In Your Head: An Interview with Dr. Sara Corse, Ph.D., Clinical Psychologist

Seeking help from a therapist in the aftermath of babyloss often raises conflicting emotions within the bereaved based on their preconception of grief, and of the psych-profession in general. "I'm not depressed, I'm grieving!" babyloss parents scream from their blogs, in defense of their decision to not seek outside help.

Maybe.

Do we really know the difference between the two sets of emotions? And why are we all worked up about seeing a therapist anyway? Does it signal that we're weak? Can't handle it? Need to take our ugly emotions inside, out of public, into an office with a shut door? Or (gulp) maybe we're even a wee bit crazy?

What about those of you who sought help and were confronted with professionals who told you to buck up? Who didn't understand what infertility and babyloss had to do with each other? Who glossed over the loss and focused on something else -- or vice versa, assumed the loss was the be-all-and-end-all to your problems? And you were left wondering: was it them, or me?

In order to try and clarify some of these issues I went directly to the source. Dr. Sara Corse is a psychologist who specializes in grief counseling and the author of Cradled all the While, a memoir of her experience in dealing with her mother's terminal illness. Dr. Corse sees individuals, couples and families at Council for Relationships in Philadelphia. (Disclosure: I, Tash, interviewer, saw a grief therapist regularly, until recently. I consider it on the whole, a positive experience.)

Tash:  Thank you so much for agreeing to this interview. How does one become "a psychologist who specializes in Grief Counseling?" That is, are there special courses or training that you do?

Dr. Corse: There are several professional pathways to working with people who are grieving. A grief counselor may have training as a psychologist, social worker, couple and family therapist or nurse. Grief is a normal life process, and as such is covered in courses on lifespan development. Therapists learn to work with both normal and complicated grieving in courses and supervised experience in counseling. Some programs offer semester-long courses in grief and there are many opportunities to specialize through self-guided readings, advanced supervision, workshops and conferences.

Why did you decide to go into this particular avenue of psychology?

I developed an expertise in grief counseling several years into my career, motivated by my own experience of loss. When I was 36, I cared for my mother as she was dying of cancer. I’d lost my father to a heart attack when I was 18, and I was struck by how different the two losses were for me emotionally. I have always been one to read everything I can get my hands on when I’m trying to process something distressing, so I read widely on death and grief. I also began writing what became “Cradled all the while” a few months after my mother’s death, and found the process of writing to be helpful, both in terms of my own grief and in terms of opening my interest in grief counseling. It is more than a decade since my mother’s death, and I now have a wide and varied clinical practice. About 20% of my clients come specifically for grief counseling and many others have had losses in their life that they have not fully grieved, and this becomes part of their therapeutic work.

I know I felt this early on (I no longer do) and I've seen it expressed by others: how do you answer the grieving parent who responds, "Well what do you know! Have you ever been through this?" What is it exactly that you can offer someone regardless of whether you've been through that particular situation or not?

It is common for people who are grieving to feel very alone with their experience. There is often a deep desire for connection with others who’ve been through the same thing, and at the same time, a wish for acknowledgement or appreciation that their loss is unique. I openly share with clients whether or not I have experienced a loss like theirs personally. In fact it is sometimes more difficult to work with someone who is grieving a loss similar to my own, because I have more of my own experiences to filter out in order to be responsive to the client’s emotions. What I try to offer all clients, however, is an open-minded curiosity and interest in their unique story of loss and a commitment to accompany them in their grieving process.

I know you don't want to start analyzing people who you don't even know, but are there any ground rules for how someone would know perhaps it's time to seek out this particular kind of help? I know a common refrain around here is, "Of course I'm depressed! My baby died!" and some people are just reluctant to seek out this kind of help due to monetary constraints, preconceptions regarding psychotherapy that were in place before their loss, or just not understanding the profession and what it can offer.

To understand when it’s time to seek grief counseling, it might be helpful to first have an idea of what normal grieving looks like. I like Theresa Rando’s model of mourning (grief refers to emotional, behavioral, physical and social reactions to loss; mourning refers to the work of processing and integrating the experience of loss).

She calls the first phase of mourning the Avoidance Phase, during which time the person in grief comes to recognize the loss. This includes acknowledging the death and working to understand the death.

The second phase is the Confrontation Phase, in which the grieving individual experiences the deep emotional pain of the loss. The work of mourning during this phase is reacting to the separation from the loved one through feeling, identifying, accepting, and expressing one’s emotions. It also involves identifying and mourning secondary losses that coincide with or develop as a consequence of the initial loss, such as the loss of the role relationship one had or would have had with that individual. During this phase, mourners recollect and reexperience the deceased and the relationship—reviewing and remembering their life, and reviving and reexperiencing the feelings engendered by that relationship. The person in mourning relinquishes old attachments to the deceased and to previous beliefs about how the world works.

The final phase of mourning is the Accommodation Phase. A new relationship is developed with the deceased, new ways of being in the world are adopted and a new identity is formed…one that incorporates the experience of grief and loss but is not wholly defined by it. And finally there is a reinvestment in life. The process of mourning a specific death can take place over many months and years, and may be revisited and reworked at different points throughout life.

This model of “normal” mourning serves as a backdrop for addressing complicated mourning. (I use quotes because the word normal seems to trivialize the pain of grief. I know that when I have been in mourning, nothing felt normal about it, and I wouldn’t have wanted anyone to suggest that it was). Complicated mourning is associated with several risk factors. These include specific circumstances of the death, such as a sudden, unexpected loss, death from an overly lengthy illness, the loss of a child, or the perception that the death was preventable. Other risk factors are related to the griever’s prior or concurrent condition, such as previous losses that were not fully mourned, high levels of life stress, depression and anxiety or a perceived lack of social support.

Grief counseling can help with both types of mourning, but is particularly useful in complicated mourning (or during complicated periods of normal mourning). So how does one know if it’s time to seek counseling?

One indicator that counseling might be helpful is feeling stuck—as with struggling to move from the Avoidance Phase of mourning into the Confrontation Phase. Denial is sometimes a cause of that feeling of stuckness. It is often a feature of the Avoidance Phase, manifesting either as not acknowledging the reality of the death or not acknowledging the feelings associated with it. Denial is not something we do, but something that happens—a natural psychological reaction which provides us with a time-out—a temporary delay of grief until we can gather the psychological resources necessary for experiencing the devastating pain associated with the loss. Although initially adaptive, if denial continues for too long, it becomes maladaptive and delays us coming to terms with the loss. Counseling can offer support in coming to acknowledge and confront the grief.

Another indicator is a persistence of depression or anxiety. Grief and depression share common symptoms, such as sadness, difficulty sleeping, loss of appetite and loss of energy. But in grief, our moods, such as sadness, anger, despair, or hopelessness, are triggered by sights, sounds, memories and thoughts about the loss. In depression, the symptoms are more persistent and pervasive. In grief, moods and symptoms change over time—from acute grief, which may be debilitating and immobilizing, to later stages of mourning when feelings can be bracketed—at least enough to function at work or at home. The feelings may not be any less strong and may still hit powerfully and unexpectedly, but they can be felt and expressed without interfering with overall functioning. In depression, bracketing is far more difficult. Mood and energy are more consistently down.

In terms of how long is too long for feeling depressed during normal grieving, some professionals use two months as a marker. On the one hand, I think 2 months is too short a time to diagnose depression in someone who is grieving the death of a child. On the other hand, if someone is struggling with feeling depressed, and having trouble resuming normal activities two months after the death, therapy can be such a helpful tool that I encourage it even if it is a part of grieving and not depression.

We've all been told at least from within this community that grief is a normal life process, and there is no wrong way to grieve. What benefits are there then to seeing a therapist as opposed to, say, duking it out on your own?

Here are some things clients have shared with me about how therapy has been helpful for them:

* feeling validated, feeling heard, feeling listened to

* feeling not alone: being able to reflect on and express their feelings with another person rather than keeping them inside

* not feeling blamed or judged

* appreciating that they don't have to reciprocate with the therapist--they don't have to take care of or listen to the therapist's feelings. They don't have to prove to the therapist that they will be okay. They don't have to take any responsibility for making the therapist feel like he or she is being helpful.

* being able to talk about the experience as many times in as many ways as they want or need without worrying about being a burden.

* being able to ask questions and get feedback and learn a framework for understanding their experiences that can support them through the phases of mourning.

* being encouraged to explore feelings that they may shy away from with the support of the therapist, and thus learning how to tolerate these emotions as they come and go during mourning.

* having a space to grieve that feels safe and where time and expectations don't (or shouldn't) matter.

* being able to talk about their feelings about or worries about other family members confidentially, and explore in therapy ways to address them.

* with couples, helping partners understand and appreciate the different ways people have of mourning, and learn to support each other and stay connect through the grieving process.

* having a place to explore other issues that are kicked up by the loss and may be important to address at this point in life.

Do you have any suggestions on "finding a good fit?" I feel as though I rather lucked out, although I did look for someone who specialized in "grief." Others in these parts have not been very fortunate in finding doctors that they feel are helpful (some sound downright oblivious to the basic issues surrounding infant death). What should we look for when we go in the first time (or few times)?

* someone who makes you feel comfortable telling your story and sharing your feelings.

* someone who has some experience with working with grief.

* someone who communicates an interest and curiosity in you.

* someone who will answer your questions, even if they come across as challenging, without being defensive or dismissive.

* someone who will engage with you around questions of fit, and doesn't suggest that he or she is the only person who can help you.

* someone you respect.

* someone who respects your boundaries—not imposing their beliefs or experiences on you and not pushing you before you have developed trust.

Along the lines of "there is no wrong way to grieve": It seems to me that, sadly, for some members of society at large there are indeed "right ways." It's not uncommon for us to occasionally get comments to the effect of "hurry it up already," or, strangely, "You need Grief Counseling!" One of our contributors (Bon) recently wrote a hospital to ask them to change the language on their fund-raising literature as she found it offensive to someone who had lost a family member at this institution. The campaign went public, a newspaper picked a line out of Bon's argument, built a story around it, gave it a controversial title, and then posted it on the internet -- and opened the comments. The public comments were stunningly offensive in my mind, one of them though told Bon to "Get Grief Counseling."

I thought that was a rather strange insult; it seemed to be indicating that the commenter was uncomfortable with Bon's emotions and that Bon was better off dealing with these feelings privately (preferably in an office with a doctor present, apparently) -- not publicly. But it also really tiptoes the line as to how the public at large views therapy, and it's worth.

Our society does communicate a strong message of intolerance for the wide range of feelings that grief entails. Tears and sadness, maybe. Anger and advocacy, not so much. And our society follows up the intolerance for the full range of emotions with intolerance for any of those emotions that last longer than a few days or weeks. Bon handled the whole situation, from beginning to end, with grace and balance. She was attuned to the impact the hospital’s fundraising letter had, not just on her but on any parent who’s baby did not survive, and took action to raise the level of awareness and sensitivity of the fund-raising world to this point of view. The public comments suggesting that Bon get grief counseling miss the mark. In fact, a healthy processing of grief often leads to an action such as Bon's. When we have done (or are doing) the work of mourning, we are able to speak out regarding the universal truths of grieving and loss and can advocate for societal change. When we embrace the full range of feelings that loss brings to our lives, and integrate our most painful experiences into a new way of being in the world, we find energy for transforming our experience of loss into something positive for others.

What do you see as the biggest hindrance to grieving?

I don’t think there is one big single hindrance, but there are several roadblocks, some internal to the person who is grieving and some external. Earlier I mentioned denial. It is the persistence of denial, not its early existence, which proves problematic. If we cannot sustain knowledge of the fact of the death and the irreversibility of the death, we cannot mourn. Another hindrance to grieving is the inability to gain necessary information to answer questions about how and why the death occurred. We often hold off on feelings of loss until there is greater understanding.

External hindrances include the impact of commonly held myths about mourning, such as the notion that grief follows a set path or sequence of stages, resolves in a matter of months or comes to complete resolution. Another external hindrance for parents grieving the loss of a baby is society’s tendency to minimize the loss. In fact, grieving the death of a child means not only experiencing the loss of the brief relationship, but also the loss of potential, about which they are continually reminded. The perpetuation of societal attitudes about grief makes it hard for people in mourning to acknowledge their feelings, both to themselves and to others, to be patient with themselves and to seek and gain support from others.

What then do you see as the most helpful thing (or things!) one can do to process grief?

In terms of denial, there are various experiences early on that can help grievers acknowledge the death and begin to experience and express their feelings. These include having the opportunity to hold or touch or view the body of the deceased, and to participate in rituals that acknowledge the death, such as a funeral.

As the process of grieving continues, it helps to talk about the death and any feelings, and to find people who are willing to listen and ask questions.

Participating in a support group with people who are experiencing or have experienced a similar loss can be helpful for exploring and validating feelings. This includes on-line support groups.

It helps to create rituals or memorials that are meaningful. Some people plant a tree or garden, donate to a cause, or launch an initiative in their loved one’s memory, enacting love and the pain of loss in a way that benefits others.

And as we’ve discussed, grief counseling is helpful, particularly when we feel stuck or alone, when we are experiencing a complicated period of grieving or when we have an inner sense that in processing this loss, we are provided an opportunity for making other important life changes in therapy.

How do you feel about online support -- like this site -- or blogging as a means of self-help?

I think it is a fantastic medium for several important processes of grieving: The work that people do in writing about their experiences, whether blogging or commenting on other people’s posts, is transformative. The writer must engage her or his emotions in the crafting of a post, which then offers both an expressive outlet and a mode of working through the experience that deepens personal understanding and connection to the experience. In posting on the internet, writers have an immediate outlet for sharing their experiences with others. Because there is an intended audience, the emotional, intellectual and creative work of blogging is different from personal journal writing—in considering what one wants to share publicly, the writer’s perspective is lifted to the universal (or at least in that direction). This process of moving from the personal to the universal is something that gradually happens during the process of mourning, and writing for an audience facilitates it.

Blogging also offers a wonderful way to network with others who have experienced something similar. Particularly for those who are new to grief, being able to read and comment on posts by people who are further along in their mourning can be very validating. For parents grieving the loss of an infant, being part of a blogging community is a way to create a set of loving relationships around oneself and one’s lost baby. Sharing grief this way brings meaning to the baby’s short life, and when others in the blogging community respond to or even anticipate one’s own grief reaction, the grieving parent feels far less lonely.

The one caveat I would mention about on-line communication is that it is different from face to face communication in terms of how people filter emotions, opinions and reactions. On the one hand, people may hide certain reactions and reveal other reactions in order to gain social acceptance or approval. On the other hand, sometimes people are inappropriately unfiltered in their reactions, such that they say things and say them in certain ways that they never would if they were face to face (internet bullying, perpetuating conflict and misunderstanding, etc.). So I would encourage people to continue to nurture supportive face-to-face relationships for grieving as well.

Have you sought out therapy in the aftermath of your babyloss?  Why or why not?  Did you find it useful/helpful?