brief psychotherapy of a grief reaction*

Folia Psychiatrica et Neurologica Japonica, Vol. 24, No. 4, 1970

Brief Psychotherapy of a Grief Reaction"'

Takashi YAMAGUCFII, M.D.'":"

Departrnerit of Nerrropsyc l i i a f r y , Nilion Uiiiverhity School of Metlicirte, T o h y o

INTRODUCTION The following report describes the psy-

chotherapy of a patient who suffered from a grief reaction. The grief experienced by this patient occurred after several separations. Within a relatively short time she lost her psychotherapist who went to another city, her husband through divorce, the custody of her only child, and both parents who moved away. For reasons which will be given she was thought to be a suitable candidate for a brief course of psychotherapy*

Research on the effectiveness of psychotherapy, as noted by Ewalt and Farns- worth3), is sparse. Recently, Fiske and oth- e r s * ~ ~ ) stressed the importance of carefully planned research on the effectiveness of psychotherapy, as well as complete and detailed reporting of cases. Each issue of therapy- transference, countertransference and goals -must be evaluated before valid compar- ison may bc made.

In regard to brief psychotherapy, Semrad and others*) reported results of their experience with 49 depressed patients selected for brief psychotherapy by the staff from 100 applicants to the Southard Clinic, Massachu- setts Mental Health Center. Evaluation after

'"Prepared under Massachusetts Mental Health Center Research Grant General Research Support -so 1 05555-06.

**Until June 1970, Clinical Fellow in Psychiatry at the Massachusetts Mental Health Center, Har- vard Medical School, Boston, Mass., U.S.A.

Received for publication Jan. 5, 1971

one year revealed improvement in 59.9%. Tt was concluded that treatment of depressive neurosis2) seems justified. Sifneosg) listed the selection criteria of appropriate candidates for short-term psychotherapy as follows:

1 ) The patient must be of above average intelligence.

2 ) He must have had ;I least one meaningful relationship with another person during his lifetime.

3 ) He must be able to intcract with the evaluating psychiatrist by expressing some affect during the interview.

4 ) He must have a specific chief complaint.

5 ) Motivation for psychotherapy-there should be motivation for change, not for symptom relief.

The present report describes a so-called borderline patient who was treated in eight, fifty-minute weekly interviews conducted under supervision at the Southard Clinic from August 27 through October 16, 1969. The patient enabled us to evaluate the effect of her brief psychotherapy relatively objectively by returning for a follow-up interview three months after termination and also by writing a letter about the follow-up interview. Fur- ther, this patient was an appropriate candidate for brief psychotherapy both from Semrad's and Sifneos' symptomatic points of view described above. Also, material from the patient's record in the Southard Clinic had been evaluated systematically, as recom- mended by Fiske.

228

P AT I E N T

‘fhc patient is a 2s-ycar-old divorced, white, Catholic mother of onc, who livcs within the cntchmcnt nrca of the Massachu- setts Mental Health Center. O n August 27, 1969. she visited the Wnlk-In Scrvicc of the Sorith1i;irtl Clinic, self-referred. In the past, slic had hccn scen by another psychiatrist in thc Southard Clinic for intensivc psychotherapy F r m September I966 through June 1967. I’hc patient was born in Georgia in I944 ;itid hns lived in the [Jnitccl States ever since. Alter graduation from high school, she received ;I yc:ir of education in both a hairdressing school and a sccret;irinl school. F o r ~ h c two years prior to evaluation she worked ;IS a legal secretary in Hoston, earn- ing S S clollai~s net weekly. Her parents arc in cxccllcnt henlth. Both x c Protestants, born in Mass;icliiisctts and now live in At- Ian tL t , Gcorgin. The paticnt is the younger ol’ two children. Her brother who is two years her scnior is married and in excellent l icdtl i . Thc patient’s cx-husband has rcmar- ricd a n d lives with the patient’s four and on c- Ii a I f - ye ;I r -(I Id d ;I i t g h tc r in Boston ; they both are i n cxccllcnt health. Thc patient herself livcs with two fcnialc roommates i n n fivc-room apartment in Boston.

The above is based on thc pntient’s own statcnicnt at thc reception desk of the Walk- In Clinic.

C ‘ O O R \ F 01: D I A C N ~ I S I N I ) TREATMENT l t r i r i ~ i l /titeri,iew ( W d k - t t i I)irrgtio\tic Evdir-

I . C‘hicf Complaint:

dmghtcr, I’m depresscd and confused.”

the Clinic for ;I month or two.” 2. Prescnt Problcm :

Late i n August 1969 this light blonde, attractive 25-ycar-old woman with a heavily

atioti):

“ I don’t know w h a t to do about my

“ I woulc l likc t o h a k c psychothcrupy in

sun-tanncd and snd-looking face canic for psychiatric hclp. She felt that il’ she could sce a psychiatrist Lit this Clinic o n l y for :I

month or two, most of her present problcms would be solved and thc intense fecliny of depression, confusion and irritation w o ~ ~ l c l v a t i i sh .

She had bccn under anotlicr psychiatrist’s care in intcnsivc psychotherapy lirst ;is ; i n

inpatient from September through llcctnibcr 1966, and thcn ;IS an outpntient until Junc 1967 when shc terminated bccnusc he left this Clinic (cf. Additional History).

As the patient discussed the therapy gi\,cn by her previous physicinn, ;I series of critical cvents loomed paraniount--nanicly, the si- multaneous s epara t io n from he r psych i ;it r i \ t . her husband and her daughter \\.hie11 h ; id occurred approximately two years prcviou+ ly. She tcrniinated her psychothcrapy at thc same tinic that shc w a s divorced by hcr hu.;- band, who obtaincd custody of their claugh- ter. At the time of the separation she saw hcrsclf as ;I bad mother and felt angry Ltnd depressed at thc sight of ohcr wonien w a l k - ing with ehildrcn. Over the past t \ vo yc:irs. she had taken care o f her daughter only on weekends. She had been involved scxu;illy with several men, including her fiance.

Thc prccipitnting factor for the reciirrcnce of her dcprcssion was a series of strcssl‘ul incidents which had taken plnce a year prc- viously-hcr ex-husband’s remnrriagc, S C X -

ual advances made to thc patient by her daughter’s pediatrician, and severance of the relationship with her liancc. This series of incidents seemed to lcud to a recrudescence of her depressive fcclings, although she still was able to take care of hcr daughtcr on weekends without getting upset o r irritatcd, until recently.

The most recent precipitations occurred three months prior to evaluation. It was approximately a year after her ex-husband’s remarriage whcn shc bccanie increasingly

Brief Psychotherapy of a Grief Reaction 229

depressed, had suicidal thoughts, was unable to concentrate, often missed work, and became irritated with her daughter. Also, she began taking four or five Aspirin tablets daily to relieve a persistent headache. Ap- proximately three months ago, she took a two-week vacation with her parents in Geor- gia and became discouraged by their reject- ing remarks. They reproached her for going out with different men and for drinking after having broken off with the fiance of whom they had approved. Above all, they strongly disapproved of her daughter’s visits, main- taining the daughter should remain with her remarried father. The patient’s mother commented, “You are very selfish” and “we won’t take care of you any more.” Her parents’ opinions angered her, though she had made a conscious attempt to relate to them after she had begun therapy. She then avoided her parents, having received different and confusing opinions about her relationship wiht hcr daughter. and subcequ- ently, decided to seek a specialist’s recom- mendation. 3. Additional History (Personal, Medical

The patient was the product of a full- term, normal pregnancy. Her infancy and preschool years were not remarkable. Dur- ing the years before adolescence, the patient’s home was managed largely by the mother, with the father appcaring late i n the evening or on weekends only. The f,:thcr, who was sales manager of a well-known company, worked long hours for a pronio- tion, and traveled a great deal. The mother, harassed by the responsibility of the home, was tired, nervous and had little patience with the children. The mother apparently was closer to her son, and the patient had to depend on weekend visits from the father whom she saw as the only person who was genuinely intcrested in her. She saw her mother as n distraught disciplinarian who

and Family):

showed favoritism to her brother. At age six the patient told her mother and

the police, who questioned the patient at the mother’s request, that a strange man had stopped in his car and had offered her lolli- pops if she would go for a ride in his car. She had refused and had run home. The next three years were pleasant for the patient with an increasing amount of attention and affection from her mother until the patient finally confessed to her mother that the en- tire incident was untrue. The mother’s attitude toward the patient became ho5tilc. When the patient was twelve, her brother made a sexual advance towards hcr. The mother slept with her at night for a short time. The patient started having temper tantiums about this time. On one occasion she attempted to run away but was stopped and held by licr brother, thcn hit by her mother. During a lit of anger, she tied a scarf around her neck and threatened to commit suicide. Nonetheless, she functioned reasonably well through high school, although she had few peers for companions because the family did not live in a resi- dential community. Later she excelled in hairdressing and secretarial schools.

When she was 18 she worked in a beauty salon. Here she met her future husband with whom she had sexual relations. During this period, she became easily upset by her mother and often argued with her so that she was taken to the Children’s Clinic at the Mas- sachusetts General Hospital and started in therapy, which lasted for nine months. Dur- ing the course of her treatment, she had a violent argument with her boyfriend and in- gested one bottle of aspirin in a suicid‘il attempt. When she was 19 she married him because she “wanted to make her parents happy,” was afraid of getting pregnant bc- fore marriage, and wanted to get away from her mothcr who did not care enough for her. The beginning months of her marriage were

230 T. YAMAGLJCHI

not remarkable and she bec;me pregnant as she had planned. After nine months of nau- sea and vomiting, the pregnancy was terminated by 21 Caesarean Section because of her narrow pelvis, and a girl was delivered.

When the patient was a few months postpartum, hcr parents announced that they were moving to Atlanta, Georgia. The pa- tinct became upset and depressed, often taking out her anger on her daughter by striking her. She felt she could not control her feelings and would call her mother and tell her to cane and get the baby, apparently trying to dclay her parents’ move. She started to havc extramarital relations with two men one month before the parents’ departure. Soon aftcr they moved, she began visiting several clinics for psychiatric care but her attcndancc was irregular. Her behavior continued to be one of increased irritability, depression, stubbornness, promiscuity and physical violence to her baby daughter until September 1966 when the patient was admitted to McLean Hospital bccause she be- c m e su ic id d.

She remained at McLean for twelve days, and was diagnosed as a borderline personality. She was transferred to this Center whcre she stayed from September 22 through Dcccmber 9, 1966. Her diagnosis at that time was that of postpartum depression in a borderline personality, although psychological tests (WAIS, Rorschach, TAT and SCT) indicated a reactive depression in a passive dependent character.

The father described the patient as a person who always needed acection. “She runs away from things. She is an extremely selfish girl, never been capable of making deci- sions.” The mother said, “She does not like discipline; she is very selfish and can’t be depended upon. When she is depressed, she

This additional history is based mainly on thc patient’s statement during the initial in-

K U 11s. ”

terview and also on the information obtained from her parents during the fnmliy confer- ences at the time of admission in 1966.

4. Description of Initial Interview and

The paticnt who is of medium height is a well-developed, suntanned, blonde, attractive female. She did not smile. She is neatly dressed and cooperative. She speaks slowly in a low voice and tends to answer qucstions briefly and articulately.

Her mood is moderately depressed and irritable; her affect is moderately blunted. Her mental content focuses mainly on con- cerns about her relations with her mother and daughter and, to ;I lesser degree, about her own depressive feelings. She has a tcnd- ency to speak about other people’s opinions rather than her own. She had no definite plan to commit suicide.

She is oriented and has a good fund of knowledge, though her insight seenicd lirn- ited. Neurological examination revealed no abnormalities.

5. Formulation of Present Problem : The retirrn of the paticrit’s rlcpr~Js;\ive

symptom may have been related to her ex-husband‘s retnarriuge (anniversary p 1 i i ~ -

nomenon). Hostile-deperidcnt ties with her daughter and mother liacl intensified and added to her depression. The sexual iiciing out seeins to have followed the incomplete termination of psychotherapy two years ngo.

6. Disposition: It was planned to do an extended diag-

nostic study in order to clarify whether she is adequately motivated, and to define her relationship with her daughter whom she has legally abandoned.

The following therapeutic goals could be possibly achieved in brief psychotherapy by reminding hcr of what she has accomplished with hcr former therapist and by dealing with the incomplete termin a t’ ion:

Neurological Findings:

Brief Psychotherapy of a Grief Reaction 23 1

a ) To resolve her present problems with her daughter,

b) To relieve her from her depressive symptoms. and

c ) To complete the termination of psychotherapy.

Upon finishing the initial intcrview as above, she was told to return for further evaluation and, if indicated. for brief psychotherapy. She consented. Medication was neither requested by her nor prescribed by me.

Second Interview (Extended Diagnostic Stll dy ) :

She began the second interview by reporting that as a result of having thought all week about the initial interview, she now was able to understand herself better, felt less depressed, had no headaches and had stopped taking Aspirin. However, she immediately remarked bitterly that she was still feeling confused about her daughter. She wcnt on to say how jealous she felt of her ex-husband who lived with her daughter. She regretted that she had married him to please her parents, who after her marriage had avoided her. She reiterated, as she would many times during her later interviews, how angry she had been with her mother. I interrupted and inquired about her first memory of her brother. Between four and six when she was taking a both with her brother, he sat down on a can he was playing with in the tub and cut his but- tocks. She did not recall any feelings then but remembered that the bath was stained red with his blood. She recalled seeing him two years ago when she strongly felt as if he were still in her way. Physically she saw him as a very unattractive man. Memory brought back to her his cruelty towards her and her feelings of anger and jealously towards him in childhood, as he was the fa- vorite of the mother.

At this point she was once again interrupted and requestcd to take the Stories Test8). She did it well, repeating the three stories as instructed, indicating no confabu- lation or other abnormal responses. After the test, however, she looked angry and tended to be taciturn, answering questions only briefly. I inquired about her previous therapy. She instantly grew radiant and said that her therapist was the only person who was able to understand her and communicate with her well. When she was asked if this was also true during the time she was terminating with him, she agreed but her angry facial expression returned. She commented that she found it hard to keep on analyzing herself, as her therapist had suggested, because she was lazy. She would rather work with a psychiatrist on problematic relation- ships, for example, the difficulties with her daughter.

I told her that I would be able to tell her next week if we would continue phychother- apy. A minute later 1 found myself feeling angry, and realized that much of her anger at her mother, brother, ex-husband and therapist had shifted to me. 1 frankly told her that I was feeling angry and asked her how she was feeling. She admitted that she was angry and irritated. She said she had be- come aware of these feelings when she was discouraged from discussing her mothtr further and when the intcrview was interrupted by the psychological test which was given without preliminary notification. She was then reminded of the time of tcrmination with her therapist when she was easily irritated by trivial things.

Third Interview: At the beginning of this intcrvicw. she

talked at my request about her marital history. She got married in 1964, became sepa- rated from her husband and their daughter on the day of her discharge from this Center

232 T. Y A M A G U C I ~ I

i n I>ecember 1966. She was divorced by him. coincidentally, on the same day as hcr termination session with her therapist in June 1967. She reviewed the termination of therapy and commented that she had taken the initiative to terminate. She had learned from ;inother patient of hcr therapist’s im- minent departure. This led to a discussion of this particular paticnt, a man with whom she had begun having extra-marital relations. At the time she had been talking to her therapist about her termination, as well as her extreme irritability. My quick association then was of her being sexually molested a t age twelve by her brother. Without telling her my association, I asked her what she had Icwncd in her previous treatment. She talked at Icngth about what she thought she had achieved with him. 1 repeated for her the four words she used to sum up her achieve- nicnt with tier former therapist, “self-worth,” “Sclf-confidcncc,” “Self-decision” and “Self- understanding,” and for the first time since our initial contract, she showed a radiant smile! At this point she also reminded herself that for one year following her termination-until a year ago when her husband rcmarried-she had been able to get along fairly well with other people and take care of her daughter without growing depresscd and irritated.

She again expressed her great need for continuing therapy with me. She suggested that if hcr therapy should be continued, she would like to pay tcn dollars for each session. I told her for thc lirst time that I had decided alrcady to continue with her on the basis of what she litid achieved with her previous therapist. 1 told her she would be able to help herself without psychiatric assistance in the ncar future. She once again showed ;I radiant smile as she left my office.

Foiirtli Interview: I bcgan the interview by saying that we

were going to have five more scssions including today’s. She consented but hastily announced her plan to go to school this month to take her collcgc equivalent courses. When I remarked that she was in a brightly colored dress today, she spoke a lot about her own clotlies as well as her daughter’s. She spoke about how important her physiccd appear- ance was for both hcr job and her mood. In line with this idea she commented that she really hated to see hcr daughter since she felt unable to buy tier clothes as good as her own. It was partly for this rcnson that soon after our initial interview shc began meeting with her daughter only oncc every other weck instead of oncc each wcck. At this point she showed tears for the first and last time during the course of therapy. While she was crying she wa\ encouraged to recall when she last had cried. It w‘ic the previous spring when she had telephoned her husband to tell him she wanted to have her daughter for Easter. He refused. She cried over the phone, feeling very angry and sad. She was unable to stop crying long after he had hung up. When asked if rhc thought he wcrc unfair. she nodded and smiled with tcars in her eyes. She then went on to explain why she was crying. She felt sorry for herself because she had been unable to see her daughtcr as frequently as she had previously. Howcvcr, she acknowl- edged that she had to sacrifice her own feelings for her daughter’s future. She then expressed her need to know if shc had made a correct decision from a profcs~ional’s point of view. 1 asked what she herself thought of her decision. She felt it was right for both herself and her daughter.

I gave termination of psychotherapy as an example of separation, and \aid that thc doctor-patient relationship was often termi- natcd abruptly, although this could be diff- cult in certain cases. She gave another big smile and greeted me with, ‘A good Thurs-


day!” before walking out of my office. After the interview, my supervisor explained to me that “A good Thursday” was not a com- mon greeting in this culture but the patient ha\ said it pcrhaps to thank me for m y understanding.

Fifth 1 r i t c I I vie\r,: The patient was late only for the fifth in-

terview and apologized sincercly. explaining that the night before shc was thinking about her present therapy so latc that she had overslept. I told her that I did not think it was a good idea to put a student in jail who came five minutes late because he had done homework and thus overslept! Her face registered momentary relief which changed quickly to one of deep sorrow. She said last week she had broken off with her black boyfriend, Frank, with whom she had bein sexually involved over the past two years and that she had been feeling extremely lonely and empty ever since, as Frank seemed to be the last object of her sexual acting out. Moreover, she had been unable to communicate with Frank because he was interested only in drinking and sex. (After this interview, my supervisor told me that hcr previous therapist was a Negro).

The patient had very recently received a telephone call from her parents who wanted to come and stay with her for several days. When she told her father about breaking off with a black boyfriend, he advised her never to tell her mother. She wished she had been able to tell the fathcr that she did not want them to visit her at all because they did not understand her.

She said she finally had decidcd to see her daughter only once a month and to spend next Christmas with her. Her ex- husband agreed to this arrangement. She made up her mind after talking with her friend, Nancy, whose relationship to her mother was similar to that of the patient and

her daughter. After the patient made this decision, she felt more relaxed although she began having fantasies about what her daughter might think of her mother in the future. Perhaps the daughter might never understand and forgive her mother. Her friend, Nancy, had eventually forgiven her mother. A t this point the patient looked quite anxious and her face registered an unsure and nervous smile. I asked her what she thought of her own mother recently. Sh said she had been understanding her mother much better, although at times she still found it hard to forget what she had done to her.

I asked her what she had felt last week when our eventual termination was discussed. She said that she was relieved, feeling that she was not really sick and yet found herself feeling more anxious and unsure about helping herself alone afterwards.

She recalled that two years ago she had mixed feclings on termination with her therapist. However, he had shown her a cartoon during their last session and had comforted her so that she had failed to let hini know about her anxicty. For a long time she had been unable to forgiven him for terminating even though he had to leave the Clinic. Quite recently she felt she understood him much better. She felt that she had previously abandoned her achievements with him, and was now beginning to accept hini again. She was showing her radiant smile at this point.

Towards the end of the session, I told her that I was planning to have her see Dr. Gudeman the following week. This was a didactic interview by which I planned to resolve some of the anxious feelings on my part and other problems of countertrans- fcrencc. I was indeed concerned that she might once again fail to terminate with her psychiatrist since in the past sessions she had often brought up long-term issues, such as her hostile-dependent relationship with

234 T. YAhlAGUCHI

her mother.

Si.\tli Iiitcr view (Didactic liiterview): At the interviewer’s request, the patient

rcviewd her present therapy and openly expressed her thanks to me. She talkcd at length about her daughter, particularly the dccisions she had made about her, and how inadequate and guilty she still felt for not taking constant care of her. She referred to the time when her daughter was a baby; the patient was so irritated by her that she often struck her and cvcn tried to “kill her” a few time5 by lcavtng her alone for many hours with the door closed.

She relntcd, as Dr. Gudeman inquired about her future plans, that she hopes to continue to work as a secretary, and to edu- cCik herself and have boyfriends only to talk with. She could not say whether or not she hopes to remarry and have children. She was reassured that her future plans to help herself without psychiatric assistance were reasonable and that her guilt towards her daughtcr was inevitable and understandable.

After this didactic interview, the interviewer reassured me that the on-going brief psychotherapy was the treatment of choice for this patient and termination should not be diflicult.

Seventli Interview: The patient telephoned the Center early

in the morning and cancelled the appoint- ment, stating she would come the following wcck.

Eightli Interview (Ternzinotioti Iriterview): She began the session by saying that her

family doctor had told her very recently that she had a gall bladder problem and prc- scribed medication and rest which was help- f u l for her. (1 recalled K, a child with Cholccystitis. wohm I took care of as an intern, whose temper tantrums vanished aft-

er his gall bladder was removed). She reminded me to the comments Dr. Gudeman made two weeks ago which she felt hiid re- lievcd much of her tension.

When it was made clear that today’s session was the last one, she expressed her sur- prise and disappointment but immediately said that she felt confident about doing without a psychiatrist. She again reviewed her termination interview with her previous therapist, this time talking about her feelings as if she were an excellent student of his. I pointed out the absence of tears, either now or then, and she was reminded of crying often at the age of five to six. At that time she frequently visited her aunt and when her parents came to pick her up, she often cried. She recalled that her parents had so often left her alone that she had learned to suppress the feeling of regret when people left her. In fact, she said, when breaking off with her boyfriends, Dick, Paul and Frank, she did not feel especially sad and, of course, did not cry, despite the fact that she had been sexually involved with each of them in the previous two years.

Towards the end of the session, I asked what she was feeling. She said that she had the feeling that she was a normal person, although she had felt that she was neurotic at the time she terminated with her previous therapist. She commented that she would not need psychiatric help any more, but hoped to have boyfriends to chat with. I commented that it was reasonable to scck such qualities in a boyfriend. She was told that she could return to the Clinic if she felt it were necessary, although 1 told her I thought she would manage on her own. She thanked me with a faint smile and left my office rather hastily.

CONDITION ON TERMINATION The patient’s condition seenicd to be im-

proved. Her feelings of depression and ir-


ritation, headaches and other depressive symptoms had diminishcd greatly and her present problems with her daughter were nearly resolved. Her multiple sexual relations with men, abuse of alcohol, and other acting out of her feclings of sadness and anger discontinued and hcr behavior had modified. However, insight into the strong emotional ties with her daughter and her mother was still limited. She was somehow ablc to stand separation from a psychiatrist and to complete thc termination of the therapeutic relationship.

FOLLOW-UP I N T E R V I E W A N D P A T I E N T ’ S

LETTER At my request, she returned for this fol-

low-up intcrview with Dr. Alfred 0. Ludwig on January 16, 1970, exactly three months after our termination. She was dressed in bright sporty clothes and smiled frequently throughout the interview. Both the interviewer and I observed that she sat relaxed at the desk facing the interviewer and often looked at me as I took notes. She was very cooperative and answered questions fluently.

She commented that she continued to sec her daughter each month and had gone to school evenings. She had made a few boyfriends but there had been no sexual in- volvement nor excessive drinking. She had becn thinking about remarrying and having children. Occasionally she felt depresscd, she thought perhaps as little as other people do, and could now handle such temporary depressive feelings more casily. She had been doing well both at work and at school where she got along well with others. She was now more peaceful with her roommates with whom in the past she had had many arguments. Since at times she still felt angry with her mother, she had staycd away from her parents.

The intcrvicwcr asked her to relatc what she thought most aided her recovery. She

said I had made it easy for her to talk, list- ened carefully to her and repeated frequently and appropriately what she said, making it more meaningful. She said I had also helped her deal with her feelings of inade- quacy and guilt concerning her daughter by making useful comments. When asked, shc frankly admitted that she had positive feelings towards me, and thanked me again for my working with her on her problems.

At my rcqucst the patient wrote a letter about her follow-up intcrview with Dr. Lud- wig. She indicated that because of the help she had received at the Massachusetts Mcn- tal Health Centcr, she now felt more confident in her ability to cithcr accept or resolve thc problems which she had been con- fronted with in the past and would be in the future. Her closing comment was “1 have a lot going for me!”

DISCUSSION All at once, two years ago, the patient

lost at the same time her psychiatrist, and her husband and daughter by divorce. Her grief was prolonged and unresolved. During this brief series of interviews, bctween Aug- ust 27 and October 16, 1969, she was, however, able to grieve and to remind herself of what she had achieved in past trcatmcnt with a former therapist. As a result, she forgave those who had left her and oncc again accepted her situation and became healthier. Nonetheless, this seemingly bricf and clear case had raised many issues, and, obviously, it has left us with some qucstions.

The first issue which is fundamental for the prcsent rcport is the management in brief psychotherapy of a grief reaction following an incomplete termination of long- term, intcnsive psychothcrapy. As Ewnlt and Farnsworth define it, psychotherapy is an experience of understanding and modify- ing the paticnt’s feelings and behavior and thus an opportunity for growing and devel-

236 T. YAMAGUCHI

oping his ability to adapt himself more coni- fortably and more effectively to his life.

Howcvcr, unfortunatcly, it is also an opportunity for ;I “tragedy” called incomplete termination. In the present case we clearly see how failure to separate hersclf com- pletely from her psychotherapist interfered with further maturation.

The second issue which is of interest is the role of the hystcrical personality dis- order o f this so-called borderlinc patient in the development of her grief reaction. In- sofar as shc is able to receive enough con- cern and enough attention, she is content, secure and healthy. Her discontinuance of thc intensive psychotherapy of nine months’ duration and her separation from both her husband and her daughter following a two- year niarriage bccame a burden, too heavy for her to bear with her tremendous depend- ency needs and cxtrenicly low sclf-esteem. Finding hersclf in a situation where she is supposct-I to livc indcpcndcntly, she easily becomcs depressed and finds it impossible to avoid acting out her feelings of sadness and angcr through scx and alcohol.

Thirdly, it is difficult to define the meaningful role of the psychiatrist in the present therapy. What is the task of the psychotherapist in aiding his patient to accomplish her limited goals, especially when she is motivated? Is it simply helping her to accomplish for the first time a complete termination with a psychiatrist? Or is it his overall support and limited interest i n her present problems, reassuring her that her future plans to niovc towards independence arc reasonable, and t1i:it her dcpression and guilt over living separately from hcr daughter arc acceptable? O r is it his making it easy, as she notcd, for her to talk and cry anti get angry approprintcly for the occasion, his listening intently to her, and his rcpeating frequently what she has said?

The esscntial elements of the mvchother-

apist’s attitude in a doctor-patient relationship as seen by Dr. Tsunco Iniura, author of are “warmness, rank- ness and firmness.” These qualities, which seem to rcprcscnt sincerity, are of greatest importance in intluencing a paticnt.

Therc are other determinants which play- ed an important role in tlie improvement of this patient. The fact that there was a dc- finite precipitating factor, namely her niul- tiplc losses, for her depression is an important factor. Another factor is the personality or position of the therapist himself (which is known to thc paticnt) and which in some way parallels the patient’s position to thc Clinic. He is here in the United States for the purpose of learning, with all the anxieties concomitant to such a situation, and which he has been able to master well; a good model for the patient in her position of learning about herself and her feelings and anxieties. Still another determinant is that the improvement of the patient is bascd on a “transfcrence cure”, a transference not so much to the therapist as it is to the Clinic, where tlie patient secms to h:ive regaincd her sense of belonging. This is very evident in her letter in which shc refers to her prcvious therapist and others i n the Clinic and licr gratefulness to the Massachusetts Mcntal Health Center (the Clinic) rnthcr than to a single person, thc therapist.

The last and most crucial issue is progno- sis. The patient had clarilied during the follow-LIP interview that her hostile-dependent tie with her mother had not becn resolved. She had remained distant from the mother. Nonetheless, she had becn getting along so much better with her daughter, and she con- sidered remarriage and another chilcl. It is difficult for us to speculate, should she again marry and have ;I child, whether she might once again necd psychiatric help. However, as Aldrich” writes, we know many, if‘ not

1 , most people, who have broken hostile-dc-


pendent ties to parents, and are still able to work out satisfactory interdependent rela- tionships in marriage without psychiatric help.

SUMMARY A patient suffering from a grief reaction

treated by brief psychotherapy is described. Several factors contributed to her grief, among them termination with her former psychotherapist without sufficient working through of this separation. The nature of the brief psychotherapy is outlined as well as a follow-up interview by an independent ob- server.

A C KNO W L E DC E M E N T

I would like to thank Bullard Professor Jack R. Ewalt, Dr. Halim Mitry, Dr. Ernest Kahn, Dr. Paul H. Arkema and Dr. F. Wil- liam Bernet for their meaningful comments and suggestions in preparing this case report; Assistant Professor Alfred 0. Ludwig for his useful follow-up interview and Dr. John E. Gudeman for his intensive supervision and didactic interview. I would also like ot thank Professor Tsunco Imura and Associate Professor Yoshinii Nogami at the Department of Neuropsychiatry. Nihon Uni- versity School of Medicine, Tokyo, Japan for their editorial assistance.

BIBLIOGRAPHY Aldrich, Knight C.: An Introduction to Dynamic Psychiatry: 321-358, McGraw- Hill, New York, 1966. Diagnostic and Statistical Manual Mental Disorders Second Edition (DSM-11) : Anier- ican Psychiatric Association, Washington, D.C., 1968. Ewalt, Jack R. and Farnsworth, Dana L.: Textbook of Psychiatry: 238-242, McGraw- Hill, New York, 1963. Fiske, Donald W., Hunt, Howard F., Lubor- sky, Lestr, Orne, Martin T., Parloff, Morris B., Reiser, Morton F. and Tuma, A. Hus- win: Planning of Research on Effectiveness of Psychotherapy: Arch Gen Psychiat 22: 22-32, 1970. lhidem: Check-List of Issues in Designs for Research on the Effectiveness of Psycho- therapy: obtained from Dr. Fiske through personal communication, 1970. Iniura, Tsuneo: Psychotherapy (In Japa- nese) : Sekai-Sho, Tokyo, 1952. Nogami, Yoshimi, Asakawa, Kazuo, Fuse, Yuichiro, Yamaguchi, Takashi, Yano, Shizuo and Ishikawa, Ryuko: Story Test-A New Method of Psychometry Utilizing a Series of Short Stories-With Special Consideration to the Repetitive Responses by Schizo- phrenics (In Japanese; English Version in Preparation); Clinical Psychiatry, 10: 285- 289, 1968. Semrad, Elvin V., Binsock, William A. and White, Burton: Brif Psychotherapy: Arner J Psychother, 20: 576-600, 1969. Sifneos, Pcter E.: Short-Term, Anxiety- Provoking Psychotherapy: An Emotional Problem-Solving Technique: Seminars Psy- chiat, 1: 389-402, 1969.

brief psychotherapy of a grief reaction*

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