initially on how she had spent precious time in turning-towards her losses, and then we explored what was current for her. Each time, we were conscious of the fact that this time together also was a sacred time, a time when we touched upon what was precious to Sally and who she was as a person. I often recalled that I needed some time to allow our time together to reverberate in me, and would often reflect upon and feel with the time that we had together as I drove home after a session.
Closeness
The third and final pre-requisite for turning towards loss, naturally seemed to emerge as a function of relationship and taking time for encounter. Closeness begins with a relating to the other (Längle, 1984/2009). It includes being touched – both physically and psychologically, and therefore requires an openness on behalf of the therapist to allow the feelings of the encounter to permeate the role. Through closeness movement emerges in us. Closeness creates feeling, a flow. Life is flowing in us in closeness. In a good and comfortable closeness, we experience openness, room, a melting of boundaries and intensification of relationship. The consequence of good closeness is the experience more vitality; closeness awakens my vitality and joy. Thus the experience of closeness is never neutral, but rather is an experience of values.
Closeness touches us. In contrast, there is no being touched without closeness. Closeness creates movement, touches us. When we are touched as human beings, when life touches us, we are not left cold. Life means warmth for human beings. When we touch each other, warmth is the natural consequence. The experience of being moved and warmth is experienced as feeling. In this movement, we experience the feeling of vitality and strength. And where vitality emerges, there is an impulse for movement into a direction. And when we feel an impulse – to move closer or further away, we are in relationship (Längle, 1984/2009).
I experienced the closeness within the therapeutic relationship as both a pre-requisite for and also an intensification of the already existing encounter with Sally. As we moved the therapeutic focus from other areas of attention (e.g., assisting Sally in returning to work, dealing with feeling overwhelmed by the complexities of rehabilitation, managing depressive symptoms) to grieving, to turning-towards loss, the closeness and intimacy of the therapeutic relationship intensified. I found myself increasingly drawn mostly towards simply being present with Sally, rather than feeling the need to plan for the particular focus of a session. I was curious about where Sally was present emotionally as she came into session, and was drawn towards a simple and empathic accompanying of her as she caught me up on her grieving and we journeyed into the felt loss together. Certainly there was also a measure of closeness that was required for this mutual turning-towards to take place, but the hermeneutic circle both required and facilitated the increasing closeness of the therapeutic work during this time.
In sum, the three pre-requisites of turning towards loss, relationship to oneself and others, time and closeness, both facilitated and intensified the grieving process in my work with Sally. The therapeutic relationship both preceded and sustained the encounter that we had as Sally moved into a more intensive time of grieving her various losses. Our therapeutic encounters were supported by close relationships that Sally had with immediate family and close friends, all of whom sought to care for her during this difficult time of adjustment. As we moved into a time of intentional grieving, the pacing of our sessions slowed down. We needed time to turn towards and feel what was emerging in response to Sally’s losses. Therapeutic slowing down and taking time was supplemented by Sally’s personal work outside of therapy as she journaled about her losses and prepared herself intentionally for our sessions. Finally, grieving was supported and intensified by Sally’s closeness to herself and to me in our therapeutic encounters. Sessions moved away from most foci on functional gains or outcomes, and we moved into a more intimate and emotionally intensive time, which increased the therapeutic intimacy. My aim during these times was simply to be present with Sally as she wept over the losses that she has sustained because of her accident. And as we did this together, natural movement began to emerge in our sessions. This process will be described in more detail next.
Grieving in Existential Analysis
Grief and grieving has been widely acknowledged to be a universal human phenomenon (Center for the Advancement of Health [CAH], 2004), and generally considered a ‘normal’ response to loss. When it comes to describing this process, however, scholars disagree on numerous issues, such as the definition of grief or the purpose of grieving. Likewise, many clients are puzzled by the intensity of their emotion after a loss and at times do not understand why they grieve. A brief elaboration on what grief is and why we grieve can be very helpful for clients and clinicians alike.
The scholarly literature on grieving is replete with varying definitions and understandings of grieving (Attig, 1996; Stroebe, Hansson, Schut, & Stroebe, 2008), some of which are consistent with our understanding in Existential Analysis, while others provide points of tension or even contradiction. Within Existential Analysis, we understand grieving as a personal response to dealing with the loss of life-relevant values (Längle, 2014).
A few points from this definition are worth noting, which help us to focus on the essence of grieving and which differentiate our understanding in Existential Analysis from other approaches. Firstly, grieving is a personal response rather than an automatic or coping reaction. Attig (1996) reminds us that initially we may have very little choice about how to respond; we simply react to the traumatic news of a significant loss. However, as our grief moves along, and as we enter into therapeutic accompaniment with grieving, we do have increasing capacity to choose to either turn towards or to turn away from our suffering. And grieving, in our understanding, is the intentional turning-towards the place in our life where we are hurting. The loss of a life value places before us the question or task: Can we and would we like to continue to live under these circumstances?
Secondly, grieving is a personal dealing with the loss of values, or, more simply, the loss of something that we experience as good in our lives (Längle, 1984/2009). These values certainly include those we hold dear, our family, our friends, our colleagues, and so grieving is rightly associated with bereavement. However, grieving also transcends death, and is rightly applied to situations in which we lose some-thing of value to us; a job, a relationship, a dream. In Sally’s case, we see the obvious loss of her pre-accident career, but we also see the loss of some of her cognitive and physical capacities. All of these require therapeutic attention as Sally grieves the life that she used to have.
Grieving Process
As we enter into this grieving process with our clients, it is natural to ask what actually happens when we grieve. How does this process unfold over time? While an exhaustive review of the literature is beyond the scope of this current paper, it might suffice at this point to state that scholars have conceptualized grieving in a variety of ways, including either phases or stages (Bowlby, 1980/1998) or tasks (Worden, 2009). In Existential Analysis (Längle, 2009; 2014) we understand grieving to unfold over time, although with the caveat that the process outlined below is likely to be much more cyclical rather than linear. Grieving occurs naturally in waves, as our clients move back and forth between intensive periods of turning-towards their suffering and times in which they orient themselves to other tasks in life. A brief description of this process is portrayed below, and examples of my therapeutic work with Sally are included.
Attitude of Letting Be. Grieving begins initially with an attitude of letting be, of allowing ourselves and our situation to be what it is (Längle, 1984/2009). Once we have can come to a place where we can accept the facticity of the loss, and we take the time to turn inward and face what we have lost, we can initially start with allowing these facts to be what they are. This letting be – in which we allow our situation to be as it is and allow ourselves to be as we are, represents a stopping of defensiveness. We choose to stop fighting against an unwanted and obdurate reality. As many of my clients, including Sally, say – “it is what it is”, and we can give a preliminary and tentative ‘yes’ to this is-ness. As long as we still struggle against the loss, there is no letting be, no grieving. But the letting be of the situation, our giving of an ‘inner yes’ to it (“it has happened and we allow it to be as it is”) brings closeness to ourselves and to our losses. In this ‘yes’ to the loss, an inner flowing starts to happen. We allow this flowing to take place within us, we step into the flow, and notice that tears naturally begin to flow. What is required of us initially is simply an allowing. An allowing of the facticity of the loss and an allowing of this flowing inside and with our tears.
This allowing was a difficult process for Sally, and this seems to be frequently the case in my clinical practice and beyond (Kreutzer et al., 2016). The complicating factor for Sally was that initially we did not know whether or not her losses, with respect to cognitive and physical functioning, were actually losses or whether she may regain some of these capacities over time. However, as Sally began to test out her capacities and I accompanied her throughout these various attempts, we were able to discern, in concert with her various healthcare providers, what she was able to do and what was beyond her capacities. One of the most painful of such losses was Sally’s job in creating and repairing medical equipment. This job was deeply meaningful for Sally and embodied many of her values. She was able to use her natural mechanical gifts to repair and craft equipment for people in medical need. What was particularly difficult for Sally was the fact that she was able to accomplish core aspects of her work (the mechanical repairing of equipment), but she was not able to complete the associated paperwork or pass required safety examinations. Moreover, Sally found herself easily distracted and confused by co-workers who would at times interrupt her work in order to ask questions or simply chat. Over time, Sally’s condition at work and at home deteriorated, and she became increasingly confused, fatigued and disoriented, even with tasks that she previously was able to accomplish. As we discerned the meaning of her deterioration together, and as Sally consulted with the other professionals, we ultimately came to the conclusion that she was simply not able to return to her work. This realization took some time for Sally to allow. Over the course of several weeks, we would meet and simply explore this question together. As Sally took time away from work and rested, she began to regain some cognitive capacities that had deteriorated under the stress of the return-to-work attempt. In one particular session, Sally came into our therapy room and announced that she had finally reached the conclusion that returning to work was not possible for her. She sighed deeply, and as our gaze met, tears began to well up. Sally had come to the conclusion, to the decision, that she was not going to return to work again. She would now try her best to allow this reality to be what it apparently was.
Tears in this context have a special message, and as much as I, as a therapist, empathized with Sally’s sadness over her losses, I also secretly found myself rejoicing inwardly in knowing that Sally has stepped back into this flow of life. Tears indicate that life begins to move again within us, that we are touched again by life, even when it is the loss of a life value. Tears tell us that we are still alive, that we are still in this life, even if we know that part of this life, the life that we knew up until this point, has been irrevocably changed. Tears are therefore the beginning of life, which emerges again, simply through our turning-towards and letting be.
Inner speaking. Through our loss there is a gap – a part of life has been taken from us (Längle, 1984/2009). The question now is – how can we now fill this gap? The tears begin to clean this wound so that it may now grow together again. In the midst of the initial wordlessness and shock over the loss, slowly an inner speaking begins to emerge. Our tears tell us that we are still alive and are moving back into life, and now we have the opportunity to add our own voice to this, to speak what is emerging within ourselves. One place to begin is to begin speaking words of comfort to ourselves. These words acknowledge the facticity of the loss; we are indeed ‘poorer’ because of the loss of a value. Some clients may see this initially as indulgent, as complaining or wining. But there is an important distinction in that it is an authentic emotional response to the facticity of a loss (Längle, 2011). Speaking words of comfort to ourselves creates warmth and strength. The speaking is not just about ourselves but it turns towards a future. Feelings begin to emerge. Through this inner dialogue we are able to comfort ourselves. Healing in this sense requires tenderness, closeness, touch. As we turn further towards ourselves, we can begin to give care to ourselves. Loved ones may be able to assist here as well. The question emerges – what do I need in this situation? I may need quietness, conversation, doing something good for myself.
For Sally, these words initially emerged in our therapeutic dialogue. I expressed my genuine regret and sorrow over the loss of Sally’s beloved job. We had worked so hard together to help her return to work successfully, and now had to acknowledge that this was not possible. As I began to express my own feelings of sorrow over this loss, Sally joined in this dialogue. She began to speak about the importance of her work, how she had been a pioneer in this area of work, doing a job that, especially in her early years, had generally been the province of men. We began to speak about the meaning of Sally’s job, the ways in which it had aligned with her values of courage and a desire to help those who could not help themselves. Sally also continued our therapeutic conversations outside of the therapy room, as she journaled about her losses and engaged her partner in similar conversations. These times of activity and turning-towards what had been lost were punctuated by times of silence and stillness. At varying times throughout the day, Sally found herself in need of quietness and would retreat to her workshop to tinker with varying projects, to return to her beloved mechanical work as she repaired items for friends or created toys for her grandchildren.
Re-Orientation. When we have now come back to ourselves and feel our own life, we can now raise our gaze into the world (Längle, 1984/2009). First we can look at what has been lost. Is life still worth living at this point? Do we want to continue to live in light of what has been lost? Through this dialogue we begin to clarify our relationship to what has been lost. What is different? What remains the same? Can we live with our life in this changed form? In light of these new conditions, and following our tears and own inner movement, the question now emerges – do we still experience ‘an inner yes’ to life?
This re-orientation for Sally emerged at various points in her rehabilitation journey. As we began to look at what she had lost, most poignantly her paid work, Sally asked herself some fundamental questions about her work and about life. Although at varying points in her past, Sally had struggled with suicidality and with a desire to want to live, at this point in her recovery Sally felt clear that life was still very much worth living. Sally’s struggle at this point concerned how she might be able to continue to use her skills. She asked herself crucial questions. What is it really that I love about this work? Do I need to be paid in order to feel be a valuable member of society, in order to contribute something? We repeatedly returned to the fact that her mechanical abilities were still largely intact and she was able to repair various pieces equipment at a slower pace but with the same proficiency as prior to her accident. As we continued to journey together, Sally attempted to engage in various volunteer activities. She volunteered at a local hospital, assisting with the repair of wheel chairs, but found that the hospital was too busy of a place, and she struggled with distraction and confusion when she felt overwhelmed by too much stimulation. Over time, Sally discovered that there were so many needs within her immediate community – her family, friends and neighbours – that she was able keep herself busy with practical projects without perceiving the need to seek out paid or formal volunteer work.
In addition to finding new ways to live old values, therapeutic work with Sally (and virtually every other client) also began to take up relationship to new values. One of the benefits of encountering the limits of her existence, was that Sally gained a clear understanding of the importance of her values. She knew, as do most of my clients, that life was primarily about relationships and love, and began to live out these values with greater intentionality. For Sally, this included giving greater attention to family relationships and friendships, but also seeking out opportunities to assist several neighbours around her who likewise were struggling with various serious illnesses.
Consequences of Grieving
Finally, it is worth looking briefly at the consequences of the grieving process. What happens as a result of turning towards our losses and allowing this dialogical process to take place? How are we changed by our grieving? For many clients, including Sally, there is an intensification of relationship; relationship to oneself, to those who walked closely with her during this difficult time of grieving and an intensification of the relationship to her values. While we did not deny the very real losses that Sally had experienced, she also was able to appreciate that she was able to live her life now with greater intentionality, with a clearer ‘inner yes’ to her values, her work and her relationships.
The consequence of this was, for Sally, frequently an experience of joy. She shared often that she found herself walking down the street smiling at strangers or having meaningful and open conversations with people at the bus stop. Simple put – Sally found herself feeling more connected to people around her, taking time for moments of connection, especially with those who were suffering, and living her life with more joy and gratitude. Sally also expressed a new-found appreciation for spirituality, and although she eschewed traditional institutional forms of religion, found herself experiencing life with greater trust in the Divine and its guidance for her life. Although she had indeed suffered profound losses, she had in the end also gained much, and for this she remains thankful.
Conclusion
Over the course of this paper I have attempted to elaborate on the
process of grieving within Existential Analysis through the case example of Sally,
a client with a severe traumatic brain injury.
I began initially with a brief literature review, in order to situate
the TBI within the relevant scholarly literature. Next I focused on personal activities of the
first Fundamental Motivation, the endurance and acceptance of the facticity of
the injury and its consequences. Following
this, the pre-requisites for grieving – relationship, time and closeness – as
well as personal activity in grieving itself, the turning-towardssuffering in loss, were explored. The varying phases of grief accompaniment
were illustrated through therapeutic processes with the client. Existential Analysis represents a therapeutic
approach that draws upon the client’s own personal presence with their
suffering, and calls upon the clinician to join the client in this profound and
sacred encounter.
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