Becoming Prepared for Life:
An Interview with Phyllis Silverman
by Rob Zucker
Phyllis Rolfe Silverman is a Professor Emerita at Massachusetts General Hospital Institute of Health and an Associate in Social Welfare in the Department of Psychiatry at MGH, Harvard Medical School. She is Co-Principal Investigator and Project Director of the Harvard/MGH Child Bereavement Study. Silverman was co-editor of the landmark book, Continuing Bonds. Her most recent book is, Never Too Young to Know: Death in Children's Lives, New York: Oxford University Press, 2000. I asked her to consider the relationship between continuing bonds with the deceased, and problematic grief.
Zucker: Can a bereaved person hold on and still move on?
Silverman: There's a paradox here. While we can't live in the past, we can't act as if we had no past. I think "holding on" may not be the correct term. It implies a kind of clinging. We are not literally "holding on." What we are dealing with is reconstructing a relationship. In many ways we are maintaining a connection with the deceased and by necessity building a different kind of relationship to him or her. This relationship changes with time, and it does grow as we grow. As we get older we understand different aspects of the person who has died and we "know" that person in different ways. As we go on with our life, we honor our loved ones by continuing to recognize the connections to them and recognizing that the connections change as we do.
Zucker: There may be a fine line, however, between establishing a continuing bond with the deceased and holding on in a manner that becomes dysfunctional.
Silverman: I'm not talking about an unconscious process, or one that makes for difficulty in the mourner's life. I am referring to people who, for lack of a better word, we call relatively "healthy." I'm talking about the fact that we have many relationships that make life meaningful and viable. We don't connect in a linear fashion - one at a time. Some of these are with people who are present in our lives and others who are not always there. Some have more immediacy in our current life while others don't. Nonetheless, in different ways they continue to be part of who we are. We live in a web of relationships that informs who we are and frames how we live.
Zucker: How do we know when someone has gotten tangled in his or her web?
Silverman: I would be concerned if people are living in the past. Remaining connected or wanting to talk about the deceased or crying about a loss after many years, is not what I mean by living in the past. Unfortunately, the term "letting go" has become part of common usage so that the bereaved are typically told that this is what they need to do. The word "closure" is getting a lot of use now as well. Many people abandon mourners rather than hear their story again. They justify this moving away by saying "it is time for them to get over it." Sometimes a simple effort to remember is looked down upon.
Actually trying to live in the past can be a problem for all concerned. In the early widow-to-widow project some 30 years ago, I knew a woman whose husband had died three years earlier. Since her husband never wanted her to work, she was unwilling to become involved in any activity that would take her out of her home. She complained to her children about how awful she felt, but would do nothing to change her life style. Eventually her children just shrugged their shoulders and gave up trying to be helpful. I don't know if counseling would have helped but she would not consider any new relationship except the one with the widowed helper from our program. She had lots of available support, many new role models, but the role of wife, as she knew it, was the only role she would consider. I don't really know why she clung to this role in this way, as I watched other widows move on in many creative ways. Maybe we didn't know her long enough. I often wonder how she managed over the years.
Death Changes Us
The critical message that too often gets ignored as we talk about the impact of a death of a key person in our lives, be it a spouse, child, parent or friend, is that we are changed forever by this loss. Much of the focus is on how people feel. We see it as a psychological experience rather than looking at the larger social context in which we live, and how this is changed. Part of dealing with loss is learning to deal with change, learning to shift gears, and developing new selves and new ways of living in the world.
Zucker: How do you respond to Selby Jacob's proposed Diagnostic Category for Traumatic Grief?
Silverman: A good clinician must be able to hear the fullness of what people are experiencing and not listen simply to put them into categories. I am not sure that clinical education prepares all clinicians to be able to listen in this way. That may be why Bill Worden's tasks and Terry Rando's six "r's" are seen as so useful. People want something to hang on to, a framework, even if it doesn't apply. The question is how much can good clinical practice be guided by formulas when so much of it is an art.
When I read Traumatic Grief, I realized that Selby Jacobs certainly does humanize his patients, and he is probably a very gifted therapist. But he couches his discussion of narrative models and other process models in guarded clinical terms which belie the common humanity underlying all of this. I worry about what others without his experience and depth are going to do with his book. There is a danger that they will over medicate, dehumanize, use labels too soon, and fail to see the consequences of their efforts.
Zucker: Is there no such a thing as an appropriate diagnostic category for any sort of grieving?
Silverman: Part of the dilemma in our world is that we have so professionalized help that we no longer value what we can provide to each other as part of living together in a community. We think we need to see an expert in order to get the proper help to meet many of life's expected vicissitudes. I totally agree with Selby Jacob's emphasis on the value of telling our story, of sharing the narrative we create, but I am not clear how to relate this to providing a diagnostic label to the story teller. The diagnosis doesn't fit this process. I think there may be a self-serving aspect to developing a diagnostic category for bereavement. On the other hand, there are certainly people suffering from major mental illnesses that need skilled professional attention. I am not trying to ignore the impact of these on the bereaved, and how such an illness can exacerbate the impact of the death for the bereaved.
Zucker: What advise do you have for bereavement professionals?
We Need To Let People Hurt
Silverman: We need not only to be knowledgeable about issues related to bereavement and loss; we also need sound clinical skills. However, we must remain in touch with the human experience to be effective and to realize that we cannot prevent pain and we can not make things easy for people. The longer I work with the bereaved, the more I realize how the personal and professional are always intertwined - at least for me. I am always testing out what I learn in the real world. I have learned a good deal as a wife, a mother and a grandmother and it is against this experience that I test out what I study, what I read, what I see. I tell my students that if what I teach doesn't hold up when examined in the light of their own experience, it may not be the experience that is wrong, but the theory. I think that the reason the book Continuing Bonds is getting so much attention is because we are listening to what the bereaved are telling us. Existing theories just didn't describe their experience.
How do we help? We help by listening, by being there, by hearing the fullness of the human experience, which we can't always ameliorate. We may want to make the bereaved feel better right away. Sometimes we hold ourselves out as being able to do that. However, sometimes the only way is to acknowledge the pain, to hold it and to live through it with lots of help from friends, family and others who can hear. I am not opposed to medication, but there is a danger of it being offered medication instead of the other kinds of help people need. We need to let people hurt. We need to teach people that when somebody dies hurting is part of the process. Would you want to live in a world where this is not true? In my understanding, much of what we learn from psychotherapy is how to understand what is happening to us and how to cope effectively. As I understand it, what is being called complicated or traumatic grief seems to result from our not having been taught to cope with living and dying, how to tolerate sadness, loneliness. My own research has shown me that more often than not it is a result of problems that existed prior to the death.
The important therapeutic questions that come to my mind do not relate to treating illness. They relate to how we prepare people for living. How do we learn to think about what is happening to us? How do we help people develop tools for dealing with adversity? Sometimes there are no formulas for understanding life. If we can teach people to see themselves as problem solvers, they will be able to find ways of living through their pain. We will all benefit. We all need to be experts to help each other and ourselves as people, not only as professionals.