Part V - the Constructivist Grief Therapy approach;

A.H.: Ok. Can we change the topic to your model – The Constructivist Grief Therapy approach? Could you describe us the main distinctive features of your Constructivist Grief Therapy?  
 
R.N: Well, I don’t even know that I would dignify it with the term model. I think it is more an approach and for me that is, it is more suggestive, more thematic than it is a model. A model often suggests boxes, arrows and, you know, schematic diagrams. Even though I have published some of these as well with respect to grief work, I think that the important theme is that when we are speaking about grief and loss in human life, we’re speaking about something thats is fundamental – that in Buddhism terms is among the four noble truths of human existence. It is not something we can evade. The reality, if you will, of human beings is that we are wired for attachment in a world of impermanence. And this sets us up for a world of hurt because it means that the narratives that we construct about ourselves – our self narratives – the story of who we are in our lives with references to specific other important relationships – those narratives will be tested and will often be in some ways challenged by the frequency with which we experience the impermanence of relationships and our own mortality as well as that of those we love. So that ultimately every person, every place, every project, every possession we love we will lose and as we lose them we have to somehow reformulate our sense of what life has been, and is, and now can be.  We have to in some sense rewrite the basic premises of our life. And this implies, I think, that we seek a couple of things. We seek some way of understanding, of integrating, of making sense of the event story of the death of our loved one. Whether we do that in spiritual terms, secular terms, practical terms, we seek some way to make sense of what has happened to us and to our loved one. And we also seek a second level of processing of the relationship specifically with that person. Not only do we focus on the event story of his or her death, but we also focus on the back story of his or her life and the loving connection we have to that person. And we strive then to access that story rather than to cut it off and discontinue it. And to carry that story forward – kind of interbreed it with our own - as we find some line of development that pulses forward through life. So, that I think suggests the importance of meaning making in the context of bereavement that we seek to review and revise those fundamental meanings by which we organize a sense of self, relationship that has continuity and coherence form our past to our present, to our now changed future.
 
A.H.: How would you distinct your approach from other approaches and models on this field of grieving?
 
R.N.: Well, of course there are still very many who think of grieving in terms of simple stages of emotional development and began with denial and move into anger and protest and then into a long period of separation distress or depression and then eventually moved into some form of acceptance. Models of this kind continue to exist and be used, but they poorly describe empirically, they are demonstrated to poorly describe the diversity of human responses to loss. I would say that in a focus on meaning making we inherently moved toward the personal processing of loss and looking on what is distinctively relevant to this loss, now in this life, at this developmental period in this family structure, in this community, in the terms of this culture. And it is a process that orients equally to potentially broad spiritual meanings, to very personal psychological meanings, to inter-subjective meaning making as in families and other collectives. And so I see it as a very, in some ways action oriented reflective approach that provides many practical implications for how we might engage the work of grief therapy. Of course there are many other models and I could describe them in detail but I do think that many contemporary models of grieving have in common an orientation to seeing grieving as a process – in English we can say grieving as a verb – in a… It’s harder to turn a duelo or la pérdida or its equivalent in português into a verb – is more of a now or a state. And I think we are moving passed the idea of grief as simply a state that we endure and that we gradually relinquish or let go of. I think we’re coming to understand it more as a series of processes that happen within us and between us that can be facilitated in useful directions. 
 
A.H.: So, which are the predictors of a complicated grief in that sense?
 
R.N.: Well, maybe we should first speak about complicated grief, at least briefly.  When we talk about complications in grieving they could take many forms, but contemporary research has largely defined one particular form of complicated grief that is very protracted, prolonged, that tends to greatly interfere with one’s functioning in relationships, in the family, on the job – this derives largely for the work of Haley Peterson, Katie Shear, Paul Bolen,Marti Horowitz, others of us, like myself, have made contributions to this empirical literature – and one can think of it as a way of being stuck in a kind of intense grieving, marked by very high levels of separation distress that do not reduce appreciably over time. Through months and years the person can be captured in what I might call a kind of dominant narrative of grief. The predictors of complicated grief interestingly are ones that we have just been reviewing - my student Lauren Brooke and I, had just reviewed the 41 published empirical studies, quantitative studies that examine prospective predictors of complicated grief  and will be publishing this work in a while. But the short answer is that they are certain objective conditions that tend to produce greater complications, and those may describe the circumstances of the death, the nature of the bereaved person, and the nature of the lost loved one. There may be interpersonal factors and intrapersonal factors that predispose people to complication. Some of those, for example, would be that the loss of a close keen, a close kind of family member, particularly the death of a child or securing enhancing relationship with a spouse – tend to be more likely to lead to complicated grief – when the death is sudden or violent, there tends to be a greater likelihood, as in suicide, homicide, fatal accident. So, some of this things are a function of observable factors in the person or the death itself. Other things are more behaviorally mediated such as seeing the body of the deceased who has died a violent death tends to be associated with more traumatic reaction, as one can reimagine, and also tomore complicated grief. And then factors having to do with the person in his or her relationship with others, such as high degrees of attachment insecurity in general in relationships that find expression in greater alarm when a loved one dies and more difficulty finding again some basis of security in that now changed relationship with the deceased or another person. So attachment insecurity would be one factor. Neuroticism generally would be another such. So there are really a variety of factors that really expand many different systems, and I think that the current literature is simply limited in the number of such factors that it has investigated. As we do additional studies that begin to tap into more areas we’re finding evidence for other risk factors. For example in our own longitudinal studies of cohorts of bereaved spouses – followed for as much as eight years, as much as four years beyond bereavement – we find that the degree to which at the six month period after the death they’re engaged in a search for meaning that they cannot satisfy, that tends to be a predictor of complicated extended intense grieving at eighteen months and even fully four years in the future. Conversely, the ability to make sense of the death at six months is associated with states of positive wellbeing, optimism, efficacy, self-pride and so on, as much as four years later. So, again, as we begin to move beyond our concern with demographic and objective variables, I think we will start to find what kinds of process variables that we can help people change in the context of therapy are also associated with favorable and unfavorable outcomes.
 
A.H.: Talking on unfavorable … Which are in your opinion the main reasons for an occasional therapeutic failure or unsucess in constructivist grief therapy?
 
R.N.: Well, I think that it probably would have much in common with the way we fail as therapists and with other conditions. I think the main concern for a constructivist therapist, the main risk, would be what I would call a tracking error, that is, somehow losing the edge of the clients growing engagement with meaning and feeling, where it’s almost like surfing.
 
A.H.: Keep close to the client.
 
R.N.: Yeah, and if you lean to far back on the board the wave will slip out beneath you and you will end up in… just still water. And I think we can sometimes lose our clients by moving too slowly

with them. Other times we can lean to far forward and the wave will crash and it take us down with it and we will, in a sense, have gotten ahead of our clients and the therapy process will fail in that way. So I think that the precise finding and staying with what is now possible for this client - what is urgently needed and what this person is ready to do - allows us to join with them, in a kind of mirroring of their pain, their concern, and also their ability to tackle this problem now, to experience this kind of growth now, to celebrate this achievement now. And I think that’s true whether the focus is on grief or on something rather different – it might there be anything specific that is difficult about grief therapy – I do think that sometimes, when the focus is grief, and people are bringing in a very difficult death, I think for example of a client I saw just last week, I saw her for the third time, and she was speaking about her mother’s growing depression, a depression that deepen as her father died one year ago, and as the mother became more ill and infirm, as the family’s finances continued to dwindle and the family business collapsed, and as the mother then began to experience all of these reductions in her life she begin to give communications to the daughter, saying “I want you to know that if anything happens to me these important documents can be found in this drawer… and you know that big picture, the painting that is in the dining room, that’s one that your father gave me for our first wedding anniversary, that’s something I’d really love for you to have”. And as she began then to grow concern about the mother’s contemplation of her own death, she struggle with the possibility that mum was planning suicide. And one morning when she called her mother, as she would do each morning to talk with her and just to share some of the day, and the phone was not answered, it was not answered fifteen minutes later, and it was not answered two hours later, then she grew panic and she went to the mother’s house, and as she came in the back door she saw a note on the breakfast table, and immediately as - you know – she read it “Dear Sara, I want you to know I have always loved you” and she knew immediately that this was the suicide note, and she ran through the house screaming and hearing nothing she ran up to the mother’s bedroom and as she did she saw a light in the bathroom and she turned, and in the bathroom with all of its white tile, she saw the horrific image of her mother sloped in the tub, the tub red with blood, and on the wall behind the mother on the white tile, written in the mothers blood, was “forgive me, I love you”… Now, one may have difficulties in therapy with an unruly adolescent or insufficient communication with a couple you’re working with or someone might be depressed about their career prospects, but when you encounter circumstances like this – and I as a therapist am also a survivor of my father’s suicide – then I think there may be specific difficulties that raise up in us, in terms of our feelings, our defensiveness, that may be distinctive to a therapy that goes deeply into issues of trauma, deeply into issues of loss, deeply into issues that may be shared with the client in a way that the client may be unaware of, but nonetheless it may stir something for us. And if we respond to that stirring with greater compassion and connection to the person story and a commitment to helping them elaborate it in a constructive direction, then therapy will be facilitated. But if we withdraw from it, and become merely technical, then we commit the tracking error and I think the therapy quickly dies.

Part VI - the training in psychotherapy

A.H.: Changing the topic for the last time, to the training in psychotherapy and constructivism. Robert you travel a lot, since decades, meeting colleagues seasoned and younger ones around the whole world, did you found relevant differences in the United States training standards compared to European ones?
 
R.N.: Oh, yes! Well, standards is too bureaucratical term for me to relate to - I don’t really care about standards. But I would say forms of training differ, would speak about qualitative differences rather than meeting a standard or failing to meet a standard. Much of the training in psychotherapy in Europe happens in institutes outside of programs, that is outside of psychology training programs which often are devoted to more lecture material, less experiential work. I think then it is typically true in the U.S. - of course we’re speaking in the U.S and Europe but other models will predominate in South-America or China and Japan and so on. I mean, we can be more global in our comparisons but just looking at the U.S. and Europe there’re many similarities and there are some differences. Except for few different setters most of the psychodynamic training in the U.S. is provided in institutes, but much of the training in other forms of psychology would rely upon placement in clinical or counseling training programs – which are APA approved and regulated and are anchored in universities and with a number of practicum settings that may be in hospitals or community agencies – so I think it is more, in some ways, it’s more academic in the U.S.. In my impression about different places I’ve gone - of course different countries do it differently - but there tends to be more of a segregation of academia and then practice sites and supervision in the European s, at least with the ones I’m familiar. I’m not sure that one is better than the other.
 
A.H.: Do you think that trainees, as generalist practitioners, should be educated and proficient in one unique model and master it or should they know more than one model?
 
R.N.: Well, I don’t really operate in the basis of too many should, let see what I can say about that. I like breadth, I find inspiration in many approaches to psychology and to culture life more generally and so all of us like to have more students be like us, in this regard. So I am happy to have students who have a broad and deep curiosity about many things, about many theories and many different people. But I think that students themselves tend to be more conservative, in part because this is new to them and they really want to do it well and it’s easier to do something smaller well, than to do something endlessly broad and multidimensional. And so I think students tend to gravitate toward a preferred model and mastering that then they can begin to innovate in the model, in modest ways and then more boldly. And I think this help us understand how, really across the course of our development as therapists, we often begin with one relatively focused perspective and then begin to breach out - much like a tree will have a trunk that will begin to yieldlarge brunches and then many small ones. So I think that, in some way, advanced practitioners tend to move toward greater integration across time and we should tolerate and understand compassionately the need of our students for simple begins, recognizing the complexity will come naturally. And my goal as a supervisor is to provide them the natural opportunities to challenge and extend their initial premises and positions.
 
A.H.: In your opinion what makes a good therapist, would you underline a specific skill or profile in order to be a good therapist?
 
R.N.: Well, I think that – very much in keeping with the honored tradition of humanistic psychology – a cardinal condition is a deep and refined capacity for emphatically grasping the personal world of another and I think that’s indispensable, really, to most forms of significant therapy. I think that it help as well to deeply embody a position of compassion with reference to human suffering and to be very wary of adopting positions of contempt or self-congratulations about the way in which we may be living better than our clients. And then I think, as well, we do well to use ourselves and our language carefully as instrument of change in therapy, to be willing to risk deep personal engagements with our clients, to be willing to show the feelings and a sense of being moved by them and their struggles, their achievements, as we engage them, and to use language powerfully and poetically in order to help them grasp, configure and further elaborate the growing edge of their understanding, while being open to other forms of symbolic exploration and expression of evolving meanings – which may entail body work as well as artistic representation and other forms of symbolizing experience that go beyond language per se. I think all of this would be characteristics of a good therapist and a final one that I would add – appears on very few lists of desiderata or positive features of therapists – but I would say wisdom. It’s insufficiently recognized at its importance, and it’s hard to define. But I think that a kind of sense of perspective, a being able to place human experiences in a broader and broader frame, while also honoring the particulars of the client’s existing frame. This is a helper stance to have as a therapist - to be able to shift from this deeply personal to the broadly existential, and to be quite comfortable functioning at many levels, in many languages, with many different kinds of clients and problems.
 
A.H.: It’s not so easy…
 
R.N.: Well, it’s an interesting way to try to make a living though, I tell you that.