A Child’s Grief

Several months after Catie died, Steve asked his sister-in-law to watch his daughters for a few hours so he could spend time with his six-year-old son. David seemed to be doing well but Steve sensed he needed a little one-on-one time with his Dad. They spent the morning together cooking breakfast, playing outside, and building Legos at the kitchen table. David loved having his father’s undivided attention. After they had been playing for a few minutes, Steve asked him how much he thought about his mother. I still feel bad about what I did—about how I made Mommy die.” “Wait, what?” “Because of when I hurt Mommy. Remember? That day she came home from the hospital and I hurt her real bad.” “That day” had occurred nearly two years earlier. Excited to finally have his mother back home, David jumped into her arms and gave her a big hug. Catie winced and immediately grabbed her right shoulder, which was still tender from surgery and radiation. David immediately let go and backed away. His mother, now grimacing, tried to take deep breaths to ease the pain. After a few minutes, she told him that she was okay but that he needed to be gentler with her. Steve had not thought about the incident since the day it happened. Considering all he and his family had been through, it had barely registered in his memory. Sitting at the kitchen table, he asked his son what he remembered. David talked about how he made his mother sick by hugging her too hard. Since he had made her sick, he was the reason she died. “Buddy, no. No, no, no. That’s not it at all.” Realizing that his son had been thinking this way for almost two years made Steve nauseous. He placed his hands on David’s shoulders and looked him in the eyes, making sure he had his full attention. He explained that the hug had absolutely nothing to do with his mother dying. “You and your sisters were the reasons that Mommy lived as long as she did.

Hard-Earned Wisdom

In 1994, Kenneth Schwartz, a forty-year-old healthcare attorney from Boston, was diagnosed with advanced lung cancer. At different times during his progressive illness, he was deeply moved by aspects of his care that were less strictly medical or technical: a calming visit from a nurse prior to surgery; a personal connection with an anesthesiology resident from his neighborhood; and, toward the end of his life, the kindness and perspective provided by his oncologist. Shortly before his death, Mr. Schwartz founded a non-profit organization to promote the kind of compassionate care that had meant so much to him. Two decades later, the Schwartz Center for Compassionate Healthcare reaches millions of patients and hundreds of thousands of caregivers to realize its founder’s vision of more humane care for the seriously ill. A cornerstone of the Center’s work is the Schwartz Rounds program, which brings healthcare providers from multiple disciplines together for frank discussions about the emotional and psychosocial challenges of caring for patients. More than five hundred healthcare organizations around the world host these ongoing, non-traditional conferences. A few years ago, the organizer of Schwartz Rounds at UNC invited us to lead an upcoming conference. She was aware of our work with the single fathers support group and wanted us to address the challenges that spouses face when caring for a partner with a terminal illness. At the next group meeting, we mentioned this request to the men and asked them for their advice. Each father had been an eyewitness to the end of his wife’s life and knew well how that heartbreaking time had impacted his entire family. Not surprisingly, they had a lot to say about end-of-life care and how it could be improved. Karl was particularly passionate. “I’ve actually thought about this a lot since Susan died. Obviously, the patient is the focus, but I think it’s also important for doctors to appreciate what the family goes through—especially when there are kids at home and the spouse is a co-parent. That dynamic alone influences so many things.”

Dating 2.0

When Lisa created her family rules shortly before her death, she wrote them for her three daughters. She wanted the girls to remain close and look out for each other during the difficult days that would lie ahead. However, Bruce realized immediately that Lisa’s rules were meant for his benefit as well. The last rule was unambiguous: . . . Support Dad when he is ready to date. He is going to need it. . . . Lisa wanted Bruce to find happiness again and did her part to make that possible. Early on, Bruce had no interest in dating and felt disloyal to Lisa for even wanting companionship. After the one-year anniversary of her death, and with Lisa’s explicit approval, Bruce reached out to an old friend who had offered to set him up. A lunch date was scheduled for the following week. As the date approached, Bruce began to doubt himself. That morning, he tried to stay busy around the office, but as lunchtime neared, he panicked. He hurried down the hallway toward the office of a co-worker with whom he had become close since Lisa’s death. “I can’t go through with it!” Bruce said as he burst through the door. “Whoa, what’s going on?” his friend asked. “I’m not ready for this. I don’t know what the hell I was thinking. To go on an actual date!?! It’s too soon.” “Okay, just calm down. Have a seat and we’ll figure it out.” Bruce continued to pace around the room. “Seriously, how can I have lunch with another woman and act like it’s okay. It isn’t. I was with Lisa for almost twenty years. I don’t want to be with anyone else.” “I thought that she wanted you to date again.” “I know, I know. But how am I supposed to act … what am I supposed to talk about the whole time? That’s it. I’m not doing it.” Grabbing Bruce by the shoulders, his friend looked him in the eyes. “Get yourself together, man! I know this is hard, but you’ve got to calm down.

Last in Line

Leaders of a support group often debrief after each meeting. So, when we started the group for widowed fathers, we made a point of scheduling time for this practice, even though it would make long days even longer. We used these conversations to reflect on any new themes that emerged during the session, the interpersonal dynamics between the men, and any changes we needed to make to the group. What neither of us anticipated was how moved we would be by these men and what they were building together. Month after month, as the two of us talked following each meeting, we marveled at the fathers’ willingness to share their fears and vulnerabilities. Their authentic exchanges with each other belied the stereotype that men are reluctant to talk openly about their feelings. Each time a father articulated a concern or newly discovered insight, the others responded with honesty and compassion. They were becoming part of something larger than themselves. We found this project as interesting and meaningful as any professional work either of us had ever done. It was also uncharted territory. Because no one had ever led a support group for widowed fathers whose wives died from cancer, there were no books, articles, or lectures to guide us as group leaders or to shed light on the unique challenges these men were facing. Like the fathers, we were participants in this experiment and were committed to giving it our best shot. The group sessions generated plenty of painful, awkward moments during which we had little or no comfort to share. They also sparked moments of profound insight, inspiration, and humor. Our post-meeting discussions gave us a chance to compare notes and appreciate the progress of each man and the group as a whole. Returning home after each session, we would tell our wives how great the group was that evening. Once a month we each felt especially grateful that we could share these successes with our spouses. During our debriefing session on the night “Ring Watch” ended, we sensed that the group was at an inflection point.

“Of Course I’m Depressed, but Do I Have Depression?”

What’s the difference between being very shy and having social phobia? Or between a “neat freak” and a person who suffers from obsessive-compulsive disorder? Or a particularly fidgety schoolboy and a child with attention-deficit hyperactivity disorder? Distinctions between the outer bounds of “normal” and “pathological” are ubiquitous in modern life and not easy to make. People who experience loss respond in different ways, with varying degrees of intensity, and for different lengths of time. Mental health professionals find these responses difficult to predict. For example, leaders in the bereavement field have disagreed sharply and for a long time about how to define normal and abnormal grief. This professional disagreement about grief and bereavement made headlines when the American Psychiatric Association (APA) considered changing its Diagnostic and Statistical Manual of Mental Disorders (DSM). Every fifteen to twenty years, the APA revises the DSM—which establishes the criteria clinicians use to diagnose psychiatric disorders—to incorporate the latest scientific research and contemporary expert opinion. Before the most recent edition (DSM-5) came out, the APA considered two grief-related proposals that sparked very heated debate. The most controversial proposal suggested modifying how professionals diagnose major depression. The previous edition of the DSM specified that clinicians could not consider someone to have major depression if that person had lost a loved one less than two months earlier. The APA intended this “bereavement exclusion” to keep mental health professionals from mistaking grief for clinical depression. Clinical researchers Sidney Zisook, MD, at the University of California at San Diego and Katherine Shear, MD, at the Columbia University School of Social Work led one side of the debate. They argued that professionals should diagnose clinical depression even in the context of bereavement as they would following any other stressful life event such as divorce or the loss of a job. Zisook and Shear thought that people could experience both grief and depression simultaneously. Perhaps most importantly, they said, people who had clinical depression during early bereavement were no less deserving of treatment for their depression.

Beyond Death and Dying

In the late 1960s, LIFE magazine was one of the most widely read and influential periodicals in the world. Renowned for its photojournalism, the general-interest magazine covered all aspects of American life. The November 21, 1969, edition was no exception. It included a review of what would be The Beatles’ final studio album, a profile of Ohio State University head football coach Woody Hayes, and an advertisement for a commemorative book on that summer’s moon landing. It also featured an article on a little-known University of Chicago psychiatrist, Dr. Elisabeth Kübler-Ross, and her groundbreaking work with terminally ill patients. In an era when public discourse about death and dying was almost non-existent and when many physicians believed that a patient was better off not knowing his or her prognosis, Kübler-Ross was encouraging candid and open conversations with people about their impending deaths. Her innovative approach and courage to challenge the status quo drew the interest of LIFE editor Loudon Wainwright. His captivating story introducing Kübler-Ross and her new book, On Death and Dying, would forever change the national conversation about end-of-life and grief. The article described Kübler-Ross’s seminar teaching clinicians about the experiences of terminally ill patients. Physicians, nurses, chaplains, and medical students watched through a one-way mirror as she interviewed a twenty-two-year-old woman who had been diagnosed just two weeks earlier with leukemia, which at that time was almost always fatal. Large black-and-white pictures of the patient showed a vibrant and beautiful young woman with long hair and a wide smile. She looked nothing like someone close to death, which in some ways was the point. She talked about her diagnosis and understanding that leukemia would almost certainly kill her. Her willingness to openly discuss the prospect of her own death must have been astounding to those observing the interview. Kübler-Ross theorized that people facing their own mortality proceed through five stages prior to their death. In the first stage, the person is unable or unwilling to accept that he or she is going to die (Denial).

The First Meeting

Dan had been terrified of speaking in front of people for as long as he could remember. As a child, he avoided eye contact with teachers so they wouldn’t call on him in class and he insisted on non-speaking parts when he had to participate in school plays. In high school, he feigned stomachaches to avoid giving class presentations and never dared to run for student council. Over time, Dan’s fear of embarrassment shaped his personality. He was shy and introverted, and he stayed away from situations that invited scrutiny. Naturally, when Dan first heard about a new support group for recently widowed fathers, he thought there was no way he could join. Opening up to a room full of strangers about his wife’s illness and recent death was nightmare material. It was precisely the kind of situation he had spent a lifetime avoiding. Still, Dan knew that he needed some kind of help. He had been in bad shape in the months since his wife had died. He felt isolated in his grief and overwhelmed by the prospect of raising two children by himself. As Dan saw it, his kids not only lost their mother but were now stuck with a father whose ineptitude as a parent was only making things worse: a cruel “double-whammy.” Despite his fears, he decided to join the support group because he felt he owed it to his children to be a better parent. Dan set the bar low for that first night: show up, sit quietly, listen to the other fathers, and avoid drawing attention to himself. If asked to share his story, he would offer only the barest of details. If called on to participate in group discussion, he would keep his input to a minimum. As he pulled into the parking lot for the first meeting, Dan felt a familiar wave of anxiety. His stomach churned and his heart began to pound. He thought about turning back. Instead, Dan closed his eyes and tried to calm down. After ten minutes, he took a deep breath and stepped out of the car.

An Unexpected Partnership

Facilitating a support group and conducting group psychotherapy require similar skills. For both interventions, the leader encourages constructive interactions between group members in the service of psychological growth. However, there are important distinctions between these two types of groups that impact the relationship between the leader(s) and participants. In group psychotherapy, traditional therapeutic rules apply: Patients receive mental health treatment for a diagnosed condition and are charged a fee for that care; the therapist and patients commit to maintaining the confidentiality of disclosures in the group; and records are kept for medical and legal purposes. In contrast, a support group is not considered formal psychotherapy. Consequently, less stringent rules apply. This distinction influenced how we conducted the Single Fathers Due to Cancer support group. The men were not our patients and we were not their therapists. We were therefore able to partner with them in ways that would not have been possible otherwise. From the beginning, a collaborative spirit defined our work with the fathers. The seeds of partnership were sown during the very first meeting when we welcomed their input and, in response to their feedback, altered both the structure and format of group meetings. In the months and years that followed, our partnership expanded and yielded unexpected benefits for us, the men, and countless other widowed fathers. A quick search of the Internet or any bookstore reveals an abundance of resources for people grieving the loss of a loved one. However, there is remarkably little tailored specifically for widowed fathers. Researchers in the grief and bereavement fields have also largely neglected the challenges these men face. As our work with the fathers in the support group continued and intensified, we felt compelled to bring more attention to this underappreciated clinical need. Our first instinct was to approach this subject academically and we drafted two manuscripts for professional journals. In the first paper, we aimed to raise awareness among our colleagues in the cancer and bereavement communities by highlighting the unique hardships of being a widowed father.

The Ring Thing

The ancient Egyptians were the first to use a wedding ring as a symbol of love and fidelity. Bands were usually made from grass or hemp and worn on the fourth finger of the left hand, which was believed to include the vein that led directly to the heart. The circular shape of the ring—with no beginning and no end—represented eternal love. Over the centuries, societies throughout the world adapted the tradition to fit their own cultures. It was once customary in the United States for only the bride to wear a ring, but this changed during and after the marriage boom that followed World War II. The number of men wearing wedding bands more than quadrupled, and today, double-ring marriage ceremonies are the norm. None of the men in the group had anticipated that “until death do you part” would occur so early in his marriage. After their wives died, what their wedding rings symbolized, and what should be done with them, was far from clear. One evening as the group settled in, Joe reached toward the center of the table to pick out his sub and bag of chips when one of us (Don) noticed something different about his left hand. “Joe, you took off your ring.” All eyes turned to Joe’s left hand. A strip of pale white skin that had been shielded from the sun for nearly twenty years circled the base of his fourth finger. Before that moment, the men had never discussed the subject of wedding rings. The prospect of dating again had compelled Joe to make the change. “It’s not that I’m interested in anyone in particular. In fact, even thinking about going out with someone right now is kind of overwhelming. But, damn, I don’t want to be lonely for the rest of my life. I hope that someday I’ll feel for someone else the way I felt for Joy.” Joe took off his ring because he wanted to believe that one day that time would come.

Winding Down

From the beginning the men had known, better than we did, that six sessions would not be enough. Changing the group to an open-ended format had been the right move, but we hadn’t resolved the question of when the group should end. The fathers were clearly piecing their lives back together and the reasons for continuing to meet were becoming less clear. As the group approached the three-year mark, attendance lagged. We wondered if it had run its course. One evening, we asked the men whether they wanted to keep meeting or if it was time to stop. We acknowledged that our work together had become increasingly collaborative but wanted them to know that they were not beholden to us. We never intended for the group to continue in perpetuity. Our focus had been to help them grieve and move forward. If they had reached that point, then they should to feel free to leave. The fathers seemed surprised when we raised this topic. They quickly dismissed the idea that they felt obligated to remain in the group. Uncharacteristically, Russ spoke first, “I’ve never felt pressured. I come because it helps.” The topic of discussion during that session was whether it was time to stop meeting. Each father knew that he would eventually leave but up until that moment Steve’s departure had been the only other occasion on which we discussed endings. Bruce reframed the issue: “Unless getting engaged and moving across state lines is the only ticket out the door, I guess we need to figure this out.” Karl approached the subject with his typical analytical style. “It sounds like there are two issues on the table. First, how does any one of us know when it’s time to stop coming? For Steve, it was easy: He got married and moved away. For the rest of us, the decision comes down to whether coming here is still helpful. Obviously, each of us has to answer that for ourselves. The second question is whether it’s time for the group as a whole to end.