Before they understand the various diagnoses and treatment options available, many clients present to counseling because of trouble navigating the same human phenomenon: heartbreak.

Under this label fall countless events such as a painful breakup, the death of a loved one or the failure to attain a major life goal. Counselors are in daily contact with clients struggling with some form of heartbreak, and many counselors initially focus on treating the symptoms, which might include sleeplessness, anxiety about the future and hopeless thoughts. But some in the field are conceptualizing this presenting problem as more complicated than major depression or adjustment disorder. By considering heartbreak through new diagnostic lenses, counselors are developing integrated approaches to treat this universal human experience.

One counselor delving into these nuances is Joanne Vogel, whose résumé reads like a catalog of the varieties of heartbreak. The American Counseling Association member and director of counseling and psychological services at Rollins College in Winter Park, Fla., began her career serving at-risk female adolescents, followed by five years working with children and families navigating the foster care system. She later directed a federal grant program aimed at strengthening couples’ relationships, and then she went on to become a certified sex therapist.

“I think that many people have expertise in the area of love and heartbreak whether they wish to or not,” Vogel says. “I began focusing on this area due to a combination of life circumstances, interest and advanced training in sex therapy. Certainly not every person experiencing heartbreak needs sex therapy, but I approach the mental health discipline with the knowledge that intimacy and love — and the ability to love after heartbreak — undergird healthy sexuality and attachment.”

Applying descriptions from a variety of sources, Vogel defines heartbreak as “an intense, overwhelming, crushing grief or distress over the loss of something or someone.” She notes this definition covers more than simply romantic relationships, including the death of loved ones; abandonment, abuse and/or neglect from caregivers or others; and major changes in life course, such as sustaining physical injury or moving and feeling uprooted. Vogel says the impact of heartbreak varies depending on the person or situation. “I try hard never to minimize the experience and its potentially devastating effects,” she says.

To that end, Vogel has likened heartbreak to posttraumatic stress, acute stress and even substance withdrawal. “For posttraumatic stress, the similarities stem from experiencing a traumatic event that overwhelms coping skills [in which] a person experiences threat of or actual injury. [In treating clients struggling with heartbreak] I have noticed the reliving, avoidance and arousal associated with posttraumatic stress,” she says. She notes that heartbroken clients may have upsetting memories, flashbacks,
re-experiencing, lack of interest in normal activities, inability to concentrate, irritability, angry outbursts or sleep disruption.

Clients dealing with heartbreak may also have reactions similar to individuals experiencing substance withdrawal, including obsessions, cravings and relapselike behaviors, such as getting back into an unhealthy relationship, Vogel says. She says the comparison of heartbreak to grief or bereavement “may be the easiest one for people to accept since it recognizes the loss component of heartbreak in addition to some of the familiar [Elisabeth] Kübler-Ross stages such as denial, anger, bargaining, depression and acceptance.”

Conceptualize the problem

Viewing heartbreak as a kind of posttraumatic stress, substance withdrawal or grief can help counselors in considering treatment options, Vogel says. “I suppose some may critique this approach for pathologizing the natural and normal experience of heartbreak in life. However, I would like to see all of the above notions and categories depathologized and used to have a common language about conditions and experiences that affect many of us and the people whom we counsel or love,” she says.

Kalpana Murthy, a licensed professional counselor in private practice in Atlanta, also has observed heartbreak produce symptoms similar to posttraumatic stress and grief. “When a relationship ends — particularly if it ends suddenly or because of an affair — the client could experience shock, loss of control or a sense that what has happened isn’t real,” she explains, adding that these clients may re-experience conversations, images or events related to the breakup. Murthy also notes these clients may experience physical or emotional distress triggered by moments that run the gamut from calendar dates to social media postings.

Vogel points out that social media has become a new venue for retraumatizing heartbroken clients. “Working in a college setting, I am acutely aware of how a ‘status change’ or update affects heartbreak in romantic relationships and the difficulties inherent in limiting information dissemination,” she says. “Furthermore, the ease of information discovery on the Internet makes such things as stalking after relationship dissolution a concern.

“The addictive quality of cyberspace and relationships creates a bit of a perfect storm for those who might obsess or ruminate. I have worked with clients to limit their use of Facebook, Google, Twitter and the Internet until the emotionality and reactivity decrease. I prepare clients for the likelihood that they will discover or hear information about an ex, and we do some imaginal rehearsal to prepare for situations, people and places that may evoke emotion or trigger certain memories.”

Psychoeducation: Heartbreak 101

John Ballew is an ACA member who has been in private practice in Atlanta for 25 years. He has found that a significant number of his clients enter treatment due to the heartbreak associated with the end of a relationship. He explains that the breakup often makes it difficult to ignore long-term intimacy issues, which may manifest as a state of personal crisis. Although this can present a good opportunity for the counselor to educate the client about how relationships really work, Ballew emphasizes that the client should always set the pace for this work.

“If a client is in a place to hear it, I will let the client know that personal crises can be opportunities for personal growth,” Ballew says. “Obviously, it is important not to offer glib reassurance or clichés about life when a client is in distress. Clients are often troubled by feeling overwhelmed in the face of loss. I find it helpful to normalize their experience and to talk about it in the context of grief.”

Murthy agrees that providing such context can be useful when dealing with heartbreak. “Psychoeducation helps them understand why people have different reactions to a relationship ending and different timelines for heartbreak recovery and grief,” she says. “It also helps them understand why they feel the way they do and normalizes their experience.”

Ballew notes that working with men regarding heartbreak often presents special challenges but adds that psychoeducation can help. “Men can be very uncomfortable with the feelings of hurt and vulnerability that are intrinsic to heartache,” he explains. “The hurt may emerge as anger instead of pain. And the therapist should be alert for signs that a male client may be experiencing shame regarding his emotional distress. The therapist is in a great position to help the client learn more about how emotions work and to become more comfortable with his interior landscape.”

Ballew adds that care ought to be paid to the physical well-being of all clients experiencing heartbreak, including helping these clients to tune into the possible physical manifestations of the experience. “The intense distress is likely to be experienced in the body, especially if the distress goes on for a while,” he says. “There is risk of hypertension, chest pain and other physical manifestations of grief. Trouble sleeping is very common, and that can precipitate other problems, from anxiety and depression to distraction at work. [Also] be alert for changes in drug and alcohol use for the purposes of self-medication.”

In treatment: Watch your language

For Vogel, the first step in helping clients through heartbreak is allowing their experience to be individualized and contextualized. “I ask questions about the person, the pet or the situation, to know — really know — that person, pet or event in a way that helps me to understand the meaning, role and symbol of such in the client’s life,” she says. “I find people are willing and relieved to share these things because many in their social support network — if one exists — may be tired of hearing about the loss and may become frustrated in the amount of time it takes to recover and heal.”

When doing this work, Vogel says she focuses on three subjects: the role of language, creative techniques and learning to dream, live and love again.

The language piece is important, Vogel says, because subtle changes in how counselors speak to clients can expedite treatment. “For instance, I begin to add words like heartache or heartsickto the discussion about heartbreak. When we think of something broken, we are unsure if it can be fixed. When I use ‘heartsick’ or ‘heartache’ in place of ‘heartbreak’ as soon as it may be appropriate, it indicates subtly that wellness can be achieved from sickness and aches often go away as we use the muscles more frequently or give them a rest,” she says.

Applying a language technique she learned through a Rapid Trauma Resolution training with Jon Connelly, Vogel speaks in the present tense about the positive remembrances of the lover, person, pet or situation, while placing the negative or conflicted memories about these things in the past tense to create distance. She also pays attention to how other people may be speaking to the client.

“In the case of relationship breakups, I tackle the ‘other fish in the sea’ idea and the tendency to tell someone simply to go out and find another person, or the idea of ‘just go out and get laid’ to forget the other person or feel better,” Vogel says. “I find that these things may be well intended but dismiss the experience or attempt to distract the person from the actual grieving process. Rarely do we find someone who tells you to go out and find another mother after the loss of a parent or to distract yourself with some other feel-good chemical. Certainly, people do this, but it fails to address the issue.”

Vogel goes on to warn that the very human response of normalizing or promoting the universality of the heartbreak experience may not provide actual comfort to the client. “You will often hear back [from individuals going through heartbreak] that you do not understand how different, unique or special this relationship was in comparison with others,” she says. In trying to comfort someone, especially a friend, it can be tempting to tell the person that he or she can “do better” next time, she adds. “While the phrase ‘you deserve better’ might be acceptable, this idea of ‘doing better’ reminds me of a coach or teacher who wants me to perform something more perfectly and somehow suggests that I am responsible for my own pain because I could have done better.

“Likewise, any notion that ‘it would not have lasted anyway’ is equally distressing because it seems equivalent to a funeral condolence of someone being ‘in a better place.’ Perhaps some will find solace in this, but most clients struggling with heartbreak or heartache will not respond to thinking that it was going to end at some point anyway.”

Vogel also cautions friends against reminding the person that the lost partner wasn’t really fun or was never available during the relationship. “This feedback may be appropriate at some point in the future,” she says, “but it is better to focus more on your friend in the short term than on what you lacked when your friend was in the relationship.”

EMDR options

Trina Welz, a counselor in private practice in San Antonio, became interested in helping clients facing the trauma of heartbreak after many years of walking clients through other sorts of trauma, including that experienced by military personnel and their families. She trained in eye movement desensitization and reprocessing (EMDR) to help that population, but has found success in applying that treatment approach to clients dealing with grief and loss as well.

“If we look at the end of a relationship as a traumatic event, there are several ways in which the EMDR protocol can be applied based on the client’s needs [and] treatment goals, and the clinician’s assessment and case conceptualization,” Welz says. “If the client is struggling with overwhelming depression and sadness, that emotion can be targeted with EMDR. If the client is struggling with the memory of a terrible argument they had with their partner, that can be an EMDR target.”

Welz notes an EMDR technique called resource development installation that can help clients recognize, access and reinforce their own resources to address the situation. “For example,” she says, “if your client is struggling with feelings of sadness after their partner has left, you can explore earlier times in [the client’s] life when they struggled but were able to be successful. Whatever resources the client identifies — courage, determination, the ability to be empathetic, spirituality, etc. — I can then use EMDR to reinforce that resource so that it becomes more readily available.

“So, instead of the client thinking, ‘I feel so sad and hopeless. Things will never get better,’ the client can think and feel, ‘Life was really hard when I was going to college and working two jobs, but I made it. I can use that same strength to get through this breakup.’”

Further, EMDR can be used to desensitize the client to the places or things that activate the person’s grief, Welz says. “After a particularly painful divorce, my client continued to live and work in the same neighborhood. Driving past the children’s school triggered his feelings of sadness and anger and the negative belief, ‘I’m a loser.’ With the use of EMDR, we were able to desensitize this trigger so that driving past the school stopped evoking those same negative thoughts and emotions, and his negative belief was replaced by the more positive belief, ‘I was the best parent I could be.’”

Murthy, also a certified EMDR therapist, finds that an integrated therapy approach helps her clients who are facing heartbreak. “My approach includes psychoeducation, ego state work to increase a sense of security, EMDR therapy, grief work, mindfulness meditation and cognitive approaches to help with resisting the urge to contact the spouse [or] significant other when further contact would not be beneficial,” she explains. “After the acute symptoms have been reduced, I then work on helping the client address relationship patterns or other issues that may stand in the way of a healthy relationship with someone new. When the client decides to discontinue therapy sessions, an effective transition process and closure session is especially important with [those] who have just gone through a relationship ending. For some clients, this may be their first experience of a healthy way to end a relationship.”

Get creative

Clearly, counselors can use many different methods to help clients get through heartbreaking circumstances. Vogel emphasizes that creative techniques can help clients transition from mourning their loss to envisioning a brighter future, while simultaneously incorporating lessons learned from the previous relationship. “I try to learn about the types of creativity the client already uses in life,” she says. “I adapt activities frequently and allow the client to help determine what type of creative medium: writing, dancing, sewing, songwriting, making a music mix, creating a collage, painting, gardening, etc.”

For example, Vogel uses a trauma desensitization technique from researchers James Pennebaker and Sandra Beall that invites clients to write about their heartbreak for 15-20 minutes on three to four consecutive days. In the process, Vogel says, clients may be able to take more or less personal responsibility for the breakup and become less sensitive to thoughts about the relationship. Clients also can bring in photos of the relationship, create a scrapbook and even create a different ending to the heartbreak, she says.

Vogel avoids talking specifically about the client moving on or finding a “replacement” for the lost relationship, but through the counseling process, she says, that end result often happens on its own. Says Vogel, “I find that using creative approaches and honoring the loss allows clients to think about the things and people that they want in their lives in the future.”

Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org