Integrative Psychotherapy Articles

Saying an Honest “Goodbye”: Three Case Examples

An appendix to:

Truth Shall Set You Free:
Saying an Honest “Goodbye” Before a Loved-one’s Death

Richard G. Erskine,PhD
Institute for Integrative Psychotherapy

Abstract

In an article entitled “Truth Shall Set You Free: Saying an Honest “Goodbye” Before a Loved-one’s Death” I outlined the background and theory of working with anticipated grief. The concept of “unfinished business” and therapeutic work with the “empty chair” was described and a brief case example was provided. This article contributes three additional case examples that illustrate the psychotherapy of anticipated grief, the expression of emotions and personal experience, and the significance of “truth telling” in the process of saying “goodbye”. It is based on the Gestalt Therapy premise that it is necessary to have a “full hello” before a final “goodbye”.

Linda’s reparation

Linda was a client whom I had seen in individual therapy once a week for 6 years. When she began her therapy with me she was 33 years old and had been a patient for a year and a half in a clinic that specialized in the treatment of borderline disorders. Linda had been referred to that clinic by her physician after Linda had told him about the discord and arguments she was repeatedly having with her husband and father. After a few months Linda abruptly quit her therapy at the clinic because she “felt criticized and defined”. She complained about the “cold” way the two clinic therapists had treated her.

Early in our therapy together Linda would often find something wrong with the way I had said something. She would complain and argue with me that I should “have said it in a better way”. She would alternate between what she called her “sweet and nice self” and her “angry self”. I paid careful attention to the potential unconscious communication in her expression of her two selves. During the first three years much of our therapy focused on working within the transference and countertransference matrix. I often inquired about Linda’s relationships with her family members and explored how she stabilized and regulated herself when relational disruptions occurred. Two significant developments emerged as a result of our therapeutic focus on her physical sensations and body tension, relational-needs, explicit and implicit memory, and our transference-countertransference dynamics. Linda stopped arguing with both her husband and me and the center of her attention shifted to her anger at her father and the inappropriate sexual touches she had received from him when she was 11 and 12 years old.

For the next year our psychotherapy focused almost exclusively on Linda’s troubled relationship with her father. Linda had never forgotten his sexual molestation of her. She said, “I always put it out of my mind” and “I wondered if I had exaggerated how bad it was”. In the psychotherapy she expressed her rage at her father for touching her vagina and rubbing her developing breasts. She was sure that they had never had sexual intercourse but she was hurt and angry at his “violation of my love”. She had never told her mother because her father had said that it was a “secret just for the two of us”. What had previously appeared to be behaviors typical of a borderline personality disorder now seemed to be the reactions of a woman who was sexually traumatized as a child.

As a result of our psychotherapy she realized that many of the arguments she had with her husband and her attempts to “push his affection away” were an enactment of her desire to push away her father’s sexualized touch. She related being “acutely uncomfortable” with her husband’s sexual touch to her father’s “violation” of her. Shortly after getting married she had confronted her father about his sexual abuse when she was a pre-teenager. He told Linda that she was “crazy”. He said: “You have always exaggerated”; “We were only affectionate with each other”. Linda came away from this altercation feeling hurt, scared, angry, and with “an urge to argue with everyone”.

In the fourth year of therapy Linda’s father was dying of cancer. She had expressed a great deal of anger in our therapy sessions; she cried and longed for “a father who I could trust”. She was grieving in anticipation of his death. I encouraged her to talk to him, to tell him what she missed in their relationship, to tell him her truth even if he accused her of exaggerating. She was reluctant and we debated about the importance of her again telling her “truth” to him before he died. We agreed that a strong confrontation like she had done several years before would not work. In compromise she decided to talk to him about many of her fond memories. She had three private conversations with him where they talked about their wonderful memories of the things they had done together over many years. As a result she was feeling closer to him and at the same time knew that she was holding in much resentment. In between these meetings with her father I talked to Linda about the importance of “truth telling” and eventually bringing her whole story into the relationship.

In the fourth conversation with her father she obliquely referred to his seductive touching of her. He blurted out, “I have been waiting for you to bring that up. I am so sorry I fondled your body. I was wrong in doing that”. He continued to apologize to her both for his inappropriate sexual touching of her when she was a child and for how he had denied her accusations several years before. Later in therapy Linda said that she was greatly relieved because the only reparation she needed was for him “to admit the truth of our relationship. That I loved him and that he exploited me because of it”. She said, “I needed him to admit that I had not exaggerated anything -- that I am not crazy”.

Linda’s spent many nights holding her semiconscious father’s hand before he died. She seemed to be a peace with him and, shortly after, I encouraged her to tell the full story to her mother. Again she was reluctant but eventually agreed because “the secret has created a distance between us”. Her mother was shocked, hurt, angry, and dismayed. The two women wept together over the unnecessary distance the “secret” had created between them. Linda continued in therapy for another year. We often talked about the new sense of affection she and her mother had for each other. We periodically reviewed how important it was for her to have the “truth telling” with both her father and mother.

Martha’s Lament

Martha is a conservatively dressed 53 year old woman with strong religious convictions. She has previously attended six intensive group therapy sessions but seldom contributes her perspective to the group’s discussion. Martha says that her silence is because she fears criticism. In the fifth session she expressed anger at the therapist for a comment he had made. The therapist attended to her anger, took her perspective seriously, and invited her to tell him more about her anger. Within a short time she was shouting vehemently to an image of her mother in an empty chair. During the sixth session she reported a sense of internal relief after she had expressed her previously contained anger.

In this current group session she is sitting with slouched shoulders, looking sad. As she begins to speak her voice is slow-paced and mournful. The following is an edited transcript of a 46 minute individual therapy session that occurred during an intensive therapy group. Martha begins her session by describing her mother’s failing health. She tells the group how she is responsible for making her mother feel good and that “my inner state is terrible, unbalanced when I can’t make her feel good”. Martha continues to describe her inner demands to preserve her mother’s “well-being no matter what”.

Therapist: So what would you say to her if the doctor called you today and said, “Come to the hospital, she’s had another heart attack and she’s got only 30 minutes to live? ”. {The therapist’s question is designed to stimulate a “creative emergency”, an opportunity for the expression of that which has been inhibited.}

Martha: Well, maybe ... I would just say what I say to her all the time.

Therapist: Now you have the opportunity to say something different....to be fully honest with her. So just close your eyes and imagine that you are sitting next to her hospital bed....and this is the moment to say the truth. Tell her everything, particularly the things that have never been said, including all the way back to your childhood. Just go ahead and talk honestly to her. Because she’s going to die in half an hour. So you don’t have to worry about hurting her. The most important thing is the truth-telling . {Here the therapist is using “therapeutic direction” to encourage Martha to engage her mother in a uniquely different and contactful way. He emphasizes that truth-telling is important. The experience of talking to the image of the person in an empty chair allows the individual to express, in the safety of fantasy, what they did not do in reality.}

Martha: Mama… throughout… my whole life I’ve dedicated my time to you, all my effort, I’ve given you all the affection, all the care I was able to give but I never dared to tell you (her voice drops) that you didn’t parent me well. Not long ago, you told me that you didn’t know if you had done a good job in raising me. So instead of answering you I told you how much I loved you ... but I didn’t tell you that you hadn’t cared for me or raised me well. (Martha is tense, she squeezes her interlaced fingers, her shoulders are hunched).

Therapist: Tell her what you did not say that day. Just close your eyes and tell her your experience. {The therapist is encouraging Martha to go beyond her usual mundane conversation, to express herself fully.}

Martha: I didn’t want to hurt you Mom, the same way that I’ve never wanted to hurt you, so I shut up. But…

Therapist: But, the truth is… {Here the therapist is “priming the pump”; he is encouraging Martha to say what has never been said. He does not provide the content; he provides only the impetus to move her to tell her full story.}

Martha: The truth is that I carry on my shoulders the responsibility for your well-being. Your whole life has been very hard so I try to take care of you. In taking care of you I haven’t allowed myself to live my own life. (Martha’s voice becomes more forceful) I’ve missed… too many things. Mostly I miss having a real mother ... a loving mother.

Therapist: Keep going. There’s so much more to say. Right from your heart. {The therapist is again encouraging her to speak honestly. He does not define what she might say; he only encourages her to continue.}

Martha: Mother, you’ve been a child. You’ve been a childish mother all my years. You relied upon me since I was born. You used me to feel good about yourself. {For the next several minutes Martha goes on to tell the image of her mother about her emotional pain and a sense of being “unprotected” and “unimportant” to her mother. She whimpers “The only way I could be anything was to comfort you”. The therapist continues to keep Martha focused on her own experience with “tell her what you feel”.}

Martha: Your family, Mama .... I know they were more important than me. (Martha weeps) I’ve asked you many times to pay attention to some of my needs. You tell me my needs are nonsense, that I am very silly, that I was a very strange girl when I asked for your attention and caring. (Martha continues to cry for several minutes).

Therapist: And tell her what happened when she labeled you like that ... when she defined you that way. {Here the therapist is helping Martha to define and articulate her own experience.}

Martha: Mother, when you define me that way, I always have hurt and anger inside. And when I try to tell you about my hurt or anger you criticized me. Many times instead of listening to my needs you scoffed at me or said, “You’re just like your father”. (Martha’s voice is much stronger.)

Therapist: And tell her what happens deep inside you when she scoffs or defines you like that. {The therapist senses that encouraging Martha to be angry again at her mother will be less healing than helping her become aware of and express her sadness and loss.}

Martha: When you defined me that way ... and you say it with such a scornful tone ... I hurt ... I wonder, “Am I a very bad person?”.

Therapist: Tell her about that hurt and internal doubt. {The therapist encourages her to elaborate on two focal points: hurt and internal doubt. Whichever Martha follows, she is likely to express what she has previously inhibited in conversations with her actual mother.}

Martha: For a long time, Mama, I’ve had a very big inner conflict, always questioning myself. When I would receive a complement from someone I found it hard to accept because I always hear your words and scornful sound.

Therapist: Tell her about the inside, what happens inside when you believed Mama’s definition of you.

Martha: When you define me in that scornful tone or say that my anger is just like my father, I have a terrible pain .... and a terrible fear of losing you .... that you wouldn’t love me ... of not deserving you. I hurt.

The therapist has been observing Martha’s tense shoulders and encourages her to describe her physical experience. As Martha becomes aware of the “weight” on her shoulders she begins to weep. Although Martha is conscious of sadness the therapist wonders if they have skipped over the anger and so he suggests that she tell mother “about all that sadness and anger that you’ve keep a secret”. Martha continues to express both her pain and anger at her mother’s superficial behaviors. She blurts out “I always thought that I was a big mistake. The bad one”. The therapist encourages her to articulate how these beliefs form a life script: “I feel worthless”. “I am no good.” “I am not loved, Momma.”

The therapist prompts her to tell Mother the whole story, the story that Martha has keep a secret. With a mix of tears and anger Martha then tells her mother about the cruel treatment she received from an aunt and how her mother defended the aunt instead of protecting Martha. The therapist suggests that Martha tell her mother what she needed from her.

Martha: As a child, Mama, I needed your protection. I would have liked you to play with me, to take me to the park, to take care of me ... but you left me in her care. She was a bitter woman who scolded and hit me. She used to criticize me and humiliate me.... and her humiliations have been a huge burden in my life.

Therapist: And what I needed from you, Mama… {The therapist is steering the therapy in a natural progression from anger, to sadness, to an expression of needs.}

Martha: What I needed from you, Mama, was for you to protect me from her. But you only lived to please her. Nobody else existed for you but her. I was insignificant ....unless I catered to you .

Therapist: Tell her how you experience that inside ... when she was busy pleasing your aunt and did not attending to you. Tell her what happened to that little girl. {The therapist now focuses on how Martha coped as a child, what meaning she ascribed to mother’s behavior.}

Martha: I felt worthless, Mama. I was no good.... I cannot forgive you for the way you treated me.

Therapist: Worthless… {Here the therapist underscores what Martha has just said: “worthless”. Such underscoring will help Martha continue with her narrative truth.}

Martha: Yes, that robbed my spontaneity.

Therapist: “Robbed my spontaneity”. {The therapist repeats what Martha has just said and thereby acknowledges that her words are significant. Such acknowledgement provides an encouragement to the client to continue telling her personal story.}

Martha: And I remember once… {Martha opens her eyes and looks at the therapist. The therapist senses that it is not yet time to stop the conversation with mother. Martha may have more to say to the image of her mother. When she is finished expressing her feelings and narrative to mother there will be time for real interpersonal contact between client and therapist.}

Therapist: Close your eyes again and tell it to Mama. Tell Mama about that memory. {Martha continues to tell the internal image of her mother more about her pain with the aunt’s cruelty, her anger at mother’s defense of the aunt instead of protecting Martha, and pain of the “scorn and humiliation” she received from both her mother and aunt.}

Therapist: Tell her your truth. Keep going. It’s so important before you say goodbye to Mama, to have this opportunity for truth-telling. ... Even if it’s telling Mama about your anger and pain. Even if it’s telling Mama about what you dislike. {Martha continues to talk to the image of her mother in the empty chair. She expresses anger that her mother “would not let me be me”. She describes mother’s lack of affection and how mother continually defined Martha, not only when she was a child but even today.}

Therapist: And what I want to tell you now before you die is…

Martha: What I want to tell you, before you die, Mama, is that I also have the right to live, that I love life. I love people and that I would like to be able to experience all that in peace, without questioning myself whether I’ve done enough, whether I’ve done it well or not, whether I should have done this or that, without being in a constant doubt. You demand of me and now I do it to myself. I am just like you...I demand things from myself ...even if I don’t want to do them.

Therapist: Tell her what that sentence means, “Now I do it to myself” ... explain to her what that sentence means. {The therapist is highlighting Martha’s awareness “I do it to myself”. Martha’s awareness may be the first step in resolving her constant internal criticism and resulting shame. Martha’s internal criticism will certainly be an important issue to return to in future therapy but now it seems important to attend to her awareness “I do it to myself”.}

Martha: Now I’m the one demanding of myself. It’s an internal demand, Mama. A constant internal criticism. (Her voice becomes sorrowful). And that internal demand never satisfies you. (after 6 seconds) It’s a repeat of all your criticism ... criticism and a lack of acknowledgement from you. You have never valued me for who I am....not even what I do for you. ... I have the feeling that all my effort was useless. Now there is no need for my internal demands.

Therapist: Tell her what you’re aware of now that she’s about to die.

Martha: (after 8 seconds, she speaks with a sad quivering voice) I’ve asked you so many times to understand me and what I get instead is criticism. You told me many times, “You’re so exaggerated”. “Here you go again, always with the same things, you’re so silly…” I’ve received so little love from you ... and I needed it so much. (she weeps).

Therapist: (after 10 seconds) So tell her what you’re gonna do with that internal criticism.

Martha: (after another 10 seconds, her voice is firm ) Mama… When I criticize myself, when I’m self-demanding I will STOP ... because I am being LIKE YOU .... and …… each time I’ll put more strength into a tolerant, more human part of myself. Each time I love myself more. Each time I value myself more (her voice is strong)

Therapist: As I put you in a grave, Mama…

Martha: (after 5 seconds) So as I put you in the grave, I wish that you have eternal peace. (5 second pause) I intend to live my life in peace, without demands. You are about to die and I will live.

Therapist: Just imagine, you could put all that criticism in the grave with her. All her critical words, all her scornfulness, and all your self-criticism, and all your self-doubt. You could bury all of that negativity with her.

Martha: It’s a good idea. I can put it all in your grave Mama and I won’t have to live with any of it.

Therapist: One important thing before she goes ... tell her what you appreciated about her. Tell her what you love about her.

Martha: What I like most about you Mama is your sense of humor ... how funny you are, your ability to relate to others, ... that playful part of you, ... even if you didn’t use it with me.

Therapist: Tell her what else you love about her. (Martha is shaking her head, at a loss to find something more she loves or appreciates about her mother. A two minuets go by without her saying anything.) She’s going to go in a minute.

Martha: Nothing else comes to mind. I’m cleaned out. I only want to speak the truth.

Therapist: Then continue to tell her your truth.... You have just a moment before you say goodbye.

Martha: ( after 11 seconds) Everything I’m saying is true Mama… (Her voice is strong). It’s what I’ve experienced and what I’ve felt. (pause of 10 seconds) Mama, I just need the right words from you....words like a message from the Bible. I need a biblical message, like: “Only say the word and I shall be healed”. (pause of 10 seconds)

Mama, please tell me that I am loved ...then I will be free.

Therapist: (after 35 seconds) She will be gone in a minute.

Martha: (after 9 seconds, in a very soft and plaintive voice) She will never tell me that I am loved.

Therapist: Then all you can do is say your truth ... and then say goodbye.

Martha: (after 11 seconds) Everything I’m saying is true… (Her voice is strong and clear). It’s what I’ve experienced and what I’ve felt.

Therapist: You may open your eyes when you’re ready. (after an 11 second pause Martha opens her eyes and looks directly at the therapist)

Since you’ve asked for something from the Bible, may I give you a quotation? (Martha nods her head in agreement)

“You shall experience the truth and the truth shall set you free”. I think the quote is from the Gospel of John.

(for 30 seconds Martha and the therapist gaze into each other’s eyes) Martha, it is the truth that will set you free. (Martha nods her head) Now would you like to begin the important part of the therapy?

Martha: I don’t understand you.

Therapist: I think the important part is yet to come. It may be important to have a truthful conversation with the real woman before she dies.

Martha: I’ve tried many times but she doesn’t want to. She tells me I’m silly. She tells me not to say things that will upset her. She says that my emotions have always hurt her. (Martha is shaking her head in a gesture of “no”).

Richard: Are you saying that she doesn’t want to know the truth? (Martha nods) ... Well, I believe you! ... There are some people who have built such a wall against intimate contact ... that they won’t hear the truth. Other people need the truth, most people need the truth so that they can live, and even die, in peace.

Martha: I would like to be really truthful with both of my parents but they didn’t want to hear my truth. They only want to tell their own story. {Since Martha has continued to shake her head in a gesture of “no” the therapist changes directions. If it is impossible for Martha to have an honest conversation with her mother then it is essential that she express her “truth” to the members of her group and experience full interpersonal contact with those who want to know her.}

Therapist: Then it is important that you share your story with us ...that we become the witnesses to your story..... Just take a moment and look around at your witnesses in this group. Can you do that? Just look around at all these witnesses. (Martha blows her nose as she looks at some of the people in the room).

Martha: It really touches me to look at them. (Martha moves to see them better). It touches me and at the same time it’s hard. It’s hard for me to look at their faces.

Therapist: I think the difference between the people in this group and the mother you were talking to is in their eyes ... what I see in their eyes is compassion and interest in your story. That’s why I wanted you to look in their eyes. (after 30 seconds Martha makes eye contact with a few people in the group) Does anybody want to say anything to Martha?

Several group members begin to speak at once about their feeling and reactions. A lively group process continues wherein some people express their sympathy and others identify with her plight.

Tessa’s clarification

Tessa was physically abused by her mother. She had a vivid memory of many severe beatings, of her mother burning her with cigarettes (she had scars to show), and of being tied to a bed while the mother was out for the night with various men. We spent three years deciphering the implicit and explicit memories embodied in her many physical sensations and gestures. Tessa would often write “horror stories” for me to read. Each of these stories contained an encoded account of her experience of physical abuse, emotional cruelty, and degradation. Our co-constructive decoding of her horror stories was the way she was finally able to construct a somewhat consistent narrative of her life. Tessa had not seen her mother all the while she was in therapy. In the fourth year of therapy Tessa’s mother was dying of liver disease. She discovered that her mother did not have much time to live. Tessa had expressed much anger throughout the ongoing therapy and she had also grieved for “the love of a mother that I had never had”.

I thought that she could benefit from a reconciliation with her mother. I encouraged her to have an honest conversation while her mother was still lucid. When Tessa entered the hospital room her mother criticized the way she was dressed, insulted her, and asked for money. Tessa spent several hours with her mother wherein she attempted to talk about her childhood. She told her mother about being tied to the bed. The mother answered, “You had fits. Something was wrong with your brain. There was nothing else anyone could do for you -- you were such a bad child”. Tessa described the beatings she received. Her mother justified the beatings and had no empathy or remorse. When Tessa showed her the scars from the cigarette burns the mother accused Tessa of having done it to herself.

Tessa returned to therapy heart broken and angry. She was angry at her mother’s callous and humiliating comments and she had hoped that her mother would express regret and ask for forgiveness. She wept with the painful realization, “We will never have a relationship”. She was also angry at me and screamed “Truth telling doesn’t work”.

Later in therapy she said that no matter what she had said to her mother that day, even if she had been very complementary and kind, she knew that her mother would insult and blame her. She concluded that her mother was now, and had always been, “self-centered and cruel”. She did not speak to her mother again. Her mother died. We continued the therapy for another two years and during this time she periodically said that the hospital conversation with her mother was very clarifying. She was now certain that none of the physical abuse was her fault. She no longer criticized or blamed herself.

Conclusion

In Tessa’s situation the idea of “truth telling” did not have the desired effect of repairing a ruptured relationship as it had for Linda. Truth telling and open hearted conversations are possible when the other party is receptive to a meaningful dialogue. If the other person is closed to interpersonal contact such truth telling may still have some benefits as it eventually did for Tessa. Over time Tessa experienced a sense of clarification and an end to self-ridicule.

For many clients having an honest, face-to-face, and intimate conversation with the significant other before he or she dies is the most effective way of resolving anticipatory grief and decreasing the intensity of grieving after the person dies. Martha was unwilling to have a direct conversation with her mother. She was certain that her mother would be unreceptive to any truthful or intimate dialogue. Instead we used the “empty chair” and Martha’s imagination to create the quality of interpersonal contact in fantasy that was not possible in reality. In all three of these examples the “truth telling”, in its various forms, either resolved resentment, repaired a ruptured relationship, or provided a sense of clarification. To quote the Gospel of John (8:32), “The truth shall set you free”.

Copyright: November 15, 2013, Institute for Integrative Psychotherapy, Vancouver, BC, Canada and Richard G. Erskine Consulting Inc.

Key Words: grief, anticipated grief, empty chair, unfinished business, truth telling, expressive psychotherapy, integrative psychotherapy

 

See also:

Truth Shall Set You Free: Saying an Honest “Goodbye” Before a Loved-one’s Death

The Institute for Integrative Psychotherapy is approved by the American Psychological Association to sponsor continuing education for psychologists, by the National Board of Certified Counselors for counselors and by the American Board of Examiners in Pastoral Counseling for pastoral counselors. The Institute for Integrative Psychotherapy maintains responsibility for this program and its content.