GOOD GRIEF:?HOPE AND DESPAIR IN EFFECTIVE PSYCHOTHERAPY

By David S. Fuller, M.D., University of Texas Health Science Center, San Antonio

(Published online by the Psychiatric Journal with Permission from Dr. Fuller.)

INTRODUCTION

For many years after my residency, I wondered why virtually every patient I saw in psychotherapy demonstrated some degree of overt or covert depression.?Their depressive features commonly coexisted with anxiety, phobias, personality disorders, substance abuse, or other manifestations of psychopathology.?It was bothersome that so few patients presented with a pure neurosis,? personality disorder, or mood disorder.? It would have been ever so much easier if I could have conceptualized their conditions as discrete entities and if a regularly effective treatment could have been applied that was specific for each diagnosis.?Instead, I discovered that most psychotherapy patients present with a mixture of symptoms.? Regardless of which symptoms prompted the patient to come for therapy, almost every one of them conveyed some degree of chronic unhappiness, resentment, despair, and expectation of disappointments.?It seemed that something akin to depression was a common denominator for most who entered psychotherapy.

I began to wonder, quite seriously, if I understood the basic nature of depression.?I concluded that, in spite of what I had learned in a well-regarded training program, my understanding of depression was, at the least, incomplete.?I knew the descriptive characteristics of depressed persons, and I knew that depression often follows the loss of someone or something valued but toward which the person has feelings of ambivalence.?I was also aware that depressed persons commonly turn their frustration-induced anger in on their introjected objects such that they experience guilt and self-castigation.?These and other things that I knew about depression, however,?did not explain what I observed in my patients.?Many of them had experienced no recent loss, and evidence of introjected hostility was often not readily apparent.?Why did virtually every psychotherapy patient have depressive features? Could it be that, in spite of the prominence of their non-depressive symptoms, a depressive issue might be of crucial importance in understanding their conditions??Could it be that helping each of these patients with their unapparent depressive issues might be essential to the success of their psychotherapy??I could only conclude that something was missing from my understanding about the depressive component of their conditions.

For years I read about depression, discussed the topic with my colleagues, and listened to my patients as I tried to conceptualize the nature of depression more clearly.?Is it always a disease entity?? Is depression ever normal??Is there a purpose in its existence??Does it benefit a person??What makes people sad - - - and happy??What conditions are necessary for depression to be concluded?? Is depression simply a disorder of mood, or is some other mental function involved??

Then, in 1963, a paper appeared in the Archives of General Psychiatry that truly excited me.? Aaron T. Beck published the first of his writings in which he suggested that the basic issue in depression is not mood at all.?He proposed that the fundamental defect is in perception.?His observations led him to conclude that the altered mood and the behaviors that typically accompany depression are a natural consequence of a person's pessimistic perception of his past, present, and future.?He explained logically and clearly that, for understandable reasons, a depressed person starts perceiving everything as though looking through hopeless-colored-glasses.

I was still puzzled, however,?about the relation between the understandable, appropriate sadness of a person who had recently lost a loved one and the more severe depressive features of a person with what is now called major depression.?I could never reach conceptual closure on this question by simply saying that one condition is normal and the other is pathological.?I also could not stop thinking about the observation that these two conditions have so much in common and that the differences, in some ways, seem largely a matter of severity.?I reasoned that if mourning or grieving is a normal, adaptive process of emotionally working through an unwanted loss until it is accepted, then pathological depression could be understood as a blocked or miscarried? attempt to work through essentially the same process.?If so, the steps in the process of grieving might appropriately serve as a model for helping a depressed person to recover and for helping a patient who presents with another major symptom but who also needs to work through an unresolved depressive problem.?

I observed that each of my psychotherapy patients were frustrated in that they wanted something important, past or present, that was, for one reason or another, unattainable.? Each, in fact, seemed to desire something consciously or unconsciously that was unattainable but for which the patient could not stop hoping.?

Then in 1970, I discovered a book by Ezra Stotland entitled The Psychology of Hope.? How encouraged I was to find answers to some of my questions through a clearer conceptualization of hope and hopelessness.?By the mid '70's to early '80's there was good evidence that not only psychotherapists but also non-psychiatric physicians need to know as much as possible about hope and hopelessness.?Evidence had by then mounted to suggest that many physical disorders (cancer, infections, ulcerative colitis, and others) more frequently appear or reappear, along with impaired immunological and other biological mechanisms, in a life context of grieving a major loss or disappointment.

I continued listening to my psychotherapy patients with an ear to hearing and understanding their themes of hope and despair.?I also tried to identify a conceptual explanation for the depressive themes that seemed ubiquitous among these patients. Such a conceptualization, I reasoned, would surely have practical applications for conducting?effective psychotherapy.

THE CENTRAL ISSUE

The central problem for many adult patients in reconstructive psychotherapy appears to be that they have been unable to accept the unattainability of some major desire which commonly began much earlier in life.?Like a person grieving, these patients continue to want what reality seems to say they cannot have. ?/span>Though often not aware of the central problem, they characteristically have struggled for years to deal with a conflict of "to hope or not to hope" for a major, ungratified desire.?The psychotherapeutic task, then, becomes one of helping the patient to address the unfulfilled, sometimes repressed, desire and to work through the blocked grieving process, thus freeing the person to pursue other, appropriate, attainable goals of adult living.

Before describing case examples and delineating principles of reconstructive psychotherapy that are appropriate for patients who need help with remedial?grieving, I would like to discuss the nature of grieving, the nature of hope, and the relation of hope and hopelessness to grieving.?

THE NATURE OF GRIEVING

Grieving, or mourning, is usually thought of as a reaction to a major loss such as the death of a loved one or the loss of some other object of importance.?Grieving can also appropriately be thought of as the process by which one resolves the conflict of wanting what is apparently unattainable.?The griever's problem is that he has a desire that is both unattainable and unrelinquishable.?In the process of successful grieving, a person at first actively tries to obtain what is unavailable and then, after being repeatedly frustrated, agonizes over whether it is or is not attainable.?When he sees it is not possible to have his desire, he then struggles over whether he can give up the desire.?In the end, if and when the grieving is successful, he accepts its unavailability, relinquishing his desire conclusively.?

Although what is desired may be a person, a situation, or a possession that was once available,?it may also be something that has never been available.?If, for example, a person is forced to give up his dream of becoming a physician, this unfulfilled, unattainable goal can only be given up by being grieved.?In fact, the need to renounce a desire that has never been fulfilled appears to be the crucial problem for patients in reconstructive psychotherapy more often than is the problem of accepting the loss of something previously available.

A common scenario in psychotherapy involves a patient who wants to have had and to have an idealized version of an important relationship that was never available in childhood.?The patient hopes, for example, to have had an approving parent, to have had an emotionally available and loving parent, to have been loved as much as a particular sibling was, to have had a nonabusive parent, or to have had a parent-child relation that provided more security.?Less commonly, the patient wants to have had a personal identity that was never a possibility.?The patient hopes, for example, to have been a member of another ethnic group, to have been a member of the opposite gender, to have been physically well, to have been more physically attractive, or to have had some other personal characteristic that was never possible.?Regardless of what desire was frustrated, the typical patient considers the desire so important that he feels, "If I could only have this one desire, I could be happy; without it, I could never be satisfied."

Mrs. Goodall, a 46-year-old housewife and mother of two teenagers, came seeking psychotherapy soon after her husband indicated he might later ask for a divorce to marry a younger woman with whom he was having an affair.?Although Mrs. Goodall thought her husband's "middle-aged fling" would not last, she had long wanted psychotherapy.

In the first interview she told of having been an illegitimate child who was born to a deeply religious woman in a small, conservative, Southern community.?From an early age, her mother had required her to proclaim at church and other gatherings what a wonderful, loving mother she had.?While the patient was in the process of conveying such ideas to others, however, she was thinking, "It's a lie; it's a lie!"?Mrs. Goodall became a straight-A student, was exceptionally well behaved, and excelled at sewing and other handicrafts, yet she felt unable to get her mother's approval. ?/span>Her mother seemed always to be criticizing her for supposed shortcomings.

While in college, the patient eventually married the first and only man she dated, a religious man who intended to be a professional.?In the 25 years of their marriage, the patient consistently and actively supported her husband.?She substantially helped him to be successful in his profession.?Although Mrs.?Goodall was never personally gratified in their sexual relations, she never rejected her husband's advances.?As an exceptional seamstress, the patient made suits and sportcoats for her husband whenever he asked her to do so.?She and her husband actively avoided openly expressed disagreements.

Occasionally the patient's mother announced that she was coming to the patient's home for a visit.? During her two to three weeks' stay, her mother would rearrange the patient's furniture and pictures and would instruct the patient on the correct way to do her housework.?Sometimes, when her mother was at her own distant home, she would buy a long coat for herself, on sale, in a size that was too large.?The patient's mother would mail it to Mrs. Goodall with the request that the patient remake the coat to her mother's size.?The patient always obliged.?In this and in other ways, Mrs. Goodall tried to earn her mother's approval, but she felt she never got it.

In weekly psychotherapy, the patient had difficulty acknowledging feelings of resentment toward anyone.?Even when her husband criticized her for being a less exciting lover than the other woman, Mrs. Goodall felt she should not be unhappy with him.?She reasoned that if she came to resent her husband's behavior, she might, indeed, lose him.?Little by little, however, she began to recognize her feelings of resentment toward both her husband and her mother and, in time, came to find these feelings personally acceptable.

Then, in therapy one day, the patient shocked me by reporting that she had already mailed a 23-page letter to her mother.?In that lengthy epistle, Mrs. Goodall had said something to this effect:?"I am through trying to get your approval.? It is a futile, hopeless quest.? I no longer need your approval, for I have learned to approve of myself.?I now know that you could never approve of me because I was the unwanted, illegitimate child that led to your being criticized in our community.?You are, yourself, the one of whom you could never approve, but you needed not to be aware of that.?Regardless of how you feel about it, our relationship will henceforth be different.?Never again are you to send me long coats to remake to your size.?Not only will I not remake the coats, I'll give them to Goodwill if you should send them.?Never again are you to come to my home uninvited.?If I ever do send you an invitation, I will truly want your visit, but I will specify the number of days you are to stay.?If you choose to accept such an invitation, I will treat you with kindness and respect, but you, in turn, should not make a single suggestion about how I run my household.?I do not know how you will react to what I am saying.?That must be for you to deal with.?I do know that the action I am taking is best for me.?I believe that, in the end, it will also be best for you."?This letter could only have been written after Mrs. Goodall resolved her basic conflict by giving up her hope for her mother's approval.?

Soon thereafter, Mrs. Goodall's 19 y/o son was to marry.?The patient invited her mother to come for a two-day visit in her home so that her mother could participate in the wedding.?At our psychotherapy session after the wedding, the patient said she had never spent a more pleasant two days with her mother.?Gone was Mrs. Goodall's unrealistic hope for what could never be and, with that, her frustration and resentment.?

Before long, it occurred to the patient that, for 25 years, she had been striving to obtain approval from her husband who was, in her unconscious mind, a replica of her mother.? Just as had occurred with her mother, she had resented her husband's failure to give approval commensurate with her efforts to please him, and she had, no doubt, found ways to displease him.? Not surprisingly, Mrs. Goodall had little difficulty accepting the divorce that her husband obtained from her before he married the other woman.

After the psychotherapy was completed at 21 months' duration, the patient found her first gainful employment in a distant city.?A few months later, she wrote me saying she doubted that she would ever remarry.?She also said she felt sure that she would be less likely to get depressed after future losses because she had learned how to grieve what must be relinquished.?

To grieve is to be conflicted.?The conflict that grieving attempts to resolve, like all conflicts, involves two frustrations at once.?The grieving person is frustrated because?he cannot have what he wants.?He is also frustrated because, in spite of an awareness on some level that his desire is unattainable, he cannot give up wanting it.

The country-western song "I Can't Stop Loving You" poignantly describes the feelings and the issues involved in grief.?The hapless singer cannot have and cannot stop longing for the unavailable lover.?Every actively grieving person continues to struggle over his desire for the unattainable, while still unable to accept not having what he feels he must have.?

Any grieving conflict can take one of three courses.?First, the conflict and its associated grieving can be resolved if the person can obtain what he desires.?Second, the conflict can be resolved if the person can accept that his desire is unattainable and relinquishes it.?This second possible outcome is exemplified by a song that was sung by the older man, Honore, played by Maurice Chevalier, in the movie Gigi.? Having given up his unattainable wish for youth, he sings, "I'm So Glad I'm Not Young Any More."?The third possibility is that the grief conflict may continue unresolved.?

These three possible outcomes of grieving can be illustrated by considering three different responses to a recent loss.?The parent of a teenager who mysteriously disappears will likely grieve the missing adolescent until he returns home or, should he be found dead, until the parent finally accepts his demise, no longer wishing he could be alive.?If unable to conclude the grief conflict by either of these two possible resolutions, the parent may experience the onset of some psychiatric condition such as an anxiety disorder or a somatoform disorder.? The psychiatric condition distracts the parent from the original conflict.?It also becomes a substitute problem with which the parent is more hopeful of getting help than with the original problem which seems hopeless.?This third scenario of perpetuating the unresolved conflict by unconsciously disguising it as a potentially treatable disorder is especially likely if the parent's frustrated wish for the missing teenager closely replicates the theme of an unresolved, similar conflict from the parent's childhood.?

By the very nature of grieving, the griever has difficulty knowing?and accepting that the apparently unattainable desire is, indeed, unattainable.?Even when a grieving person can be absolutely sure on a cognitive level that a supreme desire is unattainable, he still has an emotional need to hope that surely, by some means unknown to him, the desire can be gratified.?

THE NATURE OF HOPE

The griever feels both hopeful and hopeless about his specific desire.?A dictionary definition of hope is "desire with expectation."?Like other mental states, hope has three aspects.? Hope consists of a cognitive or perceptual aspect, an affective or feeling aspect, and a conative or drive-to-behavior aspect.?This is to say that hope consists of an optimistic perception, a relatively euphoric feeling, and a heightened drive to pursue gratification of the desire.?It is small wonder that everyone prefers the optimism, euphoria, and energizing motivation that accompany the hope of obtaining a particular desire over the opposite states of mind that accompany hopelessness.  ?

In his book, The Psychology of Hope, Ezra Stotland describes hope as the perceived probability of attaining a specific, valued goal.?Of central importance in this definition is the idea that since hope is a perception, the appropriateness of one's hopefulness or hopelessness is dependent on the accurate interpretation of sufficient, available data.?As an example, a second year medical student with unsatisfactory grades in several courses may know that he must do well on his pathology final to continue in school.?Upon hearing from a friend that his posted final exam grade in pathology is a 52, he perceives his situation as hopeless and, understandably, feels depressed.? When he checks the posted grades himself, however, and discovers that another student's grade is 52 and his grade is actually 89, he suddenly perceives his goal of proceeding in school as highly probable, and his corrected perception at once makes him feel euphoric.?His feeling state is dependent on his perception.

It is worth emphasizing that each perception of hope refers to a specific desire or goal.? Just as one does not have desire in the abstract without an object of that desire, one does not simply hope in the abstract without an object of that hope.?One always hopes for a particular desire, although what is desired may not always be conscious.?Hope also involves the anticipation of gratifying the specific desire in a particular way. rado replica uk Hope, then, is the optimistic expectation of gratifying a particular, important desire or goal through the availability of a defined supply by a specific means.?The amount of one's hope or hopelessness also relates substantially to the importance that one places on the desire or goal.?The more highly valued it is, the greater will be the associated hope if the goal is perceived as attainable.?Conversely, the greater will be the associated hopelessness if the valued goal is perceived as unattainable.?

Psychiatry has long recognized that any one thought, feeling, or bit of behavior is pathological only to the extent that it becomes inappropriate, unrealistic, or otherwise maladaptive.?It is not that hope is regularly adaptive or normal, although it is usually thought of as desirable.? Neither, for that matter, is hopelessness routinely maladaptive or abnormal.?Instead, the particular circumstances in which each perception occurs determine whether the predicted success or failure of the striving is warranted.?In fact, the flexible, appropriate employment of both hopeful and hopeless perceptions is essential for dynamic adaptation of an individual's needs and desires to changing realities.?

One's level of hopefulness substantially regulates the amount of motivational effort that will be expended in goal pursuit.?Thus, an individual's energies directed toward goal pursuit are augmented when he appropriately perceives a goal as hopeful and are attenuated when he appropriately perceives a goal as hopeless.

Why should it be that people so commonly maintain hope of gratifying an important desire or need when available evidence shows that it is clearly unattainable and that the pursuit should be abandoned??One reason may be that there is a life-preserving and a species-preserving benefit to an organism's erring on the side of maintaining hope in the face of major adversity.?The idea that hopefulness favors survival is suggested by observations made by Walter B.? Cannon in his classic paper, "Voodoo death"; those by Curt Richter in his celebrated study of the swimming rats; those by Stewart Wolf concerning the low incidence of coronary disease in Roseto, Pennsylvania; and more recent observations concerning the concurrence of hopelessness and impairment of immune mechanisms.?The survival value of hope has also been graphically described by Victor Frankl in From Death Camp to Existentialism.?It might be reasonable to speculate that humans, as well as other animals, may be neurobiologically?programmed to maintain hopefulness for one's most important strivings in the face of overwhelmingly unfavorable odds.

In the grieving person, however, the conflict between hope and despair poses the danger of motivational impasse unless the grieving is temporary and actively leads to a definitive resolution.?In a fascinating paper entitled, "Is Grief Pathological?", George Engel argues that grieving is a condition of maladaptation that leads to one of adaptation only when it is concluded.?

RESOLVING THE DILEMMA OF HOPING FOR THE HOPELESS

The process of grieving involves a series of unconsciously determined intrapsychic ploys, each of which moves the griever closer to resolving his dilemma.?In successful grieving, one progressively moves from at first strongly hoping to attain the goal, through a period of struggling over whether to give up hope, ultimately to relinquishing the goal, accepting that it is unattainable.?As Elizabeth Kubler-Ross pointed out, the process typically includes imprecisely-sequenced periods of denial/disbelief, anger, bargaining, and depression before final acceptance.?In the phase of denial/disbelief, one ignores available information in order to maintain the (false) perception that the goal is attainable. breitling replica?In the phase of anger, one acknowledges the frustration but fights back in protest, maintaining somewhat less but still a substantial amount of hope for attaining the goal.?In the phase of bargaining, one has more awareness than before that the goal is unattainable and less hope than before for fulfillment.?The bargaining griever, in a sense, is ready to consider a consolation prize.?In the excruciatingly painful period of depression, the attenuated amount of hope, still active in the conflict, is struggling against an overwhelming amount of hopelessness.? rolex replica sale It is as though the griever in that phase has to feel hopeless about all lesser goals before it is possible to give up hope for his hierarchically dominant goal.? When the pain of frustration and sadness becomes too high a price to pay to keep hoping for the supremely valued goal, the griever reluctantly gives up all hope of having his unattainable desire.? Only when this hope is abandoned and the desire is relinquished through accepting its futility is the grieving conflict resolved.?

While a person can never avoid necessary grieving, it can certainly be (and often is) postponed. The dreaded pain of grieving may be delayed for long periods of time by employing mental machinations that are completely out of the individual's awareness.? One should never underestimate the ingenuity of the unconscious mind to employ creatively a variety of cognitive, behavioral, and affective gambits to maintain hope of attaining highly valued but unattainable desires.?rolex replica sale The unconscious mind, that child-like part of the psyche that respects no rules of logic, time, or reality - - - that tenacious, scheming, goal-preserving, never-say-die part - - - can, with dogged determination, maintain the illusion of hope for obtaining one's narcissistic desires with complete disregard for frustrating realities.?

The human mind, in fact, seems amazingly facile at using a vast array of symptom patterns that maintain unconscious hope that a cherished goal does not have to be abandoned.? Without conscious awareness, a person may employ grandiose and persecutory ideation, anxious dithering, masochistic suffering, pigging out and throwing up, restrictive dieting and overexercising, abuse of alcohol and other drugs, obsessive rumination, and dissociation.? An individual can also unconsciously play a variety of life roles including those of the physically sick, the pseudo-suicidal, the phobicly incapacitated, and the dependently helpless.? The symptomatic possibilities are legion for how the unconscious mind inappropriately?sustains hope for attaining cherished goals, especially those that once might have been reasonable desires in childhood but are currently unrealistic.?

I am not suggesting, of course, that all functional psychopathology is?simply a result of failure to have grieved successfully one's frustrated strivings from long ago. That would be far too simplistic.? Unquestionably, other factors contribute to determining which symptom patterns are employed, how incapacitated a person becomes, and which psychological benefits accrue from learned and unconsciously-selected symptoms.?Some clinical features of psychiatric disorders are undoubtedly the manifestations of partial developmental arrest.?Persons with borderline personality disorder, for example, exhibit behavior that is, in substantial part, a product of arrested development of object relations.?I do, however, suggest that it is worthwhile for a psychotherapist to consider whether each and every patient may be unconsciously struggling to keep alive, through psychiatric symptomatology, hope for a desire from childhood that the patient has been unable to gratify and is unable to relinquish.

Randy, a 30-year-old man with an 11th grade education, came for psychotherapy with symptoms of a phobic disorder with panic attacks that kept him from driving alone.? panerai replica sale He has been unhappily married for six years and is the father of two daughters.?Randy has driven his own long-distance truck, has twice managed his own automotive repair shop, and has had short-lived successes in automotive sales.? Although this bright man is unusually gifted with anything mechanical, he has a pattern of rapidly-developing, phenomenal job success that he then unconsciously sabotages for reasons unclear to him.?Each of his business endeavors? fails, or he quits, or, occasionally, he gets himself fired.

In psychotherapy, Randy is generally dependent.?Occasionally he shows bursts of remarkable intellectual insight, but most of the time he extensively uses repression.?He steadfastly disciplines himself never to cry in any of the therapy sessions.?He says that, if he allows himself to feel sad, his feelings might get out of control, and he might be unable to stop feeling sad or might want to kill himself.?

Randy is the third child and the number two son among the five children in his family of origin.? The eldest is a sister, and the second child is a brother, Tom, Jr., who clearly has been Father's favorite.?He has two younger brothers.?The patient had childhood bronchial asthma that probably contributed to his mother's becoming overly protective of him in a variety of ways.? After the patient sustained a head injury with temporary loss of consciousness at age seven, the patient's father, a successful professional, is said to have related to the patient as though Randy were not as bright as the other children.?Through the years, Randy has had a tremendous amount of conscious animosity toward his father that he has frequently expressed overtly and passively.?On one occasion, Randy came close to killing his father with a hammer.?Sometimes the patient confides that he, most of all, wanted his father to relate to him as his father related with interest and affection toward his older brother, Tom, Jr.?Once the patient said, "If only he could have put his hand on my shoulder and said, 'I'm glad you're my son.'"

Randy vividly recalls a scene involving his father, Tom, Jr., and himself when he was five years old.?After the older boy cut his hand, their father was caressing Tom, Jr. and putting a Band-Aid on the wound.? Hoping that his father would treat him similarly, Randy took a razor blade, cut his own finger, and went to his father who was still holding Tom, Jr.?"You know where the Band-Aids are", he recalls his father saying as he sent the patient away.?Randy cut another finger and returned to his father who again sent him away.?The patient remembers thinking to himself, "I wonder if he would love me like Tom, Jr., if I cut myself so much that I bled to death?"?

Through the years, Randy has remained dependent on his parents, although he insists he wants to be independent of them.?His parents have, for example, provided him a rent-free house, and they have repeatedly rescued him financially when his occupational endeavors failed.?He complains bitterly over their attempts to give him advice and, as he sees it, to control him.

Randy continues to be concerned that he will have a recurrence of panic attacks in spite of benefit from a tricyclic antidepressant.?He says that if he did not have his phobia of driving long distances alone, he would pursue his life's goal of operating his own 18-wheel truck while living in another city, apart from his family of origin.?He has also said that the woman he married is a replica of his father.?It is my observation that while he wants his wife to give him respect and affection, he also relates to her in such a way as to assure that she will reject him as his father did.?

During the early part of his psychotherapy, Randy's parents one day carried him by car to his own home.?The patient was sitting in the front seat, and his father was driving.?Suddenly, for no apparent reason, Randy experienced a panic attack.? He leaned over to the left and lay on the front seat so as to avoid seeing outside.?He rested his head against the right side of his father's body.? He consciously thought, "Perhaps my Dad will put his hand down on my head to comfort me, or maybe he will say something comforting to me."?But his father continued his driving, ignoring the patient completely.? Then the patient said to himself, "Damn, he's never going to relate to me in the way I've hoped," and his panic attack immediately and completely ceased!?If this episode is a paradigm for the larger recovery he seeks, then renouncing his life-long hope for an idealized relation with someone who takes the place of his father could hasten the end of his neurosis.?

One part of Randy's conflict is his sometimes unconscious desire to be loved by his wife (or someone else) in a way that matches his idealized image of a caring father who loves a gratified little boy.?Although Randy's symptoms extract a high price in suffering and disability, they enable him to keep alive his supreme desire.?His occupational failures keep him in a child-like dependence on others, and his fear of driving alone precludes his being a long-distance truck driver who lives independently in another city.?They also permit him to "get even" with the father who always wanted him to be successful.?The other, more often conscious, part of Randy's conflict is his wish to become a self-sufficient adult who is responsible and enjoys success at work and at home.?At this point, however, he still cannot imagine being happy without experiencing the kind of relation he missed having in childhood.?Randy's conflict, I would suggest, can only be resolved when he completes his grieving such that he can relinquish his unattainable desire for a child-like relation with an idealized parent figure.?

The typical psychotherapy patient with a neurosis or personality disorder tells of a repeatedly frustrated desire in adult life that remarkably parallels an old, ungratified wish from childhood.?This phenomenon, called the repetition compulsion, consists of a patient's unconscious urge to re-encounter in adulthood, repetitiously, not only a striving for the gratification of a major desire that was denied in childhood, but also an unconscious urge to experience the frustration of that desire.?In other words, there is an unconscious compulsion to experience, repetitiously, both the hope and the hopelessness of the grieving conflict.?Presumably, the reason one needs to re-encounter both parts of the old conflict over and again is to have multiple opportunities to resolve it once and for all.? What tends to occur, in the absence of effective?psychotherapy that leads to a definitive resolution, is that the symptomatology partially obscures and partially gratifies both portions of the conflict, perpetuating it ad infinitum.?The patient thus keeps hope alive for the long-frustrated desire while also re-encountering experiential evidence that, in reality, the endeavor is hopeless.?

One of the most commonly-observed patterns in reconstructive psychotherapy is that the patient currently wants to have had an idealized relation with a key figure in childhood that can never have occurred.?The patient's efforts to resolve the conflict are stalemated because he fails to finish grieving the loss of what might have been.?In an unconscious attempt to work on the old, unresolved conflict, the patient currently tries to have a similar, idealized relation with one or more contemporary persons who are currently important in his life.?Without conscious awareness, the individual engages in his compulsively repeated struggle such?key persons as the patient's spouse, friend, boss, and therapist.?No one can accurately guess the number of marriages that end because of the husband's and/or the wife's unconscious urge to obtain from the partner what was missed in an earlier parent-child relation, combined with his and/or her unconscious urge to experience the frustration of that desire.

GOOD GRIEF IN PSYCHOTHERAPY

Psychotherapeutic efforts aimed at helping the patient to resolve the basic conflict include gently facing the patient repeatedly with the reality of what cannot have been in the past and cannot be in the future, until the patient relinquishes the unrealistic?desire.? The patient must specifically acknowledge the need to relinquish that hope, make personally acceptable his/her anger over the frustration, experience the sadness about having to give up what is a supreme desire, and, of critical importance, renounce the unattainable desire.?

Ideas similar to these appear in several publications.?In 1963, Robert J. Wetmore published a paper entitled "The role of grief in psychoanalysis."?Wetmore states that successful psychoanalysis enables the analysand to learn to grieve effectively by a therapeutic process that is, at its core, a prolonged period of grieving that permits a relinquishing of infantile, neurotic goals.  ?

In 1986, Judith Viorst published Necessary Losses, a widely-read book that conveys the theme that the mature adult must give up many childhood wishes.?"The road to human development," she says, "is paved with renunciation."?She points to the adult's need to relinquish childhood's illusions of freedom and power, the hope that one's mother can be his/hers alone, and the possibility that a girl can ever grow up to marry her dad.?The adult, she says, must also give up childhood dependencies, one's own younger self, and a variety of other impossible expectations.

In a book published in 1988 entitled Suffering From Illusion:?The Secret Victory of Self-Defeat, Sayers Brenner, a psychiatrist, focuses on another aspect of the difficulty that psychotherapy patients have accepting their failure to get ideal parenting.?With great clarity, Brenner describes how some adult patients pursue masochistic self-defeat in an effort to get even with the disappointing parent.?The solution to such a patient's conflicted wish to have had a better parent and his need to stop pursuing this impossible goal, Brenner observes, is for the patient to take steps in psychotherapy to accept what transpired in childhood and ultimately to forgive the parent.

I believe that most patients in reconstructive psychotherapy can be discovered to have one central, unrealistic hope that ultimately must be renounced.?The therapist should ask himself/herself, early in the therapy, "What has been the major disappointment of this patient's life??What does the patient feel he should have had and must have that was and is unattainable, yet is so important to his feeling satisfied, that he has been unable to give up his hope for it?"

Melanie, an attractive?married woman without children, came at the age of 28 years for therapy with the chief complaint of bingeing and vomiting for many years.?At times she had required emergency treatment for signs and symptoms of hypokalemia.?At the age of 16, the patient had experienced onset of anorexia nervosa.?That condition had, in fact, evolved into the current one of bulimia with no intervening period of recovery.?The patient's husband, a professional, has been firmly committed to maintaining their relationship.?He has been amazingly patient with Melanie who sometimes made vicious verbal attacks on him.?She felt he did not spontaneously meet her emotional needs.?It also seemed unfair to her that he rarely got upset, while she was in more-or-less constant inner turmoil.

Soon after the therapy began, Melanie developed a romantic, non-sexual relation with a married man at work.?They exchanged encouraging, friendly notes and read poetry aloud to one another while eating their sack lunches outdoors. This man clearly did not intend to end his marriage.?The patient basked in the gratifying illusion that her relation with this coworker was perfect in every way. Each was kind and thoughtful of the other, and it seemed to her that she was the number one person in his life.?When this man was transferred to another city, the patient became quite distraught, and, for a time, withdrew from therapy when I suggested she would need to relinquish her hope of having such an idyllic relationship with this man or, in fact, anyone.?

In time the patient returned to therapy.?Although she refused to take antidepressant medication, she worked at decreasing her bulimic behavior with partial success.?She was very reluctant, however, to discuss her memories of childhood; when she did, she avoided, for a long time, attaching meaning or much emotion to those memories.

Eventually it became clear that the patient had an extremely ambivalent relation with her mother.? Melanie has an older brother who was rarely mentioned, and younger sisters who are identical twins. The patient's mother had often told Melanie that she was her favorite, although her mother's behavior conveyed the opposite.?Throughout the patient's childhood and adolescence, her mother generally made all the decisions about Melanie's clothes and activities.?Her mother effectively controlled the household; the patient's alcoholic father was largely unassertive.?In her teen-aged years, Melanie tried in every possible way to earn her mother's approval and love, but her younger twin sisters always seemed to get her mother's attention.?It was when Melanie's hope and despair over these issues climaxed when she was 16-years-old that signs of anorexia nervosa had appeared.?

Through the years since she left home, Melanie continued to try to hold onto the illusion that she was the special one in her mother's eyes.?But as her psychotherapy progressed, evidence to the contrary began to mount.?Her mother would send her a box of Christmas presents nine months late that would include clothes of an unacceptable size and style and candy that had deteriorated with age.?When Melanie placed long distance telephone calls, her mother would be too busy to talk with her.?The patient's parents never came from their distant state to visit in the patient's home.?It became increasingly obvious to me that the patient would have to give up hope of the special kind of relation she had always wanted with her mother.

Melanie's grieving conflict was discussed over and over in the therapy.?She needed to stop hoping for what could not be, yet she could not relinquish her cherished hope.?She became aware that she sometimes used her bulimic behavior to express her anger at her husband for not providing her with the kind of relationship she had failed to get from her mother.?

The patient and her husband then flew to the distant home of Melanie's parents.?Her mother conveyed no warmth to Melanie and completely avoided any private meeting with the patient.?Upon their return, Melanie's bulimic symptoms reappeared with dramatically increased?severity.? A neighbor lady with whom the patient had slowly developed a close relation was, at the same time, about to move with her family to another state.?Soon, however, the patient's hope for the hopeless "hit bottom."? In a matter of weeks, she relinquished her futile desire for the idyllic relation with a mothering person that she had never had and would never have.?Soon Melanie's bulimic behavior ceased, and the psychotherapy was, after a total of 3 1/2 years, brought to termination.?

Why is it that people are so resistant to giving up hopes that need to be relinquished??One reason concerns societal expectations.? Tightly woven into the warp and woof of our society is the fundamental teaching that one should pursue his/her goals with determination, perseverance, and the expectation of ultimate success.? A now defunct television ministry proclaimed this theme repeatedly in a song entitled, "Don't Give Up!"? It is as though a person in our society who dares ever to relinquish hope is viewed as being weak, almost unpatriotic, and shamefully defaulting on a personal commitment to succeed in all pursuits that every person is expected to have made.

Another explanation for why people resist giving up their cherished hopes is that it is simply human nature.?As William Silverberg said in a paper over forty years ago, it is fundamentally human not to admit there is something that one wants but cannot have. Grieving can also be almost intolerably painful, especially when an earlier effort at grieving was never completed.?Grieving is anguish for those who have difficulty accepting their feelings of anger and sadness.?Undoubtedly, some patients fear loss of control if they experience the anger, and some fear that the sadness will become dangerously extreme or endless.? Grieving also lessens the self-esteem of anyone significantly dependent on external narcissistic supplies.?Many of those who resist grieving consciously deny how important their frustrated desire is for them.?Perhaps the paramount reasons for resisting the grieving process, however, are related to the issue of hope itself.?Resistant persons commonly have limited hope that they can actually give up the desire without being emotionally shattered, and they particularly have little hope that, once they renounce the desire, they will then feel more satisfied than before.?The real challenge of doing reconstructive psychotherapy, it would seem, is that of how to help the patient face and deal with precisely the issue that the patient would rather avoid.?

A psychotherapist must have patience, timing skills, persistence, and a considerable tolerance for going over the same issues repeatedly to help a patient grieve the loss of an important desire that is not easily relinquished.?When, however, a therapist accurately conceptualizes a patient's central conflict?as an issue of blocked grieving, then actively keeping the patient at his job of grieving substantially contributes to the therapy's effectiveness.?

Four specific actions by the psychotherapist are crucial to the success of this type of therapy.?First, the therapist must identify the patient who needs help with giving up misplaced hope and must identify that patient's specific unattainable desire that needs to be relinquished.?Second, over a period of time, at a pace limited by the patient's readiness, the therapist must facilitate the patient's awareness of the central grieving conflict.?Third, the therapist must have hope and must convey that hope to the patient concerning the benefits that are to be expected from resolution of the? conflict.?Finally, the therapist, in an unrushed but persevering manner, must keep the patient at the grief work until it is completed.

CONCLUSION

Many adult patients in reconstructive psychotherapy whose primary complaints are symptoms other than depression need help with resolving a depressive or grieving issue.?They typically attribute feelings of chronic unhappiness to psychiatric symptoms and to current life frustrations in occupational, domestic, and social areas.?While these current frustrations undoubtedly bear a relation to their chronic unhappiness, these are commonly manifestations of an unconscious need to re-experience the unresolved hope and despair concerning a long-standing, major childhood desire that was never gratified and that the patient is still unable to relinquish.?Effective psychotherapy with these individuals can be conceptualized as remedial grieving.?This therapy enables the patient not only to give up the parallel childhood and contemporary desires that are unattainable but also to be better prepared to relinquish future unattainable desires.?When this psychotherapeutic goal has been accomplished, the patient can be said to have experienced "good grief."?

ADDENDUM

The following is a short verse that I sometimes share with patients with whom I am working on the kind of issue I have been describing:

No matter how long and winding the road,

No matter how tart and bitter the cup,

There is surely a treat for you in store

When your unattainable desire's given up.

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