Mourning the death of a loved one is a ubiquitous human experience. Practically all individuals will be multiply bereaved at various points in their lives, through the deaths of parents, spouses, siblings and friends, and for some, their own children. Reactions to these losses can be intense, as reflected in depressed mood, anxiety, sadness, lack of interest in re-engaging in the world or forming new relationships (Bonanno and Kaltman 2001; Stroebe et al. 2007). Despite the intensity of such grief reactions, most individuals successfully cope with their loss and return to healthy levels of functioning in the second year of bereavement (Bonanno and Kaltman 2001). In fact, responses to loss follow several distinct trajectories, with a some individuals displaying quite resilient responses to loss, and others actually showing improvement in functioning, as in those who experience relief following a period of considerable caregiver burden or who suffer oppressive relationships (Bonanno et al. 2004).

The picture is much less optimistic for another subset of individuals (Bonanno and Kaltman 2001) who experience complicated grief, a well-documented psychological disorder characterized by severe and disabling responses to loss. In particular, individuals bereaved through deaths that are violent (e.g., homicide), unexpected (e.g., motor vehicle accident), or untimely (e.g., the death of a child) are at heightened risk of complicated grief reactions marked by an inability to accept the loss, preoccupation with the deceased, confusion about one’s role in life, and loss of purpose and hope for the future (Lichtenthal et al. 2004; Prigerson et al. 1999; Stroebe et al. 2007). The significant impairment that these individuals experience suggests they are in need of, and may be especially receptive to, interventions aimed at helping bereaved individuals (Currier et al. 2008).

This paper illustrates a number of techniques a constructivist therapist has in his or her clinical toolbox to help meet the challenges of bereavement when clients find that their own resources and those of their social world are insufficient to help them accommodate the gravity of the loss. We will begin with an overview of the constructivist perspective on grief and bereavement, paying particular attention to experiences that disrupt people’s worlds of meaning and that impel them to seek sense and significance in their losses. We then consider research examining the relationship between meaning making and adjustment to loss, finding growing support for this model. Finally, we present several therapeutic strategies that can help bereaved clients navigate their way through the grief process: narrative retelling, therapeutic writing, focus on metaphorical language, evocative visualizations, and construction of the pro-symptom position. Each technique is illustrated using excerpts from therapy sessions with the senior author (RAN), and interspersed by commentary regarding the aims of each technique.

Bereavement from the Constructivist Perspective

Echoing Frankl’s (1992) assertion that “…the quest for meaning is the key to mental health and human flourishing” (p. 157), constructivism is a postmodern approach to psychology that emphasizes people’s need to impose meaning on their life experiences (Neimeyer 2009). A fundamental proposition of constructivism is that humans are motivated to construct and maintain a meaningful self-narrative, defined as “an overarching cognitive-affective-behavioral structure that organizes the ‘micro-narratives’ of everyday life into a ‘macro-narrative’ that consolidates our self-understanding, establishes our characteristic range of emotions and goals, and guides our performance on the stage of the social world” (Neimeyer 2004, pp. 53–54). An individual’s identity is therefore essentially a narrative achievement, as our sense of self is established through the stories that we construct about ourselves and share with others.

Serving as the backbone of the self-narrative are core beliefs and assumptions about the world. According to Janoff-Bulman (1992), most people hold deep-seated beliefs that they are worthy and deserving of positive outcomes, that they have a significant amount of control over their lives, and that the world is generally benevolent and just. These core beliefs provide individuals with a broad sense of meaning and imbue the self-narrative with thematic coherence that “speaks to the author’s underlying faith in the possibilities of human intention and behavior…[and] reflects the extent to which a person believes that the world can be good and that one’s place can be more or less secure within it” (McAdams 1996, p. 136–137).

From a constructivist perspective, the loss of a loved one can challenge the validity of core beliefs and undermine the coherence of the self-narrative. Violent, sudden, or seemingly meaningless deaths can make the world appear dangerous, unpredictable, or unjust (Janoff-Bulman 1992; Park and Folkman 1997). Non-violent deaths can also challenge the validity of a person’s core beliefs. For example, the prolonged and painful death of a loved one due to cancer may make the bereaved individual wonder if the world is indeed benevolent. Alternately, it may lead the survivor to question how much control one truly has in life since the painful death was unpreventable. Experiencing the death of a loved one may also remind individuals of human mortality and raise questions about the existence of an afterlife, leading them to engage in an existential search for meaning (Yalom and Lieberman 1991). Finally, because most individuals continually establish a sense of being “known” to themselves and others in the crucible of intimate intersubjective experience (Stern 2004), the loss of a primary figure who provides this critical “mirroring” risks eroding the selfhood of the survivor. In sum, for a myriad of reasons, losses can challenge the fundamental conditions that sustain one’s actual lived experience, undercutting one’s broad sense of meaning and coherence (Neimeyer et al. 2006).

Individuals can resolve the incongruence that follows the death of a significant attachment figure by engaging in one of two general meaning-making processes (Neimeyer 2006a, b). On the one hand, they can attempt to assimilate the loss experience into their pre-loss beliefs and self-narratives (Janoff-Bulman 1992; Park and Folkman 1997), in effect maintaining consistency with who they previously were. Psychologically, this entails reconstructing their understanding of the loss in a way that reaffirms challenged core beliefs about the self and world, such as through developing familiar religious explanations for the loss, assignment of responsibility, or the making of downward comparisons (Park and Folkman 1997). Relationally, this also typically implies recruiting ongoing support and validation from other familiar figures in one’s social world or from those who have experienced similar losses (Lehman et al. 1986; Pargament and Park 1997). Alternatively, individuals can attempt to accommodate to the loss by reorganizing, deepening, or expanding their beliefs and self-narrative to embrace the reality of the loss (Janoff-Bulman 1992), often seeking validation for a changed identity in connection with a new field of social relationships. For example, while not all life experiences are predictable or controllable, the mourner may come to appreciate the personal growth and hidden benefits these experiences may bring (Calhoun and Tedeschi 2006) and engage in “restoration oriented coping” that entails experimenting with new social roles and identities (Stroebe and Schut 1999). Regardless of whether assimilation or accommodation predominates, the goal is the re-establishment of a (sufficiently) coherent self-narrative and resolution of the incongruence between the reality of the loss and one’s sense of meaning.

From the constructivist perspective, individuals who exhibit a normative grief reaction are successful at engaging in meaning making and able to assimilate or accommodate to the loss, consequently forming or maintaining a thread of consistency as well as meaningful transition in their self-narrative. Failure in these meaning-making processes, on the other hand, is associated with complicated grief reactions and the fragmentation of a self-narrative that no longer makes sense in the present (Currier and Neimeyer 2006; Neimeyer et al. 2002).

In the next section we briefly review research on meaning making in the wake of bereavement, and highlight evidence showing that for those who engage in a search for meaning, successful meaning making is related to better adjustment.

Research on Meaning Making in Bereavement

Converging evidence from several studies demonstrates that a search for meaning is commonplace in the wake of bereavement. In a sample of individuals who had lost loved ones in motor vehicle accidents (MVAs) 4–7 years earlier, 32% of bereaved spouses and 52% of bereaved parents reported that they were still attempting to find meaning in the loss (Lehman et al. 1987). McIntosh et al. (1993) found that that 86% of parents coping with the death of their infants by sudden infant death syndrome (SIDS) searched for meaning in the weeks following the loss. Similarly, about 80% of parents who lost children through accidents, homicide, or suicide even 5 years earlier admitted to searching for meaning (Murphy et al. 2003). As these and other data suggest, an extended and often unsuccessful attempt to make sense of the loss may be especially likely when the death is sudden, untimely or violent (Currier et al. 2006), or when the bereaved is highly dependent in his or her attachment on the other for a sense of personal stability and well-being (Bonanno et al. 2004). This holds true even when the losses sustained are broadly normative, as in the death of a spouse in late life through natural causes (Bonanno et al. 2004).

For the subset of individuals who do search for meaning, it appears as though finding meaning does not come easily. One study of parents faced with sudden infant death found that only 23% of parents who admitted to searching for meaning in the early months of bereavement claimed actually to have found any in the years that followed, and in subsequent interviews many reported ceasing their unproductive search altogether (McIntosh et al. 1993). Similarly, Keesee et al. (2008) found that 47% of the bereaved parents were unable to make any significant sense of their loss over an average of 6 years, and Lehman et al. (1987) found that 64% of the parents bereaved via motor vehicle accidents had not found any meaning in the loss. Thus, when losses are premature, sudden and violent, the assault on an individual’s assumptive world can be especially severe and protracted.

When the bereaved are successful in finding meaning, evidence indicates that they fare better than their counterparts who struggle to make sense of the experience. Studies have reported that finding meaning is related to less intense grief (Schwartzberg and Janoff-Bulman 1991), higher subjective well-being (Stein et al. 1997), and more positive immune system functioning (Bower et al. 2003). In their study of bereaved parents, Murphy et al. (2003) showed that finding meaning was related to lower mental distress, higher marital satisfaction, and better physical health. Similar links to better adjustment have been found in other samples of bereaved parents (Keesee et al. 2008) and in adults who lost loved ones in a mining disaster (Davis et al. 2007).

In sum, research demonstrates that many individuals engage in a quest for meaning in wake of bereavement, and suggests that bereaved people struggling to make sense of their loss could benefit from interventions that foster this process. Several of these are the topic of the next section, along with a brief note on research supporting their effectiveness.

Constructivist Strategies in Grief Therapy

We have chosen to illustrate several meaning-making strategies by examining the experiences of two grieving clients, captured in therapy dialogue. Despite the commonality conferred by their having been bereaved, the two differ in several important respects, including race, age, family circumstance, type of loss suffered and their response to it. The first, Karen, was a 34-year-old African–American mother of three living children, ages 4–16, who presented for therapy several months following the birth of her stillborn baby, who she and her husband named “Spirit, because that’s how she came to us.” For Karen, this conjunction of birth and death raised troubling issues of meaning, which contributed to her seclusion and resentment of others who also were expecting children. By way of contrast, Beth was a 39-year-old woman of Scottish ancestry, married, without children, who sought therapy following the sudden death of her father some 2 years earlier from heart failure. Although characteristically controlled in her emotional expression, Beth delved deeply into a complex father-daughter relationship marked by early closeness, interrupted by years of distancing and substance use on her part, followed by ultimate reconciliation and sobriety, and finally by unsettling and corrosive separation distress brought on by his death. For both women, their grief had become preoccupying and had begun to interfere with their relationships with friends and family. Both also gave informed consent to the recording of their sessions for use in professional training in psychotherapy.

Because constructivist therapy tends to be technically eclectic but theoretically consistent (Neimeyer 1993, 2009), we will illustrate techniques that entail retelling the narrative of the loss, therapeutic writing, attention to language and metaphor, evocative visualization and articulation of the pro-symptom position. Although a vast range of procedures could make a contribution to a constructivist grief therapy, we will concentrate on those that proved particularly helpful and transformative in the lives of these two clients, each of whom sought therapy from the senior author (RAN) for bereavement related complications.

Narrative Retelling

A research informed constructivist conceptualization of the challenges of bereavement emphasizes the struggle faced by many of the bereaved in meaningfully integrating the loss into the story of their lives, while also conserving a modicum of coherence in their experience over time. In keeping with this perspective, therapies that emphasize a fuller re-telling of the narrative of the death under conditions of safety (Rynearson 2006), can provide a measure of social validation for the account, and redress the empathic failure or silence with which many of the bereaved are met, especially when their losses or their responses to them are non-normative (Neimeyer and Jordan 2002). Importantly, such retelling—specifically focusing on the hardest parts of the experience and “staying with” them until the associated images and meanings can be held with less anguish—plays a pivotal part in demonstrably efficacious treatments for complicated grief (Shear et al. 2005). As with exposure-based therapies for other forms of traumatic events, re-narration of the loss promotes mastery of difficult material and helps counteract avoidance coping. Equally important, it can help identify aspects of the experience for which further meaning-based processing is necessary.

From the outset of her therapy, it was clear that Karen was struggling privately with unremitting anguish over her baby’s death in utero at 7 months of gestation, however much she tried to wear a strong face for others. Among the complications in her bereavement was her sense that Spirit did not have the same “reality” for others that she held for her, a sense that was reinforced by the prevailing silence about her stillbirth several months before. In part to make space for a fuller telling of the loss and the life it ended, the therapist concluded the second session by inviting Karen to bring in some photographs of her loved ones, including Spirit, to make more tangible the family narrative featured in their discussion to that point. Karen readily accepted the invitation and brought with her several envelopes of photos to the next session.

After reviewing with pride a number of pictures of her living family, Karen gently proffered a photograph of Spirit dressed in a receiving gown, with a diminutive teddy bear in her tiny arms. The therapist studied the photo, remarking on her dainty features and nodding his head slowly as Karen discussed how the nurses had dressed the baby by for this commemorative photo. Then, in a dramatic segue, Karen brought forth another envelope, and remarked:

  • Client: These are actually the hospital pictures I had my sister develop. These I myself have never seen, and they were taken in the hospital room right after I gave birth to her.

  • Therapist: These are pictures you haven’t felt ready to see.

  • C: Yeah. I’m a little afraid that they are maybe a little difficult.

  • T [meeting her eyes, and speaking in an unhurried voice]: Do you feel ready to see them now?

  • C: Definitely.

  • T: What would be best for you then? For you to take them out and look at them? Or would it be helpful if I were to look at them…

  • C [breaking in]: You can definitely look first.

  • T: Shall I give you an idea of what they look like, and then see if you’d like to see them?

In accepting the packet of photos, unseen for the previous 6 months, the therapist is attentive to the momentous responsibility with which Karen is entrusting him, and is careful to negotiate a frame for the retelling that will be sufficiently safe for the bereaved mother to confront the painful story of her daughter’s birth and death, in tragically reversed order.

  • T: I feel very privileged to open them.

  • C: Yeah, I saved them to open with you.

  • T [slowly removing the stack of photos, holding them at an angle oblique to Karen’s view]: …This is a picture of her with a white teddy bear in kind of a white bed with flowers…

  • C [leaning in to look]: Umm, her casket.

  • T: I guess this is her casket. This must have been the grand funeral that you told me about…

  • C: This was the funeral home, and the funny thing was the chapel was named Lawrence Chapel.

  • T: And what meaning does that have for you?

  • C: Well that’s my family name. That’s my [maiden] name. It was kind of coincidental.

  • T: That’s a meaningful coincidence. What do you make of it?

  • C: You know, I don’t know. My sister and I just kind of went, “Wow!”

  • T: And it was not planned; you weren’t seeking it out?

  • C: No, not at all. I mean, we didn’t even know there was a Lawrence Chapel anywhere.

This sort of meaning attribution to an apparent coincidence has been reported in qualitative research by Nadeau, who coined the term “coincidancing,” to refer to the verbal and emotional “dance” in which two or more bereaved family members engage in interactive sense making about a seemingly random event in the context of a common loss (Nadeau 1997). Here, Karen was joined by her sister in finding an island of meaning in a sea of meaninglessness.

  • T: Yes, it does seem extraordinary that the chapel carried your name…. Here [drawing out another photo] is a little more distant view of the pews where people might see her during the service…. Now when was the service and how many days following her…

  • C: It was about five days, about five days [taking each photograph, and studying it intently].

  • T [glancing up at Karen’s eyes]: What is it like for you, being taken back there visually?

  • C: You know, it’s, it’s almost like I’ve stepped outside, and I’m looking at somebody else’s. It’s just like, “Wow, that was my baby.”

Alert to the functional value of this distant viewing for Karen, the therapist gently explored this style of coping further.

  • T: How does the stepping outside feel to you?

  • C: Easier then stepping in. Much easier.

  • T: So it’s a little bit like a protective distance, almost.

  • C: Yeah.

  • T [again meeting Karen’s eyes and nodding]: These seem to be pictures in the hospital now…. Do you feel ready to see those?

  • C: Yeah. Yeah.

  • T: Here is one that might be [your husband]…

  • C: Yes, he was the only one there, the only male there, yeah.

  • T: It looks here as if he might be placing her in your arms? Wrapped in her blanket.

  • C: You see that I couldn’t sit up, so it was kind of hard to lay down and hold her.

  • T: Just to place her on your chest, and people close to you…. Here I can see you gazing at her and reaching out to touch her. What was that like? I mean you had held her intimately inside you for 7 months, and to be able to see her and to touch her in such a physical form?

  • C: I was just thinking the poor thing didn’t have a chance. And I think when they handed her to me I kind of gasped because she looked dead. Her eyes and lips were discolored. You could even tell which side of her face that she was laying on for the longest. It was a horrible week.

  • T [nodding slowly, studying photos]: And these pictures, you really see her face. It’s kind of a face-forward shot [pause, noticing Karen’s shift in expression, moisture in her eyes]. Does your feeling of being outside or being in the scene change as you see more pictures?

  • C: Yeah, they just…. It’s real all over again.

  • T: It just seems almost hard to believe in a way. I can see you shaking your head.

At this point Karen is fully immersed in the retelling, aware of its emotional vividness, as she continues to recount the experience and seek meaning in it. Weaving together both intentions, she then hands the therapist a printed program.

  • C: Yeah. The poor thing…. This was what I put on the back of her obituary, and I think that was probably the best I could find to explain how I felt. I think my sister wrote it.

  • T: Can I read this or would you like to read it?

  • C: Yeah, you can read it.

  • T [reading slowly, evocatively, as Karen looks on, transported]: “Born still [the title of the column]. Seven long months I carried you. I felt you kick more than any before you. I would smile and say how you were going to be just like your big sister. As you grew within me, your dad and I wondered who you were going to look like when you emerged, whether you’d be a boy or a girl. We anticipated your arrival and I couldn’t wait to hear your first cry and see your first little smile [therapist’s voice breaking slightly with controlled emotion]. We would welcome you with all you needed—love and warmth, a big brother and three older sisters. After my strong laboring, you came and did not cry, did not breathe. We had not expected this. The record will say that you did not live and will register you as a stillborn child, but for me you lived all that time in my womb. I felt you kick and so I know that you were there with me. Now I know that you are in the grace of God, in his sight, our perfect little angel. I know that for us you were born still. We will carry you with us forever, my child, my love. You will always be a part of all of us. You were always ours, and you are ours now. Death and life are the same. You were born still. –Mommy and Daddy”

  • C: That’s it.

  • T [tears now escaping his eyes, matching those of the client]: I feel the emotion coming to me as I read these words, as if they were being spoken by you and your family right now.

  • C: And that’s really the only, the best way to describe how I felt, how I feel.

  • T: Yes, the idea that she was born. You’re affirming this, right? Affirming the life she had within you, and the way you carried her, not only then but the way you carry her now…

Together the client and therapist went onto underscore the reality of Spirit’s personhood, her status as a being worthy of being grieved, and her mother’s obvious intent to hold her in her heart and memory as a living presence. In this and other passages in which she returned to and further processed aspects of the story, she gave voice to a previously unspoken narrative in all of its emotional resonance, rendering it more coherent, more meaningful, and reaffirming her continuing bond to the precious daughter she had loved and lost.

Therapeutic Writing

Although many therapists working with bereaved clients use conventional writing assignments (e.g., a “goodbye” letter to the deceased) to supplement their in-session work, constructivists have a special affinity for “narrative medicine” in the context of grief therapy (Neimeyer et al. 2008). Therapeutic writing can take many forms, ranging from inviting the bereaved to write about themselves in light of their loss from the standpoint of a compassionate other, through biographical work chronicling their shared life with their loved one, to meaning reconstruction interviews in which they re-access vivid images of the loss and seek fresh significance in them (see Neimeyer 2002, for a compendium of therapeutic strategies). Controlled research on the efficacy of expressive writing underscores its effectiveness (Wagner et al. 2006), especially when it explicitly prompts meaning-based processing of the loss experience (Lichtenthal and Cruess 2010). Further developments in Karen’s therapy suggested its specific relevance for her.

As she completed her review of the photographs of Spirit’s birth and funeral, Karen drew forth one additional photo from a medical envelope—an image of the ultrasound of her baby taken at 4 months of gestation. Ominously, she pointed to a remarkable, if slightly vague image in the foreground, suggesting the form of a woman with discernable facial features, wearing a flowing gown, and moving across the grainy figure of her unborn baby. The doctors, she said, had been hard pressed to explain it, assuring her only that it was not the umbilical cord. At the time she dismissed it, although upon showing it to her sister, her emotionally expressive sibling “screamed.” Three months later, when Spirit was stillborn, the image took on a darker potential significance, as a kind of “death angel” haunting the fetus, leaving Karen with unsettled feelings about a universe populated by other malevolent beings that can intervene in human life with tragic consequences. Alert to the importance of this meaning making about the loss, the therapist suggested as the session neared its end that Karen write a letter to the image to pursue answers to the urgent questions its existence on the film posed for her. Karen bravely accepted the task.

In their next meeting, Karen produced the handwritten letter, and once again asked that the therapist read it. He did so, aloud, to invite further processing of its contents.

  • T: It does seem to have a female quality because of the image. And so these words you write are: “What are you? Why were you there? Were you a warning? Were you there to take my baby? I feel like you were there to rob me of the life that I was carrying. Some say you’re an angel. Some say I’m imagining you. But that can’t be true. You weren’t there in human form, but there all the same. [Therapist pauses to allow his welling emotion to recede.] Why would God bless me with life only to take it from me? Before I could even hold her, see her eyes open, hear her cry just once? This is not fair. Did I do something wrong? Is it my fault? Why does it even matter anymore? There’s nothing I can do and nothing that no one can do.”

In her unmistakably anguished and earnest prose, Karen launched an explicit search for meaning in the meaninglessness of neonatal loss, articulating a host of perturbing questions about the agent—natural or supernatural, self or other—responsible for the death of her child. Although the therapist provided no facile answers for Karen’s existential protest and questioning, the simple voicing of her written queries, combined with the therapist’s mirroring of her emotion (Neimeyer 2009), provided a measure of validation for their legitimacy, and gave permission for an ongoing quest for significance. Indeed, this is precisely what happened, as the writing and its exploration catalyzed further family conversations, leading to a rapid shift in the meaning assigned to the malevolent ultrasound image. Thus, in the next session Karen remarked:

  • C: I was actually thinking [more] about the ultrasound…. I don’t know what exactly it was but it was something.

  • T: So [do you think it was] of a benevolent kind or a malevolent kind… for good or evil or both?

  • C: I do believe that it’s mostly for good. Even though I had sinister feelings associated with that picture, I think it’s mostly my anger about what happened…. I think it was not an evil being.

  • T: Not an evil being…. But even though there was plenty of understandable anger at this outcome, it wasn’t…out to injure and hurt but had some other purpose?

  • C: Well, my aunt…she studies theology, and she says that… when you die someone always comes to get you. You never go alone. Somebody… one of your family members, one of your ancestors will come to get you.

In a way that was coherent with her core spiritual constructs, Karen effectively reconstructed her understanding of the role of this “spirit” hovering over her in vivo fetus, construing it in terms that gave it importance and purpose. Bringing her intense angst and questioning into a focused written form seemed to foster both its personal and interpersonal exploration, ultimately helping her process the most perturbing aspects of the loss, and work her way toward a story that she could both hold in her heart and share with trusted others.

Metaphor and Evocative Visualization

Humans have the ability to communicate verbally and do so in purposeful ways—we say what we do for a reason. One obvious implication concerns the importance of attending to the nuances of language used by our clients. Joining clients in the co-construction of metaphoric exchanges can be especially helpful, insofar as analogical meanings can render more intelligible the “growing edges” of a client’s sense making (Neimeyer 1996), and has been associated with more memorable and transformative therapeutic sessions, as judged by the client months later (Martin 1994).

Beth’s exploration of her private anguish over the death of her father nearly 2 years before returned repeatedly to themes of aloneness, the myriad ways in which her relatives and even her husband seemed remote from her pain, leaving her with the sense of carrying the whole burden of her grief. When prompted by the therapist in Session 4 to say more about her feeling of disconnection from these people, Beth spontaneously offered a vivid metaphor to describe her sense of separation, which the therapist then joined her in elaborating:

  • C: You know, even though I’m feeling… the desire to be closer to my friends… I just do feel like there’s a Plexiglas [separating us].

  • T: Like an invisible screen, almost?

  • C: Right.

  • T: You can see them, but you know there’s something there that you can’t quite… get through.

With this apt image of disconnection in full view between them, several paths of further exploration were open to Beth and her therapist. For example, they might have continued to mine the verbal nuances of the image: the implication that Plexiglas resists forcible attempts to penetrate it in either direction, or that it permits a visual illusion of closeness when in fact it imposes a substantial barrier. Although teasing out these potentially revealing entailments in direct dialogue might have been fruitful, the sensory quality of the image suggested to the therapist a different angle of approach, one that invited creative “loosening” of her constructs (Kelly 1955/1991) regarding her position relative to others. Specifically, he drew on evocative visualization, encouraging Beth to close her eyes and enter the scene at a visual and tactile level, in order to foster meaning making that might be less bound by highly conscious verbal constructs (Neimeyer 2009). Rather than simply talking about her erected Plexiglas, the goal was to invite Beth to experience it, to become aware of its location and proximity to her own body, while articulating details to help her label and understand its implicit meaning and function.

  • T [slowing his speech, and pausing a few seconds between each utterance]: I wonder if you could just close your eyes with me for a minute [therapist closing his eyes, then reopening them after a few moments to track the client’s nonverbal responses].… Because that’s such a powerful image that it seems to just deserve a minute. Just try to imagine this Plexiglas [speaking softly, allowing voice to trail off]…. When you have an image of it, maybe you could tell me a little bit about where it’s positioned in relation to you.

  • C: It surrounds me, all the way around [eyes closed, gesturing with hands], in an octagon shape.

  • T: And, does it consist of these octagonal walls, these kind of eight sides of Plexiglas? Or is there something on top, or what does that look like?

  • C: Nothing on top.

  • T: So the walls kind of go straight up.

  • C: Mmm hmm.

  • T: How high are they in this image?

  • C: About eight feet.

  • T [pausing, closing his own eyes briefly to visualize this, then speaking slowly]: About eight feet…. A lot of eights here. Does that have a meaning for you? Eight sides, eight feet?

  • C [pausing, then wrinkling brow and starting slightly]: My dad died on the eighth! …I didn’t even realize it…

  • T [pausing, then affirming]: Not all things that are significant are conscious, are they? They’re just kind of there.

After “marinating” Beth in an evocative visualization of her sensed isolation, the therapist gently invited her attention to the implicit meaning of the repeated surfacing of the number eight. Thus primed and prompted, Beth quickly grasped the intuitive correlation between her severed connections with important others and her ongoing preoccupation with her father’s death. In so doing, she took a small but significant step forward in the process of meaning reconstruction, rendering a troubling experience slightly less baffling.

  • T: And I wonder if… it might help to close your eyes again to reestablish a little bit of privacy around that. And just to visualize [your family and friends] out there in a shadowy way. And then, put that wall of Plexiglas between you and them. In that image are you doing anything in relation to this octagon of Plexiglas? Are you stationary or moving?

  • C: …just kind of standing there. You know, I can move within just so much space… and then I can touch the glass [reaches up with hand, as if contacting the invisible surface].

Beth went on to describe a light within the octagonal enclosure, with the shadowy figures of the people in her world on the outside.

  • T: Are they doing anything, these shadowy figures?

  • C: Almost… like a fish in a fishbowl. If you were a fish in a fishbowl and you saw people walking around…not really paying attention.

  • T: So who’s in the fishbowl and who’s out?

  • C: Me, I’m in the fishbowl [laughs nervously].

  • T: You’re in the fishbowl…. I see. Okay.

  • C [smiling]: Hmm.

  • T: What’s the little smile, and the little hmm?

  • C: Just putting it all in perspective like that.

  • T: Huh. What does it do or say or feel like to you?

  • C: … I didn’t even put that together, ever. Or even, while we were talking… coming up with the image of having Plexiglas between myself and others.

  • T: … It’s your image, right? But it seems to fit perfectly.

In their exchange Beth and her therapist have begun to articulate a meaning of her sensed isolation in her bereavement that was previously at best implicit, namely her containment in the walls of her grief, in some sense on display for shadowy significant others who mill around, while she moves within a constricted ambit. Beth’s verbal and nonverbal responses to explicitly grasping this relationship represent a modest insight, a form of stepping outside or above the scene in order to recognize its entailments. George Kelly, the original clinical constructivist, characterized this shift as “transcending the obvious” by erecting a superordinate perspective from which old patterns could be viewed in a more comprehensive frame (Kelly 1969).

This passage of therapy illustrates two further principles of constructivist practice. First, it affirms the conviction that all significant moments of change are anchored in experientially vivid encounters with self or others, rather than in therapeutic commentary, interpretation or instruction, which nonetheless have their place in subsequently helping “hold” such moments consciously and foster their consolidation. Second, it suggests that the therapist should do no more than is necessary to direct the client’s attention toward the exploration of useful “growing edges” of her or his awareness (Neimeyer 2009). When successful, the result is typically a spare, Zen-like aesthetic of economy in therapist-sponsored discourse, in the service of the cultivation of an intersubjective field that has buried within it the seeds of emergent meaning.

Encountering the Pro-Symptom Position

In commonsensical understandings of psychotherapy, the client enters treatment to get help overcoming a problem, symptom, interpersonal conflict, or the emotional distress that these entail. Of course, different approaches to therapy orient to this task differently, promoting more adequate coping with stressful situations, developing cognitive skills in disputing or counteracting self-defeating thinking patterns, promoting more satisfying interactions with others, interpreting historically maladaptive patterns, and so on. Despite this diversity of strategies and techniques, all of these conventional approaches share the unstated premise of the client’s anti-symptom position, namely that the problem is something to be resisted, retired or replaced with more effective behavior.

Some forms of constructivist therapy, however, adopt a fundamentally different stance, one that begins with empathic validation of the real pain associated with the presenting problem, but then moves efficiently toward an exploration of the client’s pro-symptom position (PSP), that (initially) non-conscious construction of meaning that makes the problem vitally necessary to have, despite the distress it occasions. In particular, coherence therapy nests concrete behaviors and feelings within higher-order implicit meanings that make continued adherence to the problematic way of being nonetheless vitally necessary (Ecker and Hulley 2008). Originally dubbed “depth-oriented brief therapy” (Ecker and Hulley 1996) because of its penchant for revealing and dissolving the roots of symptom production swiftly and efficiently, coherence therapy works in a thoroughly experiential manner to bring to light the client’s problem-sustaining premises so that they might be considered consciously rather than simply enacted unconsciously. As these premises are exposed and captured in words, with no attempt to dispute or counteract them, the client commonly comes to either dissolve them in light of other living knowledge with which they are incompatible (direct resolution) or to embrace them as valuable and freely chosen principles for negotiating the world (reverse resolution). Further elaboration of Beth’s fishbowl of loneliness moved in the former direction, as she pondered her evocative imagery, noted her profound sense of being misunderstood by family and friends, and tentatively volunteered, “…I’m not sure if it’s me, with the Plexiglas there, or if it’s them. And, I almost seem to think that it’s me because I feel it… pretty much with everyone.”

Alerted to this hint of an operative PSP, by which Beth installed the very walls of Plexiglas isolation that contained her, the therapist initiated a form of “radical inquiry” using overt statement, a direct, sharply etched voicing of the client’s implicit emotional truth, which the client is then asked to consider or repeat (Ecker and Hulley 1996).

  • T: Maybe just try saying to [your friends and family], “The truth is I want this distance from you. It hurts too much to be so misunderstood. So I’m not going to allow it. I’m not going to get close.”.…See how that feels to give voice, to see if it seems true.

  • C [deliberately]: “I’m going to put up a Plexiglas barrier between us, because it hurts too much to be misunderstood.”

  • T: “I would rather be in this fishbowl than with you.”

  • C: “I would rather be in this fishbowl than with you.” [pause] That’s sad.

  • T: Sad. Sadness comes with that? [pause] What more comes with that sadness, by way of thoughts or perceptions or feelings?

  • C: It’s sad that these people that matter to me the most have to be so far away.

Consciously inhabiting this PSP rather than standing outside it, Beth quickly grasps the hidden logic of her loneliness, and in the characteristic serial accessing that accompanies this expanded awareness of implicit meaning, contacts the genuine sadness that this distance from others entails as a necessary cost. As a further assessment of Beth’s unconscious agency in producing the isolation, the therapist then implements an alternative technique, symptom deprivation (Ecker and Hulley 1996), inviting the client to experience her interpersonal reality temporarily deprived of the symptom of isolating confinement in the fishbowl of her grief.

  • T [nodding his head compassionately]: Yeah [pause]. Let’s try something else here, just an extension of this, if you feel ready to do it? [Beth nods her assent, and the therapist continues, slowing his delivery.] Let’s close our eyes again [therapist does so, to give client “permission” as well]…. Just go back to that fishbowl…. And now just imagine that you kind of wave and invite them in now, and they start climbing over the sides of that fishbowl, eight feet up, and climbing down into that with you [pause]. How does that feel to you?

  • C [nearly “jumping” and quickly opening her eyes]: Like I just learned karate and I did a flip out of it [laughs]!

  • T [nodding head and smiling as well]: Yeah! So it’s like a Crouching Tiger, Hidden Dragon kind of whoosh! You’re really scooting out of there…. So, if they come into the fishbowl, you leave it. Better to be a “fish out of water” than to be there with them. [Beth nods uneasily.] So, what did that feel like as they were coming in?

  • C: Claustrophobic

  • T: Claustrophobic [with inflection, noticing a change in the client’s breathing]. So almost suffocating in a way, or…

  • C: I feel like a tightness in my chest after thinking about it. Like anxiety maybe.

  • T [pensively]: Anxiety…. What are you anxious might happen if… they really get close. Just right up there next to you?

  • C [looking away, then again meeting the therapist’s gaze]: Well, I have a really bad temper…

What followed was a dramatic recounting of an family confrontation some 20 years before, when Beth, inebriated, was confronted by her equally drunken mother with an exquisitely painful accusation, triggering a violent confrontation in which Beth “blacked out,” and “came to her senses” mere seconds before strangling her limp and defenseless mother to death. Seemingly from that point on she had implemented a firewall of distance from others in situations in which the line between closeness and danger could easily dissolve, to their mutual detriment. Thus, in the context of her intense grief regarding her father, imprisoning herself in walls of Plexiglas, though corrosively lonely, was much the better option. Quickly grasping the relevance of this spontaneous recollection for the maintenance of her distance from others, Beth continued:

  • C: My fishbowl is maybe a safe place but it’s lonely. But it’s where I am.

  • T: It’s a lonely place…. Is there any sense in which staying in the fishbowl feels important to do, despite the loneliness that comes with it?

  • C: Yeah, because I feel like I need to protect myself I guess.

  • T: I need to protect myself… [writing on clipboard and handing it to the client]. Ok, I wonder if you would just try reading that aloud and let’s just see if that feels like it’s emotionally true.

  • C [reading from clipboard]: “The truth is, the loneliness is worth it, because it buys me the protection of being inside the fishbowl of grief instead of in a painful world.”

  • T: How does that sit with you?

  • C: I guess that’s pretty true…. That kind of nails it. Because I don’t quite feel like anybody really understands…. No one really gets it, what it is to be me, so I need the Plexiglas to keep them back. That’s true.

In the remaining two sessions of her therapy Beth more fully integrated the emergent meanings captured in her pro-symptom position, and in so doing moved toward greater awareness of the coherence of her actions and intentions in connection with her grief. For example, while acknowledging how her father’s death had a special meaning to her, she also began to accept where others were in their own reactions to the loss, and even opened herself to a form of teasing and playfulness with her husband that had been virtually absent in recent months. What also became clear in other portions of her narrative was her strong desire to fully acknowledge and accept that the loss of her father as a physical being was permanent, despite her clarified conviction to cultivate an ongoing connection to his memory and life philosophy.

Conclusion

Bereavement may be the one nearly universal stressor for human beings, and evidence is clear that for a substantial minority the associated grief may become nearly a life sentence. Viewing these challenges through a constructivist lens brings into sharp focus the struggle to meaningfully integrate the loss into the survivor’s life narrative, in a way that establishes a thread of consistency and significance in the midst of a turbulent transition. Evidence for the adaptiveness of meaning making in the wake of loss gives support to this view, and suggests the relevance of meaning-based processing of bereavement, both within and between sessions. Our goal in this article has been to describe and illustrate a handful of such strategies in the context of constructivist grief therapy. We hope that in doing so we have provided encouragement to the many therapists who join their clients in seeking meaning in the midst of morning, and revision of a life story punctuated by loss.