Sadness and loss: toward a neurobiopsychosocial model.

A previously untreated 25-year-old female graduate student with masochistic traits but no axis I or II disorder entered twice-weekly psychodynamic psychotherapy with a stated goal of ending an abusive romantic relationship with a colleague. In the early months, sessions were filled with the patient’s childhood memories of emotional mistreatment by her parents, whose constant fighting left her feeling abandoned and terrified. She contrasted these memories with loving memories of her grandmother, in whose nearby house she recalled afternoons of calm play, cookies, and attentive nurturance. The patient’s grandmother was elderly when treatment began, and in the fourth month of treatment she became unexpectedly ill. The patient visited her daily and was with her when she died. The patient then entered a period of grief, spending much of each day thinking about her grandmother. However, she continued to be productive at work, did not develop a major depressive episode, and retained the capacity for pleasure and socialization. Therapy sessions followed a pattern: the patient would arrive in a euthymic state and begin to talk about her grandmother. The therapist responded with supportive clarification and mirroring, using phrases such as “you really loved her” or “she was the one who understood how scared you were.” Sometimes as a result of such comments, and others the patient made spontaneously, the patient would blurt out, “I cannot believe she’s dead!” followed by crying of varying intensity, lasting 3–10 minutes. During this introspective period, she would lower her face, cover her eyes, and break off communication with the therapist. She reported feeling intensely sad during these periods, being flooded by loving memories of how her grandmother looked, sounded, and felt, and understanding the reality and finality of the loss. Further empathic comments by the therapist, such as “You really miss her,” prolonged these episodes; typically the therapist would attend silently. After several minutes, the patient would reengage by drying her eyes, adjusting her clothes and hair, and resuming eye contact while talking about how lonely the world was without her grandmother. To this the therapist typically responded with reflective statements, such as “It feels like you will not ever be known in that kind of warm way again,” which often led the patient either to further but more muted episodes of tearfulness or, more frequently, to the somewhat comforting idea that her grandmother’s spirit was watching over her. By session’s end the patient was no longer tearful; she would smile politely as she left to return to work. She reported many similar episodes outside of therapy, estimating that there had been at least several hundred over the few months following her grandmother’s death. Over a 3month period, the frequency and intensity of these minutes-long sadness episodes decreased; by the fourth month of bereavement, she discussed her grandmother only occasionally and focused largely on current relationships and concerns. The therapist did not offer the patient medication or advice on coping, because he considered her grief process to be normal, spontaneous, and healthy. During the therapy termination 2 years later (the therapist was graduating from training), dreams in which the grandmother was dying recurred and were interpreted in the context of dealing with loss of the therapeutic relationship. This led to brief episodes of sad crying during sessions about the loss of the therapist.