These are hard questions, but they require some sort of answer. While Recovery meetings normally deal with trivialities, as these provide a good focus for practicing Cognitive and Behavioral Therapy methods, we do need to acknowledge and do our best to understand the difficult situations that members may face.
The DSM is published by the American Psychiatric Association. It offers a common language and standard criteria for the classification of mental disorders and is used by doctors and clinicians to diagnose conditions. The DSM-IV was published in 1994, and in its definition of depression it included an exclusion for bereavement. Briefly, if a patient had suffered a major loss and presented the symptoms of depression shortly thereafter, they would not be classified as mentally ill. While on the surface this sounds very reasonable, it has some unusual implications for treating those who may be suffering. The DSM-5 was published in 2013, and one of the most controversial changes was the removal of the bereavement clause from the definition of depression.
An article appeared in Innovations in Clinical Neuroscience titled: "The Bereavement Exclusion and DSM-5: An Update and Commentary" which addresses the questions around this change. The concern presented by critics of the DSM-5 is whether by changing the definition of depression to not account for a patient's recent loss amounts to medicalizing grief.
One way to think about this question is to consider whether depression and grief are separate but similar experiences, linked causally, or completely different. The argument for removing the bereavement clause in the DSM-5 rests partly on the idea that suffering from the grief induced by loss should not disqualify a person from receiving treatment for depression. While a person is not necessarily suffering from a mood disorder if they are suffering from grief, we should not reject the idea that a person might suffer from both at the same time and reasonably seek treatment for their depression while grieving. Attempting to treat depression while suffering from grief is complex, since the symptoms appear similar, and we need to be clear that fixing one issue may not address all issues.
Given that grief and depression have many of the same symptoms, how do we separate them?
In Recovery meetings we focus on the notion of temper. You can think of the colloquial expression where we say one "loses their temper", as the prototypical example. Distinct from temper Abraham Low presents the notion of a genuine feeling in MHTWT from the chapter titled "Tantrums Have Much Force but Little Feeling" where he writes:
If a mother loses her child her sadness may have an irresistible quality.
In the language of Recovery, temper is distinct from genuine feeling. The sadness of the bereaved mother is a genuine feeling. That feeling is original, primary and pure. In contrast, temper is derived, secondary and adulterated. I shall try to explain these terms. Every feeling has thoughts attached to it. A sad person is bound to think that the world is flat and stale. In this instance, the feeling of sadness produces the thought of staleness. It is not so that the bereaved mother forms first the thought that the world is stale and, consequently, falls prey to sadness. The reverse is true: she is first sad and then thinks the world stale. The feeling of sadness is original, the thought of staleness is derived from the feeling of sadness. You can express the same relation between feeling and thought if you substitute "primary" for "original," and "secondary" for "derived." You will then understand that, in the instance of the mother, the feeling of sadness is primary, and the thought of staleness secondary. The terms "purity" and "adulteration" are easily explained. The mother feels sad, pure and simple. She is not angry, fearful, jealous or envious. She has no desire to dominate others, to be consoled by them. She is just sad, and her feeling is not contaminated by an admixture of other feelings. It is original, primary and pure, i.e., genuine. Contrast now this genuine feeling of sadness with Ada's temper tantrum. In Ada's own words, after the sister left, "before long I had myself worked up into a panic." The feeling did not descend on her; she "worked" on it, produced it and fanned it into a lusty fire by means of inflammatory thoughts. What precisely was the nature of her thoughts? Ada says it was the idea of being left alone, the idea of helplessness, the idea of perhaps needing help and not getting it. If that was true she could easily remedy the situation; visiting a friend or merely going for a walk, or to a show would have cured the loneliness. Instead, she "worked herself up." We know what that means. It means that Ada now gave herself up to all kind of sinister thoughts.
In Low's presentation, the genuine feeling of sadness and the anxiety that results from temper may feel very similar but they have distinct sources. The genuine feeling of sadness is "original" or "pure" in Low's terms, whereas the temperamental response is derived and has unrealistic thoughts attached to it.
The root idea of Cognitive Behavioural Therapies is that many of our difficult feelings arise because of faulty thoughts about ourselves, the world, and the future. In Recovery we focus on the experience of "working-ourselves-up" which is an acknowledgement that we fan the flame of our symptoms and make them seem worse than they actually are.
We should not make the mistake of dealing with genuine grief in the same fashion. While there may be scenarios with some cross over between genuine grief and temper, that doesn't mean the same techniques will work for both.
What is Grief?
The symptoms of grief are similar in many respects to the symptoms of depression.
Physical symptoms including: tightness in the throat or heaviness in the chest. An empty feeling in the stomach, and a loss of appetite.
Reduced concentration. A preoccupation with the emotions of loss and an inability to concentrate.
A Sense of Numbness. Grievers often report that the first reaction they experience after notification of a loss is a sense of numbness. This numbness can be physical, emotional or both.
Disrupted sleep patterns. Not being able to sleep or sleeping too much. Dreams of their lost loved one (or scenario), sometimes acknowledging the loss within the dream, sometimes the dreamer is reunited with a loved one and only realizes the loss (again) on waking.
Changed eating habits. Grievers talk about having no appetite or that they eat nonstop- or both.
Roller coaster of emotional energy. Grievers may experience a number of emotional highs and lows often leaving them feeling emotionally drained. May include feeling guilty or angry over things that happened or didn't happen in the relationship with the deceased (lost situation, etc).
The "Grief Recovery Method" is described in detail in a handbook published by the Grief Recovery Institute written by John James. This book presents a collection of steps to work through or complete a grieving process- much of the method focuses on talking through the details of a lost relationship with a partner. The Grief Recovery Institute offers group counseling and one-on-one counseling, and is one example of many similar organizations.
The Grief Recovery Handbook discusses many interesting ideas, among them it includes a broad definition for what experiences might result in grief. Grief is defined as:
Grief is the normal and natural reaction to significant emotional loss of any kind. Grief is the conflicting feelings caused by the end of, or change in, a familiar pattern of behavior. Grief is the feeling of reaching out for someone who has always been there, only to find when you need them again, they are no longer there.
This definition is rather expansive, which I think is good. Some individuals don't appreciate this broad definition. A woman wrote a review of this book where she complaining that she had suffered through both the divorce of her first husband and death of her second husband and remarked that there was no comparison between these experiences. She stated that she could still see, argue, laugh and share anecdotes from the past with the first husband, but that none of these basic things were possible with the deceased husband. She found the equivocation of divorce and death as similar grieving experiences offensive.
Suffering is by no means universal in intensity or detail and each loss experienced by any person will be unique and is not comparable. I think John James does acknowledge this and is making an effort to describe some of the common experiences and tools that can work and those that usually don't work, although I think its also understandable to be put off by any solution that is overly formulaic, or claims to be universal.
Flawed Methods for Dealing with Grief
In The Grief Recovery Handbook John James discusses common strategies that don't work, and I think reviewing this list is helpful. It is more difficult to define how we should deal with grief than how we should *not* address grief, since there are so many ineffective strategies. From the summary workbook:
Time heals. Time does not heal, action within time does. We know people who have waited 10, 20, 30 or even 40 years to feel better.
Grieve alone. Often this advice is subtly implied, “Give your mom her space” or “He just needs a few minutes alone in the other room.” As children, we learn that this means that sad feelings should be hidden or experienced alone.
Be strong. Usually the Griever is asked to be strong for others. “You have to be strong for your [wife]” or “Be strong for your children.”
Don’t feel bad. This is usually followed by an intellectually true statement but is not helpful at all to the Griever, “Don’t feel bad, his suffering is over.” or “Don’t feel bad, at least you knew her as long as you did.”
Replace the loss. This is common with pet loss or the end of a romantic relationship. “On Tuesday we’ll get you a new dog” or “There are plenty of fish in the sea. You just have to get out there and date again.” Most likely there has been no action taken to grieve over the loss of the pet or relationship, just an attempt at not feeling the emotions attached to the loss.
Keep busy. “If I just keep busy then I won’t have time to think about the loss.” This one is sad because some people spend their whole lives with this mentality and never get a chance to grieve and complete what was unfinished with the particular loss.
When struggling with difficult feelings it is also common for people to use strategies to control their feelings, although this is generally not considered to be a healthy response. A control strategy is anything you do that is designed to distract you from your suffering, or change how you feel. In moderation these activities can be fine, they become problematic only when they take over, and the trouble is that often they do.
The most obvious example of a control strategy is having a few drinks in the evening to calm down before going to bed. For some, drinking to hide from their feelings can have serious consequences if it turns into a daily habit. Eating is another common control strategy. For example; having a chocolate bar to distract yourself can be fine, however, overeating foods high in calories or sugar can lead to overweight or put one at risk for diabetes. Control strategies can turn into addictions and these can take many forms. In addition to consuming substances, shopping or collecting items are other examples. These behaviours can lead to vicious cycles where they cause as much pain has they cover up, especially if they result in debt, isolation, health problems, and interfere with normal life activities. In these situations their value as a distraction is lost, and they become problems in and of themselves.
What Can We Do About Grief?
There are many different answers to the question of what can we do about grief, and I can't provide any kind of general strategy in a single blog post, but systematically avoiding grief and refusing to express genuine feelings is not part of a functional solution. Learning to be at ease with the loss is. Of course if we were at ease with the loss, we wouldn't be in pain, and grief wouldn't be an issue for us, so how do we become at ease with the pain that results from grief? Maybe we don't? Maybe the best we can do is reduce the intensity and work through the experience so we can remember our past without being overwhelmed or crushed by the feelings connected to our loss.
The strategy presented by John James involves exploring loss and the associated feelings of grief through a collection of exercises which focus on the idea that processing grief involves acknowledging incomplete communication and expressing your feelings of loss to another person. In the case of death and also in the case of other losses where our future plans with the individual were cut short there are often things that we wish we said that we never could. Forgiveness is a concept that is often presented as part of dealing with the death of a person that we may have been in conflict with. John James says some very insightful things about forgiveness he writes:
Forgiveness is giving up the hope of a different or better yesterday.
Most people seem to convert the word forgive into the word condone. The definition in Merriam-Webster's Tenth Collegiate Dictionary illustrate the problem:
FORGIVE: "to cease to feel resentment against (an offender)."
CONDONE: "to treat as if trivial, harmless, or of no importance."
If we believe the two words to be synonymous, it would be impossible to forgive. The implication that we might trivialize a horrible event is clearly unacceptable. However, if we use Webster's definition of forgive, we are on the right track.
The insensitive, unconscious, and sometimes evil actions of other people have hurt us. Our continued resentment and inability to forgive hurts us, not them. Can your continued resentment harm him or her? Clearly not! Can it harm you? Unfortunately, yes. As with all recovery components, the objective of our actions is to set us free. We forgive in order to reacquire our own sense of well-being.
The notion here that forgiveness is about no longer resenting the actions of someone from our past, rather than condoning them is a helpful part of working through the grief associated with a lost relationship that may have been fraught or difficult. Exploring forgiveness may not apply if the lost relationship was relatively trouble free. Grieving is a process which must include many actions. While forgiveness is a component of The Grief Recovery Handbook presented by John James, it is just one part of a fairly complex process grounded in discussing your feelings with other people and exploring the history of your loss.
Grief counseling facilitates the process of resolution in the natural reactions to loss. It is appropriate for reaction to losses that have overwhelmed a person's coping ability. The Grief Counseling Resource Guide from the New York State Office of Mental Health provides a description of the grief counsellor's role:
The Companioning Model of Bereavement caregiving developed by Dr. Alan D. Wolfelt is one in which we as bereavement caregivers help people to integrate life’s losses by being present to them and observing them—companioning. He tells us that observance comes to us from ritual. It means not only “to watch out for,” but “to keep and honor, to bear witness.”
Utilizing this model of bereavement caregiving, the helper:
- Listens in a supportive manner to individuals’ concerns.
- Helps disaster survivors recognize that, in most cases, their emotional reactions are natural, normal, and to be expected.
- Assists survivors to reduce additional stress by organizing and prioritizing day-today and recovery-related tasks.
- Helps individuals to understand and recognize the wide range of reactions to trauma, such as numbness, frustration, confusion, anger, anxiety, sadness, and feelings of helplessness.
- Assists individuals to draw on their own strengths and develop healthy coping mechanisms that permit them to gradually resume their pre-disaster level of functioning.
- Sensitively and caringly helps individuals to grieve their losses in their own unique ways.
- Systematically draws upon an array of recovery resources for appropriate referrals.
There are common problematic approaches that people stumble into as part of dealing with grief, and while some of these may be obvious, it is remarkable how easy it is to pick up a bad habit while struggling with loss. The more complex challenge is to find a method of grieving that is healthy, and gives us a strategy to search for peace, or at least be less traumatized by our loss. While grief is generally not a focus of our discussions at Recovery meetings, as we don't view loss as a mental health problem to be fixed, but rather a natural genuine response to difficult situations, we make every effort to be aware of the genuine suffering of our members.
Recovery meetings provide helpful tools, and these tools are applicable to the struggles that many people must deal with, however the path to becoming a complete person may be long and involve many detours along the way. Personally I've found that when in genuinely difficult situations where I struggled with loss Recovery tools helped me to remain realistic in my approach. We can always take a difficult situation, like the death of a parent, and make it far worse than it needs to be by inserting squabbles about who is right and who is wrong when dealing with the details of a will, or managing our parents home after their death. Recovery tools and other Cognitive Behavioural Techniques cannot make bad feelings associated with grief go away, but they can help us to remain realistic when confronted with the most challenging situations, stay focused on dealing with life's most difficult losses and remain genuine in how we handle them.