Sadness and Loss: Toward a Neurobiopsychosocial Model

previously untreated 25-year-old female graduatestudent with masochistic traits but no axis I or II disorderentered twice-weekly psychodynamic psychotherapywith a stated goal of ending an abusive romantic rela-tionship with a colleague. In the early months, sessionswere filled with the patient’s childhood memories ofemotional mistreatment by her parents, whose constantfighting left her feeling abandoned and terrified. Shecontrasted these memories with loving memories of hergrandmother, in whose nearby house she recalled after-noons of calm play, cookies, and attentive nurturance.The patient’s grandmother was elderly when treatmentbegan, and in the fourth month of treatment she be-came unexpectedly ill. The patient visited her daily andwas with her when she died. The patient then entered aperiod of grief, spending much of each day thinkingabout her grandmother. However, she continued to beproductive at work, did not develop a major depressiveepisode, and retained the capacity for pleasure andsocialization.Therapy sessions followed a pattern:the patient would arrive in a euthymicstate and begin to talk about hergrandmother. The therapist respondedwith supportive clarification andmirroring, using phrases such as “youreally loved her” or “she was the onewho understood how scared youwere.” Sometimes as a result of suchcomments, and others the patientmade spontaneously, the patientwould blurt out, “I cannot believeshe’s dead!” followed by crying of vary-ing intensity, lasting 3–10 minutes.During this introspective period, shewould lower her face, cover her eyes,and break off communication with thetherapist. She reported feeling in-tensely sad during these periods, being flooded by lovingmemories of how her grandmother looked, sounded,and felt, and understanding the reality and finality of theloss. Further empathic comments by the therapist, suchas “You really miss her,” prolonged these episodes; typi-cally the therapist would attend silently. After severalminutes, the patient would reengage by drying her eyes,adjusting her clothes and hair, and resuming eye contactwhile talking about how lonely the world was withouther grandmother. To this the therapist typically re-sponded with reflective statements, such as “It feels likeyou will not ever be known in that kind of warm wayagain,” which often led the patient either to further butmore muted episodes of tearfulness or, more frequently,to the somewhat comforting idea that her grand-mother’s spirit was watching over her. By session’s endthe patient was no longer tearful; she would smile po-litely as she left to return to work. She reported manysimilar episodes outside of therapy, estimating thatthere had been at least several hundred over the fewmonths following her grandmother’s death. Over a 3-month period, the frequency and intensity of these min-utes-long sadness episodes decreased; by the fourthmonth of bereavement, she discussed her grandmotheronly occasionally and focused largely on current rela-tionships and concerns.The therapist did not offer the patient medication oradvice on coping, because he considered her grief pro-cess to be normal, spontaneous, and healthy. During thetherapy termination 2 years later (the therapist wasgraduating from training), dreams in which the grand-mother was dying recurred and were interpreted in thecontext of dealing with loss of the therapeutic relation-ship. This led to brief episodes of sad crying during ses-sions about the loss of the therapist.