Book Review: First Person Narrative on Grief and Loss- My Own Country, a Doctor’s Story, by Abraham Verghese

Anna H
Sallie Foley
SW 617- Death, Loss and Grief
Property of the author; do not use or reproduce without express permission.

Abraham Verghese’s narrative on his time as an infectious disease internist treating AIDS patients in the rural, east Tennessee town of Johnson City provides a vivid and compelling depiction of the manifestations of grief and loss which can overwhelm medical and familial care givers in ministering to terminal patients. In reading it, we may find a compelling and deeply personal account of the experience of death, both anticipated and sudden, and the vast array of emotions expressed and felt by those who are required to cope with such losses, as those anticipating their death, and those who are left to care for them, and others to follow. During the first stages of the AIDS epidemic, starting in the summer of 1985 when little was known about the disease and all the stereotypes and stigmas attached to its being an illness of only the urban, gay male and drug-using populations still held largely true, Dr. Verghese begins his tale of slow-dawning but horrific comprehension of the impact AIDS has on patients and family alike. Despite his seemingly pristine country location, as Verghese develops a burgeoning caseload of patients, most of whom are gay men, he unfolds for his readers the rising feelings of panic and helplessness experienced by both the medical and general communities in the face of a disease which is even still considered by many to be a death sentence. Along with the devastation of an HIV/AIDS diagnosis, Verghese opens our eyes to the myriad of losses accumulates through lifetimes of hardship for nearly all of his patients as members of these already pariah groups: familial rejection for sexual orientation, enormous struggles for daily survival in poor and rural areas, and wide-spread social dismissal combine to compound the grief expressed in this book. As he describes sometimes poignant and stirring, other times graphic and disturbing vignettes of living and dying with AIDS, we relive through Verghese’s memoir the acute pain of immediate threat to livelihood that the disease became to his patients. Through his personal struggles to provide care to this much-feared population, we experience again and again the wash of sadness and loss as one after another of his patients becomes a real person in his, and by extension our eyes, only to waste away in pain and die.

Patients are often aghast, even devastated by the news that he must give them, and the range of emotion his patients, and by extension he, feel in anticipation of their death runs the spectrum from nonchalance, denial, rage, courage, depression, and grief to empowerment and a sense of purpose. Family members’ reactions frequently extend as far, but the grief Dr. Verghese and his patients feel is at times compounded when family members react as much of the broader community does: with fear, prejudice, and condemnation for a lifestyle they do not understand or on which they look down. Deaths are often met with the same mixture of feelings from patients and Verghese, some are ready and it is a mercy to see their physical pain ended, others are a frightening indictment of a community’s lack of compassion, or grief- and anger-filled accounts of the seeming futility of trying to help those with this “virus from hell”. Similarly, these patients all cope with their grief in different ways, and in doing so, give Verghese an outlet to express both his and their mixture of emotions. Several patients, such as Fred, who renews his commitment to gay activism in leading the TAP support group for other patients like himself coming to terms with their diagnosis of AIDS, offer the readers bright spots of hope and comfort in the otherwise seemingly bleak remainder of their existence. Some, like the patient Luther, rage at their predicament and give outlet for Verghese’s own bitterness at being able to do little to save anyone he treats. Still others, such as Gordon, gently come to terms with their illness by first grieving, then integrating their loss of future, and often past missed opportunities with loved ones, into a calm and peace which touches us and begins to sooth his and our pain in their death even as it blossoms.

From Dr. Verghese’s point of view, the most difficult aspects of facing death by AIDS is the fear of further loss of self—either in the community, with family, or in one’s autonomy—before one has actually died, coupled with the immense and overwhelming loss of being able to do little, if anything to stave off that eventual loss of self. AIDS is not a quick death, nor is it painless, and it causes much frustration, fear, and grief in his patient’s anticipation of their decline, as well as with regard to Verghese’s sense of self as a doctor and the expected power to heal. As privy to Verghese’s personal experience, we come to realize the toll this cycle of connection with and loss of patients takes on him when he becomes the only doctor trained in AIDS or even willing to provide primary care for his part of Tennessee. Through his treatment of, attachment to, and loss of these patients, we feel the deepening sorrow and sense of despair Verghese has as the death toll rises among these people he can only nominally help, and we grieve with him for all the suffering, caused by both an unrelenting disease, a fearful, too-often hateful community, and the visible deterioration of autonomy held dear by all of these people. They grieve, for the loss of futures they no longer can experience, for the disconnect they often have experienced with their families and that the little time they have left with, for the pain of being shunned and the pain of having to depend on those who are willing to care for them as they physically fall apart.

Thankfully, Verghese learns over the course of the book that, in part with his help, there is much that can and does improve in the quality of this end of life care, so much so that the death sentence AIDS starts out as in 1985 commutes to a gradual decline of maybe years by 1989. With him we discover the profound importance of palliative care and personal connections as he focuses more and more on quality, as well as quantity of life, referring patients to the TAP support group as frequently as he prescribes antibiotics for opportunistic infections, and making personal connections which heal his patients’ souls in a community with only marginal tolerance for the “gay disease” and those who still live with it. His acceptance and even embracing of his patients offers him what his medical degree cannot: the chance to be accepted and cared for as fellow human beings. It is this, more than any other medical approach described in the book, which does the most good in alleviating or at least tempering the grief they all feel. Verghese feels kinship with his displaced patients as an un-rooted, Ethiopian-born Indian working in America; the displacement from community, disconnect from family and ascribed tainted quality that leaves AIDS patients with an untouchable feeling is echoed in the doctor’s own personal life, and, despite ultimately developing compassion fatigue which forces him to detach from this community at the end of the memoir, throughout it we feel the strength of the bonds he develops. These acts of care are the balm—both he as their caring and compassionate doctor, and from those family members and friends giving loving support—which enable many of Verghese’s patients to live out their days in relative peace. Regardless of poverty, which is pervasive in rural east Tennessee, or sexual orientation, the cause of much fear and hate in the community, Verghese is able to form bonds which help diffuse grief, aiding to shift the model from the stigmatization of dying from AIDS to finishing life as much on one’s own terms as possible.

The DeSpelder and Strickland quote that “death is inseparable from the whole human experience; the study of death touches on the past, present, and future” is very much true in the account My Own Country provides of people living with an AIDS diagnosis. For some it is an erasure of any possible future, for many, as Verghese describes and maps out, it is the culmination of a progression of past events for those gay men in rural America who began with a desire to leave home to find a life which fits who they are, and which cannot be obtained in their home communities, but who ultimately return home to their families to integrate past and present, to make up for a lack of future, and to die. By the memoir’s end, Verghese observes that AIDS has gone from an isolating killer of a small, shunned few to providing the surprisingly reassuring possibility of community and support which encompasses both the anticipation of death and the living of the rest of one’s life. This emissary of death has offered a way of living, coping, and loving to those who share its sentence, and rather than be the fugue of mourning for lost futures, AIDS provides the surprising victory march by which his clients come to embrace life more than they had before. Certainly, grief and fear of death are a strain in all the moments thereafter- there is no escaping that the disease is killing them. However, as Verghese comes to realize, the community formed to grieve and cope with the loss of such a diagnosis, which extends to include those family members affected and grieving themselves, becomes one which also makes room for his patients to have a sense of self again, and in doing so, they find reason to celebrate as well. Grief at the loss of community, of past displacement which sent them seeking lives away from their birth home, gives way to the growth of a new community home of their own, in which they may be welcome.

Survivors of Suicides: Struggles with Complicated Grief and Approaches to Treatment

Anna H.
Sallie Foley
SW617- Death, Loss and Grief
Intellectual property of the writer. Do not use without express permission.

In his book on addressing grief from a clinical perspective, Grief Counseling and Grief Therapy, Worden (2009) reserves much of a particular chapter specifically to address the issues that arise when faced with a death due to suicide. It is, he notes, a particular type of grief which causes much trouble beyond the normal feelings of pain and loss at the death of a loved one: “Nearly 750,000 people a year are left to grieve the completed suicide of a family member or loved one, and they are left not only with a sense of loss, but with a legacy of shame, fear, rejection, anger and guilt,” (179). Out of all the different experiences throughout the western world, few evoke as complicated and visceral a reaction as surviving a loved one who has died due to suicide. Suicide has been criminalized in countries and been deemed a sin by many cultures; many people frequently continue to see it as the ultimate act of selfishness. It is a type of loss where people don’t send condolence cards, one that is often left unacknowledged, and for which there are few, if any, good explanations. Suicide causes so much disruption among families and communities beyond the normal scope of grief for the death of a loved one that many surviving friends and family struggle for years with loss that stigmatization, coupled with shame, rage, confusion and guilt makes more complicated than any other type of death we encounter. There are, however, many therapeutic means through which people can alleviate these complex and burdensome layers of grief, so that in time they may uncomplicated their grief enough to incorporate it into their love and memories of the person they have lost. This paper will discuss in greater depth the various types of struggles surviving loved ones face when they shoulder the complicated grief of a completed suicide, and several modes of therapy which have been found particularly helpful in mediating their pain.
Grief reactions to the death of a friend, loved one, or family member always include sadness and periods of pain in missing the person whose life has ended. When a the loss is due to suicide, however, these normal feelings can become terribly enmeshed with a myriad of other, often more destructive feelings caused by stigma associated with this particular type of death. “Suicide survivor” is term which has come into clinical parlance to describe anyone who experiences these significant, painful consequences for a suicide within their social network, and there is a recognition that this term is applicable to a significant percentage of the population—perhaps as many as 7% of people in the United States (Jordan, 2009). While not everyone exposed to suicide feels its impact in the same way, the grief experienced by survivors of suicide is most commonly characterized by the shame and guilt they carry with regards to their connection’s death, compounded by other tumultuous emotions such as anger, hurt, betrayal, confusion, and— frequently— shock at the unprepared-for loss. There are thoughts that for many, these complications for survivors of suicide, like those who survive the loss of a loved one to an accident, are suffering in large part due to the sudden, unexpected nature of the death, for in such losses there is no time to say goodbye, or prepare one’s self for the absence of the deceased (Lindqvist, Johansson, and Karlsson, 2008). However, Jordan observes that there are no “clear operational definitions” for a suicide survivor, along with a notable lack of longitudinal studies with regards to their integration of the loss, further indicating that, at least within Western culture, there remains a significant taboo when to dealing with suicide and all that it touches, even when it comes to helping treat those who suffer in its aftermath (Jordan, 2009).
Feigelman, Gorman and Jordan (2009) discuss in great detail both the ways in which stigma in response to suicide has developed in Western culture and the damaging effects it can have on the dead person’s survivors. In Europe, from as early as the Middle Ages the punishment for suicide from the Church and the State extended beyond the deceased to their family: property could be confiscated and held by governing agents, and all immediate relatives could be excommunicated from the Church (Feigelman, Gorman and Jordan, 2008). It is the continuation of this stigmatization, coupled with guilt, which appears to be the primary cause for complicating the grieving process for survivors of suicide up to the present day. In a survey conducted with grief support groups, Feigelman, Gorman and Jordan observed that, when comparing the effects of stigmatization responses in a group of 462 parents who had lost children to suicide with 54 whose children had died to traumatic death and 24 from natural causes, those parents who encountered stigmatizing responses from their peer, support and family groups had greater difficulties with their grief, including the development of depression and suicidal ideation on the part of the survivor, (Feigelman, Gorman and Jordan, 2009).
Distorted communicative perceptions based upon stigmatization within family and social systems in reaction to the suicide can have a significant impact on the ways in which the survivors cope. Families can experience, or themselves develop feelings of blame (or being blamed) for the death, feel the need to keep the nature of the death secrete from extended family or the larger community, and undergo a sense of social ostracism (Jordan, 2008). Even for those who do not encounter any outright negativity regarding their loss, the experience of ambiguity and lack of social protocol for how to be supportive of a family grieving for this sort of loss can lead to exacerbated feelings isolation, shame, and condemnation (Jordan, 2008; Worden, 2009). Worden describes a client who came into his office and lamented that “‘no one will talk with [me]… they act as if it never happened,’” (Worden, 2009). This is not to say that there is no social support for survivors of suicide, nor that all social interactions produce feelings of shame or stigma; there is evidence to suggest that near to half of the survivors of suicide may experience a strengthened feeling of closeness to their remaining living family members and friends or support structure (Feigelman, Gorman and Jordan, 2009). For the other half, however, it does underscore the complicated reactions both felt by the survivors for themselves and as members of the community in which they live. What may be of most import when considering the negative effects of stigma is the expectation— prevalent throughout the centuries, despite the growing recognition in our present time that suicide is almost always predicated on mental disorders and psychological illness— that there will be little support for the survivors, and that they are somehow to blame for their loss (Feigelman, Gorman and Jordan, 2009).
The other, perhaps most pronounced experience for survivors of suicide is the often overwhelming sense of guilt they feel: for not anticipating the actions which caused their loved one’s death, for not recognizing their pain, for not being able to somehow save him or her, and in turn, save themselves the pain they and others sharing their experience now feel. As with stigma, Pridmore and McArthur note that feelings of guilt have been associated with suicidal loss since antiquity in the West; going back as far as ancient Greece they see maladaptive feelings such as guilt, shame, anger, and sorrow (Pridmore and McArthur, 2009). Worden discusses that while guilt is frequently a feature of normal grief responses, the amount of guilt felt by survivors of suicide is inordinate and often overpowering (Worden, 2009). People who feel this amount of guilt can end up feeling themselves deserving of punishment, which can be very damaging to the survivor’s psyche and in turn can have physical consequences (Worden, 2009).
This sense of pervasive guilt may be especially the case for children and adolescent offspring of parents who have died from suicide: apart from the negative indications parental suicide has for child mental health outcomes in the future, the disruption of family functioning both before and after a parental death from suicide can have a significant impact on the psychosocial functioning of offspring (Kuramoto, Brent, and Wilcox , 2009). Worden discusses the ways in which reality testing when working with youth is particularly important, that families and clinicians be alerted to self-blaming and guilty feelings in children, as there is a correlation between being affected by suicide as a survivor and the survivor experiencing suicidal ideation in him or herself (Worden, 2009). Higher levels of shame, anxiety and anger have all been found in adolescent children whose parents died by suicide than in those whose parents were killed or died in other, less traumatic ways, and there is an increased risk for behavioral problems, well as possible decrease in overall functioning within the bereaved family unit (Cerel, Fristad, Weller and Weller (1999) in Kuramoto, Brent, and Wilcox , 2009). Jordan notes that many people incorporate their feelings of guilt and self-blaming into an ongoing analysis after their loved one’s suicide to determine if they were somehow the cause of it; unfortunately, these feelings, and the need to assuage them, can cloud the survivor’s recognition that their loved one, like up to 90% of suicide completers, had severe mental health disturbances, and these—not their actions or inactions—were what led the loved one to take their own life (Jordan, 2008).
All grief incorporates these elements or guilt and a wish to blame, and while the expectation of stigmatization appears to be particular to survivors of suicides, the social isolation felt by those who are grieving can cause additional pain beyond their initial loss; in the complex grief of survivors of suicide, there is another piece, comprised of anger and feelings of abandonment, which prolongs and further complicates the survivor’s ability to integrate their loss back into the tasks of living. Worden discusses the intensity of angry feelings survivors may experience when they perceive the death as a rejection; children and spouses may feel betrayed or as though their loved one’s death was a direct means of leaving them, and their grief may take on qualities of resentment or even rage (Worden, 2009; Kuramoto, Brent, and Wilcox , 2009). These mixes of emotions often feed into their guilt, and can have an impact on self esteem, that they feel as though their worth as the survivor is less because they were the ones who were left. There may also be questions in the survivor’s mind as to whether their deceased loved one was driven to death, which can be compounded by feeling of anger and hurt that they felt the need to kill themselves, or were not ‘strong enough’ to continue living (Jordan, 2008). Guilt and unworthiness at surviving often war with rage and immense pain at being left alone. Particularly in the case of teenage suicide, where there may be little sign of severe emotional distress disclosed before the act of suicide, surviving parents struggle with the unexpected nature of the death, their anger at being deceived by their children, their overwhelming pain at the loss of a child, and their guilt as seemingly failed parents (Lindqvist, Johansson, and Karlsson, 2008). Without intervention, such complicated grief, especially if coupled with post-traumatic stress if the survivor was a person who discovered their loved one’s death or body, can mix to cause grief so complicated that it overwhelms a person’s ability to work through their loss on their own such that they can continue living (Jordan, 2008).
In order to help intervene in complicated grief for survivors of suicide so that they are not wholly overrun with their feelings and cease to experience life themselves, it is of primary importance that the clinician acknowledge the death of their loved one and the entire spectrum of grief they feel because of that loss, to aid in overcoming the first hurdle of dealing with an unspeakable loss (Worden, 2009). The stigma of such a socially unacceptable behavior must be undermined in the eyes of the client, both so that the therapist may form an alliance with them and that they may feel that here is a safe place to begin coming to terms with all their feelings regarding their survivorship without being judged for any of them. Given that barriers to grief experience stemming from negative experiences regarding their loss can be linked to depression and suicidal thinking on the part of the survivor, it is paramount that a therapist acknowledge the reality of the loss along with the client, and bridge the loss of community they may have experienced (Feigelman, Gorman, and Jordan, 2009; Worden 2009). In surmounting the feelings of social and community isolation, it may be necessary for the clinician and client to take stock of what relationships are healthy and supportive to that client, and which may be more painful than they are worth currently (Feigelman, Gorman, and Jordan, 2009). This may even entail supporting the survivor in instructing their support system how to better work for them, which in turn will help destigmatize the association with the type of loss they are experiencing. Establishing this groundwork of support and belief for the client’s feeling, whatever they may be, is important in all cases, but all the more so when they are the survivor of a socially unacceptable loss.
While accepting the losses and the tumult of emotions the survivor has faced, however, it is important to keep in mind that the therapist needs to reality test a client’s feelings of guilt and blame, gently challenging or correcting distortions as they come up in conversation. Such gentle questioning can be highly appropriate for a client who feels excessive guilt, shame, or abandonment, as these feelings can stand in the way of Worden’s second task, processing the pain of grief. He gives the example, for instance, that it is acceptable for survivors to feel some level of relief that a person who had been experiencing such emotional anguish might no longer be in pain, even as they also feel anger at that person for leaving: such a jumble of emotions not only needs to normalized, but examined from an outside perspective, in order for a client to come to terms with all that they feel in association with their loved one’s actions (Worden, 2009). Similarly, while relieving the guilt many people feel for just having emotions which might be deemed somehow inappropriate, it is also necessary to give them the permission to feel as they do. These normalizing and giving permission tactics can be utilized either in one-on-one or group grief work settings with success, as individual attention and contact with other survivors are both beneficial in acknowledging the unique horror and relieving the isolation associated with suicide (Jordan, 2008). The best supports for survivors may come from other family members and close social connections, and it may be useful to incorporate them into a therapeutic situation, to act as witnesses and, in doing so, assuage some of the guilt and stigma of grief of this nature (Feigelman, Gorman, and Jordan, 2009).
Stepakoff (2009) suggests that, since suicide explicitly is a destructive act, a treatment of particular use for survivors of suicide involves active and willful countering of destruction, in the form of finding meaning and solace in creativity. To this end, she recognizes poetry therapy, the “utilization of poetry and related forms of literature and creative writing in order to improve psychological functioning” as a technique which is of great help to some survivors of suicide (Stepakoff, 2009). Lindqvist, Johansson, and Karlsson (2008) suggest that one of the hardest things to cope with is a survivor’s attempt to see a meaning in the actions their loved one has taken, and it can play a vital role in the ways in which survivors struggle with or accept their loss. Poetry therapy, therefore, is a means by which survivors can break their silence and express their struggles regarding the meaning of the suicide in an externalizing manner (Stepakoff, 2009). She outlines what she sees as the four primary tasks of for using poetry in working with survivors of suicide as:
“(a) to describe, in a fresh, creative manner, common aspects of the grieving process after a suicide, thereby helping participants feel less isolated; (b) to model exceptionally honest and brave self-expression, thereby freeing participants to express themselves more frankly and fully; (c) to give external form to internal, difficult-to-articulate emotions and perceptions, thereby helping participants contain their psychological pain; and (d) to serve as objects of aesthetic beauty, thereby instilling in participants renewed feelings of vitality and hope.”
(Stepakoff, 2009).
The approach is in keeping with Worden’s thoughts on helping survivors make meaning of their experiences of pain and grief by participating in the search for an answer for why this terrible even occurred, as well as work through task three, adjusting to a world without the deceased (Worden, 2009).
There are two forms of poetry therapy—receptive, which relies on the use of preexisting poetry, and expressive methods, which invites a survivor to use their own words, in poetry, or other creative writing form—either of which can be used on one’s own, or and especially to start out with, as facilitated by a therapist. Stepakoff outlines the use of receptive poetry as following one of two general methods: the survivor may pick a poem themselves in which they can find meaning and an echo of their feelings about the loss, and can read it aloud or to themselves; alternatively, the therapist can guide the survivor through the process where they facilitate the interaction and chose a poem which seems most appropriate. The former is more often utilized in the context of individual work, while the latter tends to be more in grief group settings, but either way constitutes classic poetry therapy, wherein the client’s task is to discern what they relate to in the body of work, and use it as a catalyst to discuss how they are experiencing their loss (Stepakoff, 2009). The expressive form of poetry therapy utilizes the client’s own words and thoughts to achieve what Worden discusses as the process of grieving; it includes the survivor’s writing down and often reading aloud the thoughts and feelings he or she experiences throughout the therapy, and at specific point in time, as they feel certain things. The theory behind this work is rooted in the idea of catharsis— that it is necessary to come to some resolution of powerful and often hurtful emotions through a purification or purging of the thoughts or feelings—and the practice of externalizing feelings, such as what is used in narrative therapy work, to separate out how a survivor feels from who that survivor is (Stepakoff, 2009). In doing so, the goal is to build in the client the ability to pick up, examine, and feel for a portion of time the overwhelming set of emotions he or she has been fraught with, without being overwhelmed by the constant presence of those aspects of grief within themselves.
It is not the resolution of the grief that is sought, but rather the rebuilding of the survivor’s life with their grief integrated into their future which therapists attempt to achieve when working with such clients (Jordan, 2008). Incorporating poetry therapy and other externalizing models into a framework where the therapist is present and accepting of the pain and grief the survivor brings into the room is a key to working with this population, and in doing so, we as therapists offer a means of easing the sorrow enough that a survivor can, in time, begin to remember their loved one while moving forward with their life.  
Bibliography:
Feigelman, William, Bernard S. Gorman, and John R. Jordan, (2009). “Stigmatization and suicide bereavement.” Death Studies, 33 (7) 591-608.
Guglielmi, Maggie Colleen, (2009). “The impact of stigma on the grief process of suicide survivors.” The Sciences and Engineering, 69(8-B) 5027.
Jordan, John R. (2008). “Bereavement after Suicide.” Psychiatric Annals 38(10) 679-685
Kuramoto, S. Janet, David A. Brent, and Holly C. Wilcox (2009). “The Impact of Parental Suicide on Child and Adolescent Offspring.” Suicide and Life-Threatening Behavior 39(2) 137-151.
Lindqvist, P., L. Johansson, and U. Karlsson, (2008). “In the aftermath of teenage suicide: A qualitative study of the psychosocial consequences for the surviving family members.” BMC PSYCHIATRY, 8:26.
Pridmore, Saxby and Milford McArthur, (2009). “Suicide and Western culture.” Australasian Psychiatry 17(1) 42-50.
Stepakoff, S., (2009). “From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief.” ARTS IN PSYCHOTHERAPY 36 (2): 105-113.
Worden, J. William, (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing Company, 4th ed.

Personal Reflections on Grief and Loss

Anna H
9/15/09

In considering how I have personally come in contact with death and loss, or experienced grief, I must first acknowledge that I do not feel as though I have had much first-hand knowledge of what it is like to lose someone. I have been blessed to have not lost anyone immediately close to me, neither friend nor nuclear family member. That being said, however, it occurs to me that there are a number of different categories of loss which I tend not to consider to be “as important” somehow when applied to myself (though they are significant in the lives of others). When I allow myself to broaden my approach to loss- as I would with a client, though perhaps reticently for myself- I come to realize that there may be much for me to say on the topic which I can speak to personally.
My experiences with personal grief stem more from an awareness of people and opportunities I have not had. Some of my greatest losses are more concerned with the sense of lacking and wanting, rather than the traditional experiences of severed attachments due to death. I am the daughter of divorced parents, who separated when I was 4 years old; therefore, I have not had the experience of growing up in an intact family system, with the support and ready attention of both biological parents. While the divorce in and of itself might qualify as a major loss, in my mind the grief comes not so much from their separation as such, but from the losses that occur as a result of not having them together. I do not remember what it was to have my parents love one another, to model for me how a good working relationship functions, or for us to work as a happy family. These losses of what I could- perhaps feel I should- have had in my growing up are much more what I feel, as I was not old enough to know what things might have been like before my parents became unhappy with each other. Loneliness, and the awareness of missing good family relationships, has therefore been the most pervasive cause of grief in my life.
Beyond my parents, I have grown up with very few family ties: my parents each were isolated themselves from their extended and nuclear families, and, though for different reasons, the end result was that as their daughter, I know very little in the way of familial support or interaction. My mom’s mother died of breast cancer when I was two and my mother still grieves for her, but I do not know what it is like to feel that pain immediately, because I didn’t get the chance to know her; it is for that that I grieve. My father’s parents both lived in Florida and were very much out of regular contact with my Dad due to his strained relationship with them after they kicked him out of the house at age 18 for getting his first wife pregnant; they both died by the time I entered high school. My mother’s father, who died only this past April, was my last grandparent, but due to the falling out she as the result of much hurt and anger over my grandparent’s divorce and my grandfather’s marriage to the woman with whom he had an affair before that, I too lost the chance to develop a meaningful relationship with him. As much as family means to me in theory, my personal experiences with the ways in which families interact has been extremely curtailed by the actions of my parents, beginning long before I was even born. While I don’t often think of these things as losses per say- they are so far removed from my experiences that I again don’t know to miss them most of the time- when I allow myself to realize the extent of my family connections, I am aware that my ties with family beyond my mother, father and stepmother are only tenuous at best, and due to the nature of relationships damaged before I had a chance to experience them, I inherited the disconnection and isolation of my parents’ choices.
I can remember growing up in some ways very much alone, as both an only child, and the daughter of a single, working mother who out of necessity had to leave me at home, or with care-givers for extended periods of time from the age of 6 until I moved to college. That isolation seemed to follow me into my middle and high school experiences, and in reflecting back on my experiences as an adolescent, I am cognizant of a significant amount of time spent on my own, at home by myself. Because I had very little in the way of extended family connection, I have long been aware that my friends are in many ways my family of my own choosing, and as such the separation and drifting apart that occurs when life stages and physical closeness wane have been acutely and painfully felt on my part. This is my greatest source of fear for future loss, which in and of itself may play a part in my understanding of what it means to experience grief: after the initial pain of a loss has begun to subside, there still remains the fear that another, equally hurtful loss will follow the next time I engage in a close relationship or friendship, and either through loosing again and again, or else by never having the ability to find someone else, I will remain alone.

Getting Through Grief with Yourself: Relearning Self-pleasure After the Loss of a Partner

Anna H.
For Sallie Foley, 5/3/09
SSW 700- Treatment of Sexual Dysfunction


Despite the copious amounts written in books and journals addressing the theories of, and approaches to, understanding and treating depression, grief and loss, and sexual (dys)functioning as isolated topics, very little can easily be found that looks at the intersection between these very common aspect of life. The loss of a romantic partner-- be it due to a breakup, separation and divorce, or death-- is a near-universally experienced part of human relationships. Stroebe, Schut & Stroebe report that particularly among older populations, as many as 45% of women and 15 % of men older than 65 become widowed (Stroebe, Schut & Stroebe 2007). Sadly, losses of this nature, though relatively common, are most often accompanied by a significant period of grief or bereavement, encompassing a multitude of emotions ranging from severe loneliness, to anger, relief, confusion or depression. Included among these are the very real, but not often acknowledged, needs for physical comfort and expression of one’s sexuality; despite this reality, however, modern healthcare and culture does little to acknowledge that sexuality remains a part of those people struggling with depression due to grief and loss, particularly if they are widows, widowers, or the elderly. Although self-pleasuring may or may not have been part of a client’s sexual routine before or during their time with their partner, learning-- or relearning-- ways to derive feelings of pleasure in both sensual and sexual experiences, safely, in the privacy of one’s own home, with the help of a sex therapist, can empower grieving clients to provide themselves with another means of solace.

In this paper I will discuss the ways in which therapists can help bereaved clients begin to reintegrate sexuality into their lives on their own, after the loss of a their partner, by affirming their need for comfort and pleasure and teaching them sensuality-focused means of self-pleasuring, even in the midst of grief. I will begin first with an overview of what Worden calls the “mourning process”, looking at how people proceed through what occurs after loss (Worden, 2009). I will continue on from there to discuss the integration of sexuality into grief, bearing in mind that the assumption of this paper is that clients are not dealing with a low sexual desire disorder per say, only sexual desire mitigated by grief. Due to the dearth of study on specific treatment for learning to use self-pleasuring as an outlet for sexuality and a source of comfort during the mourning process, I will finish with a discussion of sex therapy approaches used in treating low sexual desire, low arousal, and overcoming orgasm difficulty. Through these, I hope to suggest a course of sex therapy tasks meant, in conjunction with continued therapy for bereavement and support, to make one comfortable with masturbation and more attuned to their body’s sexual response.

This paper focuses specifically on self-pleasure and masturbation practices as a safe and non-threatening sexual activity that can continue to be enjoyed even after becoming single, though there are many others which can be explored to whatever extent the client has interest. All that must be emphasized with a cautionary note is that a client’s emotional and physical safety stay of paramount importance in whatever sexual expression is chosen. Clients dealing with grief and loss are likely suffering through some degree of depression, and clinicians must be particularly aware of their clients’ moods, affect, and engagement in high risk behavior as a result.

Sexuality is not often talked about as an aspect of bereavement that deserves to be addressed and promoted as an aspect of life which does not simply end after the loss of a partner or spouse. Sex therapists have for years promoted the idea that adult sexuality continues for as long as we live, and even major life changes such as losing a partner do not have to spell the end of one’s sexual life or the enjoyment of sensual activities. “Divorce may impact your sexuality by depriving you of a partner… and widowhood… has a unique impact on your opportunities, desire for, and capacity to be sexual, but neither need derail your sexuality or sexual identity,” (Foley, Kope, & Sugrue, 34, 2002). In the context of grief and mourning, however, in order to get the stage of a therapeutic relationship where clients are ready and want to address their sexual needs, it is important that clinicians in all fields of therapy first understand better what the experience of loss does to a person, physically, emotionally, and psychologically.

Stroebe, Schut & Stroebe outline in their review of health outcomes related to bereavement that there are extensive implications for physical as well as mental health when one has lost a loved one, including strong support for the idea that the “quality or nature of the lost relationship has much effect on outcome [for the survivor’s experience of loss]” (Stroebe, Schut & Stroebe, 1967, 2007). Therefore, the impact on surviving spouses of deceased partners, or individuals who have just been through divorce, separation, or breakup, is that one can expect to go through much during his or her time of grief over both the loss of relationship and partner. Physically, loss frequently manifests itself in a variety of behavioral and psycho-somatic changes which make up, in part, the experience of grief. These can include changes in a number of activities and aspects of daily living which are also hallmarks of depression, such as fatigue, agitation, weeping, social withdrawal, loss of appetite, sleep disturbances, and physical complaints (Stroebe, Schut & Stroebe, 2007). Further, depression as a normal result of grief can directly negatively affect how one responds to things that once gave them pleasure, sensually and sexually. Changes in general mood, attitudes towards sexuality, and physical wellbeing can be as mild as losing interest temporarily in one’s favorite past times, or can be as severe as to cause anhedonia, or the inability to take pleasure, physically or mentally, from normally pleasing events and activities. Seidman and Roose describe reduction in sexual interest as one of the most common changes in sexual response during depression, which can express itself physically as well as emotionally; for example, roughly “one third of depressed men develop loss of nocturnal penile tumescence (NPT), suggesting that depression can impair the neurophysiology of arousal or genital vasocongestion,” (Seidman and Roose, 2001). For the purposes of therapy, what this translates to is that clinicians can reassure their clients confidently with normalizing statements that, if they experience symptoms of marked decrease in arousal or sexual interest, these are common grief reactions influenced by both the loss itself, that they will likely dissipate or lessen over time, and if the client wishes to work on them clinically, they are completely welcome to do so, as sexuality is a normal and healthy part of life, even during major loss.

Emotionally and psychologically, Worden explains that there are “tasks” involved with processing and moving through the “phases” of mourning which, though a client may not follow a linear progression of milestones, are nonetheless essential to understand if clinicians want to provide support and help through loss (Worden, 2009). The first of these is “to accept the reality of the loss…that the person is gone and will not return” (Worden, 2009). This becomes a more complicated matter if the client’s partner is not deceased, but rather they are divorces, separated, or otherwise no longer in a relationship. As the literature I found devoted to the process of grieving spends little time addressing losses of these natures, I will for the purposes of this paper apply the tasks of grieving a dead partner also to the tasks of grieving a now-ended relationship. Regardless of the type of loss, many newly-single or widowed people go through a period of denial, during which they struggle against the concept that their relationship has ended and will not be the same again; it may take a person a very long time to come to terms with this. The second task, according to Worden, is to “process both the emotional and behavioral pain of grief,” (Worden 2009). While the degree of pain over a loss may vary from person to person, and certainly is can be effected by the circumstances of the relationship’s end, all people feel some level of sadness and pain when a deep and once-profound romantic bond has been broken. The third task Worden describes is for clients to begin to adjust to the world without their loved one by their sides; this includes making “external adjustments” in their new roles as single people, and possibly single parents, while continuing to live their lives, and “internal adjustments” to how they now must think of themselves (Worden 2009). Finally, the fourth task Worden discusses is that the bereaved person must find an enduring connection with their former partner “in the midst of embarking on a new life”. At the core of this task is integrating the ended relationship into their lives, as something which shaped and was of great value to them, perhaps for many years, while at the same time acknowledging and beginning to move towards a new phase of life where that relationship is no longer a dominant feature.

A note on differences among grief experiences with regards to stigma in society and gender. Greenblatt noted in 1978 that the experience of widowhood is far more common, and implies that such loss is potentially more difficult to bear, for women than for men:
Spousal mourning is a problem that mainly affects women because they have greater longevity, are usually younger than their husbands, and their marriage rate after bereavement is lower than that of widowers. Loss of spouse is, of course, a tragedy of major proportions. A widow is not only faced with loneliness, loss of companionship, and unmet sex needs, but also lacks the comfort, information, and support of a partner of many years. If her income is reduced, which is often the case, the widow may find herself poorer…. The widow’s place in society may become complicated; many widows, as well as their friends and relatives, view widowhood as something of a stigma.
(Greenblatt, 1978)
While it is easy to dismiss these observations as antiquated and outdated because of their age, there remains a significant amount of truth to them, although I would argue that the stigma and hardships described above apply equally to both men and women. A person accustomed to living with their partner and sharing a household does need to suddenly cope with the practical loss of supportive income, as well as the emotional support and companionship of their former mate, as Worden notes in his third task of making the internal and external adjustments necessary to continue living with this new and major life change. Further, it does seem to be the case that those who go through grief at the loss of a partner, particularly those who are already marginalized such as the LGBTQ and aging populations, end up denied recognition as continuing to be sexual beings. Bent and Magilvy are some of the few who explicitly acknowledge that grief in lesbian women who have lost life partners is further complicated not only by their marginalized status in society generally, but in regards to significant legal disadvantages such as visitation rights for partners in hospitals, being allowed to be beneficiaries of wills, and in some cases custody battles for children (Bent and Magilvy, 2006). Feelings of intense hurt, anger, and confusion with regards to the legal issues surrounding partner loss for this population can make the mourning process all the more painful. Foley, Kope and Sugrue note that “unlike a woman’s young adulthood, later in life her single “sexual self” may not be highly valued by the culture. Women often remark that they have to encourage themselves to stay sexually vibrant,” (Foley, Kope and Sugrue, 2002). Very little research can be found which specifically studies the sexual health or wellbeing, or even the role that sex continues to play, in the lives of those who are mourning partner loss. As Greenblatt seems to be suggesting, the general population, despite the high likelihood that most of its members will experience just this type of loss at least once in their lives, seems unwilling to acknowledge that those with grief still wish to experience sexual pleasure. In part, gender differences may be considered to try an account for this bias when looking at the way men and women view sex and it role or function in their lives, despite our modern views about female sexual liberation, it continues to be at least more acceptable for a man to have sexual needs than a woman. Regardless of this gendered division, it is important to affirm clients in their sense of loss and loneliness in missing sex and sexual expression or intimacy with their former partner, and to encourage them in their wish to remain sexual even now that they are single.
With the understanding that clients can process these multiple tasks of mourning simultaneously as life and emotion dictate, I suggest that a counselor or sex therapist’s role begins to shift from just grief work to also exploring and reclaiming the client’s sense of sexuality in the context of loss is when the client has begun to take on Worden’s third task. Recognizing that those feeling emotional pain and grief over the loss of a partner may include clients who were seeing someone for 6 months or coupled to for 56 years, it is important for clinicians to let clients who come to them with grief process it and progress through their own phases of mourning without an expected timeline for “getting better”, or even getting to the point of wanting to incorporate their sexuality into their healing. Clients may not initially feel the desire to feel or act sexually, and a client’s sexuality may be dormant for quite some time; some clients may never want to be sexual with another partner again. Foley, Kope and Sugrue remind clients that there is hope, after one becomes single again, of remaining sexual, even without their former partner:
Some single women who were previously partnered can honestly predict that there is little likelihood that they will find a new sexual partner. Their sexual response to this status is as varied as their circumstances. Some choose not to be sexual at all, others continue to masturbate and explore sensuality, and some even choose to have occasional sexual experiences.
(Foley, Kope, Sugrue, 2002).
Though addressed to women, these considerations apply to all people reintegrating sex after partner loss, since, after a time, many people do find their sexuality reemerging, whether or not they feel they are done grieving. It is at this point that sex therapists may best add their input in regards to sexual expression and health, to reassure them that their sexuality, as an integral part of their humanity, is not at all inappropriate or wrong, and in fact can be a wonderful way to self-sooth and satisfy their desire for pleasure.

The tasks of working on low sexual desire hinge on a client wanting to feel sexual, or experience sexual pleasure- so too with expressions of sexuality after loss. If the client has reached a place in their mourning process where they wish to have the means to fulfill themselves sexually, then clinicians should be ready to provide them with ways that they may get reacquainted with their sensuality and sexuality, and back in the groove. Providing permission for a client to discuss their desire to have sexuality back in their lives and offering the therapeutic context as a safe place in which to redevelop a sense of sexual self after their partner is an ideal first step, as it reaffirms trust in the therapeutic relationship, and shows the clinician’s willingness to address all needs presented by their client as they cope with loss. As a warm up for therapists to begin work on sexual exploration, it is a good idea to ask the client for a background on their self-care regimen. Understanding what they are, or are not doing, to take care of and enjoy their bodies gives you a good jumping off point for addressing the physical need for human contact, and eventually sexual needs, and leads directly into the first exercises aimed at getting clients back in touch with their sexual and sensual selves. Ask if they ever go to a salon, or get massages, or if they have in the past, how comfortable they were with that experience. Such activities are a good way to provide for the need we all have for human contact, which may not otherwise be satisfied if the client does not have children or close friends nearby. Worden points out that “being able to discuss emerging sexual feelings, including the need to be touched and to be held, is important. The counselor can suggest ways to meet these needs that are commensurate with the client’s personality and value system,” (Worden, 2009). Engaging such activities, if they do not already, is also a non-sexual way of easing clients into a reawakening of their sensuality, and getting them to begin enjoying the sensations of their body again.

Sensate focus exercises are an excellent place to begin the therapeutic work of reintegrating sensuality and sexuality into a client’s life, regardless of whether they masturbated before or during their previous relationship, because they allow for a slow and non-threatening progression from imagination to action. Hertlien, Weeks, and Gambescia, emphasize the use of sensate focus exercises in the context of systemic sex therapy as part of treatment for several different sexual dysfunctions (Hertlien, Weeks, and Gambescia, 2009). In the context of reincorporating masturbation and self-pleasuring into the lives of bereaved clients seeking comfort and an outlet for their sexuality, sensate focus techniques can be a particularly useful tools to “practice skills they have learned in the office” for getting reacquainted with their bodies’ enjoyment after much emotional suffering and to
[e]xperience sensual and sexual touch within a familiar, relaxed, comfortable environment. The therapist prescribes detailed cognitive and sensual behavioral homework that incorporates sensual and eventually sexual touch. Each assignment involves small incremental steps that help to build confidence, competence, and an increased sense of efficacy in overcoming the sexual problem.
(Hertlien, Weeks, and Gambescia, 2009).

In the case of bereaved clients, the assignments taught also help to slowly restore their comfort and enjoyment of their sexuality without their partner’s involvement. Worden cautions that “there are those whose only sexual experiences have been with their deceased partner, so the counselor may need to address any anxiety concerning new sexual experiences,” (Worden, 2009). In reality, whether or not a client had had sexual experiences with someone other than their former partner, if they were in a long-term, committed relationship with that person and, for one reason or another, are no longer with them, then it makes sense that a client might feel nervous, uncomfortable, or perhaps even guilty at wanting to still be sexual without them. It is therefore an important task in therapy, in conjunction with the actual practice of sensate focus, to allow time for sadness or a renewed grief that the client now must practice their sexuality on their own, even if they are ready and want to begin moving forward.

Sensate focus is usually taught as a partnered activity, and it is therefore necessary to adapt the exercises to be done individually, and for at least some of the non-erotic focus exercises, such as receiving massage, to be done by a professional. Originally, the purpose of sensate focus was to systematically desensitize an anxious or disengaged partner to the anxieties and distractions which were preventing them from enjoying fulfilling sexual relations with their partner. However since “the blueprint of the exercise must carefully fit the situation”, clients can feel reassured that sensate focus can work for them as well, and that the plan they and their therapist come up with to gently and unhurriedly bring sexual experiences back into their lives will be only built to do what they want it to, and not push them too far or too fast (Hertlien, Weeks, and Gambescia, 2009). To achieve this, progression through the exercises must be made in very small steps, to avoid feelings of frustration or failure, be it to respond without grief or to respond at all.

Hertlien, Weeks, and Gambescia put forth nine functions of sensate focus which can be reconsidered and drawn on as they relate to grieving clients without partners. Of those that apply to clients wishing to resume their sexuality by themselves, the first is for the client to “become more aware of his or her own sensations”, meaning to pay attention, during the exercise, purely to the physical senses they experience when they, for example, run their hand over their arm, or rub lotion into their feet (Hertlien, Weeks, and Gambescia, 2009). This may be particularly difficult to do when starting out with a client who is in the process of mourning, as they have been working so hard already in managing their emotions, maintaining their daily lives, and trying to move on after their partner is no longer with them. The grieving process described above from Worden is a challenging and highly strenuous emotional and mental task, and to tell a client to focus on setting all that aside for a while may be met with relief, or anger, or utter bewilderment. Eventually, however, the hope is that in training their mind to let itself rest for these few minutes or hours, and just experience sensations that are pleasurable and comforting, the client will find the ability to both enjoy their sexuality for itself and use it as a healthy, temporary relief from all the other feelings they have. The second function which can be utilized by the single client is to “focus on one’s own needs for pleasure” (Hertlien, Weeks, and Gambescia, 2009). In this context, this translates to the client training him or herself to pay attention to what their body tells them it wants, and not feeling guilty or conflicted about satisfying those needs and wants without the help, participation, or support of their former partner.

The third and possibly most vital function that such clients can make use of in their own plan is to “expand the repertoire of intimate, sensual behaviors” that they currently have (Hertlien, Weeks, and Gambescia, 2009). This can mean anything that the client is comfortable and has interest in exploring: if they enjoy the feel of satin, perhaps they can see what it is like to sleep on satin sheets; if they never learned how to masturbate, now is the time to learn. It is important to use positive language when offering or hearing out options for clients to consider when expanding their sexual repertoire, and to encourage anything safe that might promote arousal and sexual feelings to get a client in a sexual frame of mind. Clients may wish to incorporate erotic novels, videos, or pictures into their practice, and this may be particularly useful if they wish to try and develop new sexual fantasies that do not involve their former partner. Alternatively, if for example remembering erotic moments with their deceased spouse is not too painful, and they can incorporate them in a healthy way which allows them to experience sexuality without their partner, but still keep the memory of them close at heart, clients should not be discouraged from using what feels good to them.

Foley, Kope, and Sugrue include masturbation in their chapter on overcoming low arousal as an exemplary means of finding out what one enjoys and one of the safest ways to experiment with sexuality on one’s own. “A number of writers have suggested that masturbation serves as the ideal learning opportunity for people to explore hour their bodies respond to stimulation,” (Foley, Kope, and Sugrue, 2002). Unfortunately, masturbation remains a largely taboo subject, which the client may take some coaxing to talk about, be it to admit to doing it, in which case they should be applauded for knowing and enjoying their bodies, or to admit they don’t know how, to which a therapist would do well to reply that their client is not alone, and if they want to try learning, there are a number of fun and non-threatening ways to go about it.

In a society where sexuality can focus more on giving pleasure to a partner than giving pleasure to yourself, masturbation has developed an unsavory reputation as being selfish, dirty, and practiced by those who aren’t getting any ‘real’ sex…. The fact is, masturbation is a great way to get in touch with your own sexual responses, rhythms, and desires, and can be part of anyone’s sex life, whether or not he or she has a partner. Masturbation is a natural, healthy part of sexuality and sexual practices worthy of recognition in its own right, whether or now you ever use a vibrator.
(Blank and Whitten, 2000.)

To help with masturbation practices in both men and women, many counselors recommend the use of sex toys, including vibrators, massagers, dildos, and anal plugs, both to increase stimulation for those people who have had trouble orgasming with manual stimulation, for those who simply want a change of pace, or for those miss the feeling of fullness being with a male partner can provide. Blank and Whidden have reassuring words for those of more conservative backgrounds who might be uncertain about introducing anything man-made into their sexual activities: “The only real difference between using the vibrator and using your hand(s) to masturbate [or a penis for penetrative sex] is that the vibrator moves faster and has more endurance. It won’t change the ways and places you like to be stimulated,” (Blank and Whidden, 2000). Clients should never feel ashamed or embarrassed if they are unsure or don’t know how to masturbate, with or without the help of a toy, and again it is the job of the therapist to reassure their client that their exploration of their sexuality on their own is healthy and positive.

Using these techniques, therapists and counselors can work with bereaved clients who have lost partners to replenish their sense of a sexual self and to reassure them of the importance of their continued sexuality, if and when they are ready to return to it. Recognition of their struggles and pain, acknowledgement of their loss, and support and constructive help in creating exercises to aide them in their return to life as a sexual being, as well as a bereaved person, are the first important steps that a therapist can offer in to met their client’s needs. Always keeping in mind the process of mourning in which clients are actively engages to one extent or another, and the need for clients to have time to grieve over the immense changes they have had to go through-- both in their everyday lives and in their expression of sexuality-- therapists can help facilitate clients’ learning of the use of self-pleasure as a means of self-soothing, an outlet for sexual feelings, and a tool to sustain them as healthy individuals for the rest of their lives.

 
Bibliography:
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