Cognitive behavioral counseling of unresolved grief through the therapeutic adjunct of tapestry-making

The Arts in Psychotherapy, Vol. 26, No. 3, pp. 165–171, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0197-4556/99/$–see front matter

PII S0197-4556(98)00062-8

COGNITIVE BEHAVIORAL COUNSELING OF UNRESOLVED GRIEF THROUGH THE THERAPEUTIC ADJUNCT OF TAPESTRY-MAKING

FRANCES REYNOLDS, PhD*

perspectives. These insights illustrate the value of an “integrative” approach to therapy. Practitioners whose work is grounded in a specific theoretical perspective may come to accept its sensitizing concepts as “given” and taken for granted. Yet all theories are filters for our complex experiences, serving to highlight some aspects for attention, and relegating other aspects to background. Counselors and clients may discover fresh insights from examining their experiences from more than one theoretical viewpoint. The client’s problems were interpreted as unresolved grief and so some analysis of this problem from a cognitive behavioral perspective is presented. The key objectives of cognitive behavioral counseling are outlined, followed by application of these principles to a creative arts process of tapestry-making.

This paper describes counseling work with a client whose presenting problems could be framed as unresolved grief. An integrative approach was taken to therapy, with cognitive behavioral adjuncts brought into an essentially client-centered perspective when relevant. In collaboration, the client and counselor discovered the therapeutic value of creating an image in tapestry. This experience appeared to help the client come to terms with past losses. The therapeutic aspects of the creative activity are analyzed from different theoretical perspectives. Introduction The client work discussed in this paper is unusual in two respects. Firstly, the client’s grieving process was guided in part by cognitive behavioral principles. Secondly, a creative arts adjunct to verbal counseling was conceptualized within a cognitive behavioral framework. While cognitive and behavioral theories are increasingly used to guide brief forms of psychotherapy and counseling, there are few published accounts of griefwork being informed by these perspectives. Cognitive behavioral approaches appear almost entirely missing from the creative therapies literature except in the field of music therapy (Bunt, 1994). The therapeutic use of art is perhaps more commonly informed by psychodynamic or client-centered principles, and the later discussion will examine aspects of the therapeutic process from these contrasting

Analyzing Grief Grief is a complex experience, and may be provoked by a wide variety of loss and separation experiences (Parkes, 1985). Grief reactions commonly include feelings such as sadness, anger and guilt; cognitive problems such as inability to concentrate, obsessive reflections about the lost object and memory losses; behavior disturbances such as social withdrawal, disturbing dreams and crying; and physical sensations such as tightness or emptiness in the stomach, shortness of breath and hypersensitivity to environmental sights and sounds.

*Frances Reynolds is Lecturer in Psychology and Rehabilitation Counselling at Brunel University, Osterley Campus, Borough Road, Isleworth, Middlesex TW7 5DU, United Kingdom. 165

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There are a variety of theoretical perspectives to guide counselors or therapists in working with grieving clients, and an integrated approach may be beneficial (Barbato & Irwin, 1992). Different interventions may be helpful according to the client’s position in the grieving process. Initially, the task of the counselor is to listen to the client’s story and accept the painful feelings which arise (Staudacher, 1987; Worden, 1982). While nonjudgemental listening is important to help the client disclose painful experiences, it may not provide sufficient conditions for the resolution of grief, particularly for clients who experience chronic or masked grief (Worden, 1982). In chronic grief, the response to loss is prolonged and perhaps marked by limited emotions (such as intense sadness or anger). In masked grief, the person may not attribute ongoing psychological difficulties to the grief process, and may indeed avoid all references to or reminders of the loss. They may have been supported in this avoidance by the family, leading to the “cognitive incubation” of grief (Eysenck, 1968; Gauthier & Marshall, 1977). The therapist may need to discover ways of helping the client to recontact the range of emotions experienced by the loss so that these can be worked through and some greater resolution achieved. Grief from a Cognitive Behavioral Perspective There are relatively few accounts of therapists working with grief from a cognitive behavioral perspective (Gauthier & Marshall, 1977; Kavanagh, 1990; Mawson, Marks, Ramm, & Stern, 1981; Ramsey, 1979). How may the cognitive behavioral perspective be relevant to griefwork? The cognitive perspective (Beck, 1976; Stern & Drummond, 1991) emphasizes the role of ongoing, unwarranted negative thoughts and assumptions in perpetuating problems such as depression. For those who are grieving a loss (be it of a person, possession or valued aspect of the self), the event itself may be very real and not open to reinterpretation. However, the person’s responses to that loss, including thoughts of regret, self-blame and so on, may work against resolving grief. At a cognitive level, there are similar targets whether working with grief or depression more generally. Beck (1976) noted how depressed clients tended to hold negative cognitions about the self (as deficient, blameworthy, and so on), the world (as lacking essentials or as invalidating valued assumptions), and the future (as promising nothing but fur-

ther strife, guilt, helplessness, and other unpleasant experiences). The therapist is likely to assist the client in identifying and challenging this so-called “negative cognitive triad.” The behavioral perspective emphasizes how behavioral patterns and habits come to be maintained in the long-term by subtle rewards, including attention from others, and relief from anxiety. In the context of grief, avoiding reminders of the loss and inhibiting expression of feelings, may reduce the burden of sadness in the short-term. However, in time, the person may become “entrapped” by their avoidance behavior. The fears of examining their loss experience intensify and their grief reactions may become more prolonged. The foundations of exposure therapy and systematic desensitization rest on the premise that confronting anxiety-provoking situations is a potent way of reducing their threat value (Marks, 1987). In cases of grief, it has been noted that individuals with complicated and prolonged responses to loss frequently avoid reminders of the lost person or situation. Some counseling interventions (such as inviting the client to bring mementoes, photographs and other “linking objects” to the session) aim to revive memories of the loss and associated emotions (Volkan, 1972). Such techniques can be viewed from a cognitive behavioral perspective as helping to challenge avoidance (and the long-standing “cognitive incubation” of anxiety). There is a common misinterpretation that cognitive behavioral therapy is only concerned with intellectual responses to situations and is highly directive. The varied interventions can be highly eliciting of strong emotional expression, and the therapist needs to be able to “hold” these emotions within a strong empathic alliance (Newell & Dryden, 1991). Working with Grief Through Experiential Processes Cognitive behavioral forms of therapy frequently include behavioral “projects” as homework. The client may most readily challenge long-standing cognitive assumptions about the self and the responses of others by trying out new behaviors. Experiential creative processes may help the client to access buried feelings and test their cognitive “landscape” of assumptions and expectations. However, the therapeutic use of art is rarely included within cognitive behavioral therapy. From a cognitive behavioral perspective, creative activity may facilitate clients in gaining awareness of

TAPESTRY-MAKING tacit negative assumptions. The visibility and permanence of the art product may help to challenge beliefs about low self-worth. Creative activity is by definition novel and so may to provide the client with new behavioral coping strategies, as well as evidence that change is indeed possible. Those working with art more often ground the work in a psychodynamic perspective. There is an acceptance of the power of the unconscious and art activities are regarded as having the potential (within a safe therapuetic relationship) of releasing painful, repressed material. The frame in art therapy has been likened to a container for the feelings therein (Schaverien, 1989). The art object can act as a bridge between the unconscious and the conscious (Case & Dalley, 1992). As the client may not be fully aware of the deeper nonverbal meanings held within the artwork, anxiety about engaging in the therapy may be alleviated (Dekker, 1996). Art may have particular value in griefwork, readily providing the client with a means of structuring chaotic feelings, as well as constructing a symbolically satisfying closure. Creative activity also permits the client self expression and the opportunity to experience a more potent self, less tainted by feelings of guilt or rejection. The counseling work described below reveals how the healing properties of creative work can be understood within a cognitive behavioral framework. In later discussion, further reflections on aspects of the process that are better understood by alternative theoretical perspectives will be offered. The Client Anne (name changed) was 45 years old when she came for counseling. She was married, with two children, aged 14 and 10 years. Employed full-time as a teacher, she described herself as over-immersed in work and excessively conscientious. Presenting Problems She described her initial reasons for coming to counseling as longstanding depression and marital discord. She dated the onset of her difficulties as occurring about 5 years previously, when the family moved from their first home to a larger house. The children had been born during the 9 years (1980 – 1989) spent at the first house. She described her husband as blaming her for abandoning the home in which he had felt safe and contented. Even 5 years

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later, minor everyday disputes would tend to be escalated by the husband into accusations of blame for this move and the ensuing change in their lives. The client believed that he had never recovered warm feelings towards her. Anne described a pervasive sense of helplessness, knowing that events could not be reversed and yet feeling great regret and apparent shame for the ongoing difficulties in the relationship. In the third session, a more specific difficulty was disclosed, the client expressing shame at the apparent “irrationality” of the problem. She described how she could not bear to look at family photographs from the period spent at the first home. She did not even feel comfortable looking inside the cupboard where the photographs were kept. She disclosed with considerable sadness that even thinking about the children’s early years brought such feelings of regret that she feared being overwhelmed. The client noted that this avoidance of photographs and memories was increasing, rather than abating with time. The past was tainted with such recrimination and regret that she very rarely engaged in any reminiscence of that time with her husband. She saw the past as split off, and disowned as a dark secret. Such disowning appeared to render the present rootless and meaningless as well. She feared that the children also sensed the disquiet, worrying that they too would not be able to “own” their pasts with confidence or pride. Interpretation The client was evidently entangled in a complex web of difficulties. However, in essence, she could be understood as locked into unresolved grief for the losses (of home, and beliefs about her husband and marriage relationship), which occurred 5 years previously. The husband also seemed to be locked into unresolved grief. The past had become idealized, unexamined and associated with painful feelings of regret and shame. Such feelings had remained potent rather than discharged, through avoidance of discussion and photographs of the past. The grief could be understood as masked, as the client did not consciously attribute her difficulties to the losses experienced. Integrative Approach to Counseling An initial contract was established for 10 sessions, subject to later review. It has been argued (Lamb, 1988) that delayed mourning may be more effectively

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accomplished if a limited time period for counseling is established that both encourages urgency, but also respects the client’s need for boundaries around the pain of grief. Sessions 1 and 2 The initial exploration was essentially client-centered, allowing the client to locate and describe her feelings and beliefs about her self-worth, blame for events and helplessness in the face of marital difficulties. The counselor worked towards establishing a relationship of trust. Session 3 When the strong avoidance of early family photographs was revealed, the behavioral technique of graded exposure seemed likely to be helpful. It has been noted by Marks (1987) that exposure to the anxiety-provoking stimulus is the most effective strategy for overcoming long-standing phobias and compulsions. Avoidance temporarily relieves anxiety, reinforcing subsequent avoidance actions, but leaving the sufferer with chronic fears. However, exposure, if it lasts for long enough (30 minutes to 2 hours), usually results in the abating of fears/anxieties. The fears need not be of physical objects or situations. In the treatment of chronic nightmares, deliberate self-exposure to the imagery has been shown to be helpful. Behaviorists argue that exposure allows the person to habituate to the anxiety. On the other hand, the technique may be effective because of the emotional and cognitive work that goes on during the anxious time when the person is confronting the feared stimulus. Cognitive-symbolic work on the part of the client is illustrated later in this paper. The theory of graded exposure was explained to the client and she drew up a hierarchy of threatening photographs –from most to least threatening to her well-being were photographs of: 1. 2. 3. 4.

Her children in the former home or garden Inside the former home Garden of the former home Holidays during 1980 –1985 period (away from home).

She was intrigued by the theory and evidence about this approach to threat and anxiety and agreed to ask her children to sort out relevant photographs from the lowest level in the hierarchy. As homework, she

would look at these photographs for extended periods, with her children as supportive company. It can be argued that encouraging this active involvement of the client to tackle personal difficulties following a behavioral strategy need not be incompatible with humanistic values, and it did not diminish the therapeutic alliance or facilitative climate of the counseling. The client expressed relief that “at last something might happen.” Therapeutic movement was much desired by her. Session 4 The client described her experiences of studying the selected photographs. As the holiday photographs had produced (contrary to her expectations) relatively little anxiety or regret, she had decided to go further with the exposure experience than planned and had spent time studying photographs of the 1980 –1985 garden. She described feelings of overwhelming grief for specifics such as cherished plants, the view which she had much admired and for the work she had accomplished in the garden. She also experienced sharp sadness about the deeper losses, for example, of her beliefs in the strength of her marriage and her own self-worth. She reported gaining some understanding of the losses that preoccupied her husband. She kept faith with the premises of exposure therapy and persisted in “staying with” the photographs and pain, which was surfacing. She then described a sudden intuition—that she could create a tapestry version of the photograph. Although she was not experienced in needlework, she had completed two pictures from kits (with the picture already designed), and felt confident that she could work from a photograph. The author sensed the therapeutic value of constructing a picture, which could then be “owned” physically and psychologically. Tapestry-making is a slow process and would hence require very lengthy exposure to the anxiety-provoking material. The client, therefore, found her intuition validated within the collaborative counseling relationship. Over the next 6 weeks, the client proceeded to draw up the design from the photograph and sew the tapestry. This project became the main “homework” of the counseling sessions, with the cognitive and emotional work stimulated by the sewing reviewed in each session (together with other issues). With more than 4 hours spent each week on the stitching, in the sight of the initially anxiety-provoking photograph, this seemed to be an effective vehicle of exposure

TAPESTRY-MAKING therapy, with all the cognitive and emotional process which it entails. Session 5 The client described the drawing of the design and first stitching as slow and emotionally painful. I can hardly bear to look at the photo or material. I decided just to do the rose border this week as the design works around the roses. I felt such sharp pain and longing to be back there, when everything seemed so safe and special. She spent 3 to 4 hours on this part of the picture and at the end of this time reported that the pain had become less intense. She began to experience curiosity about whether she could indeed finish the whole picture. Session 6 I’ve done so much thinking this week. I’m finding that memories are returning when I’m stitching that haven’t surfaced for years. Like the tree—we rigged up a rope swing for the children. I felt happy and sad remembering that. I like to see the solid tree emerging from the stitching. It feels good to touch and see it growing as I stitch. Like it’s my tree again. Not only were painful feelings being experienced instead of avoided, but the first signs appeared that the past was becoming integrated with the present (through recovery of forgotten memories and a sense of re-ownership). There was evident mourning for specific losses, and the counseling session provided a safe space in which to explore and acknowledge these. Session 7 The client seemed to be experiencing less helplessness and a greater sense of control over feelings and events. Symbolically, this was manifested in her decision to “axe the shed” from the garden tapestry (“it always did look a bit of an eyesore”) and to add some flowers on the lilac tree. There were further clues to her greater sense of freedom. “In the picture, I’m looking at the garden from the back door. This week

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I feel like I can move around in the picture a bit more—I’m not so pinned back against the door that I can’t breathe.” The very physical signs of anxiety (“pinned back so I can’t breathe”) were subsiding. Such changes were also apparent in the larger issues discussed in the counseling sessions (the experience of moving on and being less preoccupied with the past) and in the appearance of some humor about past events. Session 8 I feel I’ve worn out all the regret by pouring it into the stitching. It really has almost gone. And I’m beginning to see that our time there wasn’t totally glorious and peaceful. There were good bits and bad bits. I was particularly struck by that when I was stitching the grass (which seemed to go on forever). I suddenly remembered the bother we had clearing cats’ mess off the grass before letting the children out to play. Our next door neighbours had about 7 cats so the flower beds couldn’t cope and they would come into our garden and mess on the lawn. I decided not to put any in the picture but I know it’s there! The client in her humor revealed that the past had become more differentiated. She was no longer thinking in black and white terms (a feature of depression as noted by Beck) but could accept the mixture of good and bad. The mourned past was no longer idealized. The availability of more realistic memories further explored in the session, perhaps helped to dissipate the regret. Session 9 When I started the picture I felt sure that I wouldn’t be able to hang it up. I had thought of burying it in a sort of funeral ritual which would mark that episode of our lives. But I think I will hang it up as a monument to my recovery. The client appeared to recall the garden more objectively, as something lovely and loved, but through fewer layers of distorting emotions. The work had also helped the client develop a more satisfactory self-image. She discussed how the experience had touched more creative facets of her self. It was interesting that the tapestry in its completion

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would provide a concrete ending to the emotional process which accompanied the stitching. The picture acted as physical evidence of cognitive and emotional healing and preparedness to move on. Session 10 The finished tapestry was brought to the last session. The client described how she could now see the anger which had infused the first efforts The roses were all over the place. The stitches were really uneven and some were reversed in direction. I wasn’t aware of that at all at the time. It seems symbolic that I started with angry red and finished with brilliant yellow thread. The tall straight stems of the roses were last to be put in place. Nothing could knock them down. That made me feel that there was something deep down, organising the making of the picture, making the most of the experience. Anne agreed that 10 sessions had been sufficient time for her to achieve changes in her feelings and selfimage. Although problems with the marriage had by no means been fully resolved, the client had begun to view her husband’s anger as less personally directed and more an expression of his own unresolved grief. Through this, she felt somewhat less vulnerable to his attacks and more prepared to help him talk through his feelings. She also found that her husband was relating to her more warmly, and attributed this to her more responsive, less depressed state. Reflections—Drawing on Diverse Theoretical Perspectives Recreating a grief-provoking photograph through needlework had considerable therapeutic value. It stimulated not only a lengthy behavioral and cognitive exposure to a threatening reminder of the past (likely to result in reduced anxiety), but it could also be understood as the vehicle for considerable emotional and symbolic griefwork. The first task of griefwork is to experience the pain of grief (Worden, 1982). Lengthy exposure to photographs (or other mementoes of loss) may trigger painful feelings that can then be confronted rather than avoided. During the lengthy periods of stitching, the client noticed recollections of forgotten memories, though often painful, helped to challenge idealistic

thinking, and led to more ownership of the past—with less splitting and a greater integration with the present. These experiences seemed to help the reintegration that is the ultimate goal of griefwork. The cognitive behavioral perspective provided a useful rationale for the hierarchical approach to dealing with anxiety-provoking material and explained the value of “staying with” anxiety for substantial periods. Nevertheless, some of the material elicited by the project appeared to reflect unconscious processes and these aspects may be better explained by psychodynamic concepts. For example, the initial focus on particular aspects of the scene (foreground roses) and colour (red), together with the rather “untamed” approach to stitching, resulted in a vibrant, rather messy product at first. It was only once some of the repressed feelings had been discharged that the client could reflect on the several hidden meanings of these initial choices. Later work moved towards increasing levels of self-awareness and reflection, including decisions to alter the scene. Such choices could be interpreted as metaphorical attempts to control and perhaps distance the self from the grip of the original experience. At a deeper level, the finished picture also provided a physical closure of the episode, with a symbolic function much like a headstone to a loved one. The physical frame held much more than stitches. The stitching process permitted disengagement from yearning and regret while creating a physical marker of the past. Feelings of fragile identity often accompany loss. In the present case, these were magnified through the long-standing conflict and other-blaming which was occurring in the marriage. The completed project helped to disconfirm the client’s feelings of helplessness and poor self-worth at home. The creative skills developed through the project could be understood as helping the client to integrate previously unacknowledged or forgotten facets of the self, a therapeutic goal emphasized by Jung (see Tuby, 1996). Lastly, the counseling process seems to illustrate clearly the “collaborative” approach advocated by cognitive behavioral therapists (Newell & Dryden, 1991), as well as by client-centered therapists (Silverstone, 1997). The therapeutic relationship contained the necessary elements of empathy, genuineness and unconditional respect (an experience in particularly short supply in the client’s life). A high level of mutual regard enabled the counselor to appreciate the client’s own intuitions about her needs and insight

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