Grief is not a mental illness, but rather a normal, healthy and pretty rational reaction to extreme loss. Under normal circumstances, grief or bereavement does not require formal treatment with a therapist. People can often heal on their own with some support from family and friends which could be in the form of a sympathetic ear, a hug, and the tincture of time. There is no one normal grieving course, though most people feel relief of intense sadness after 1 year. However, sometimes grief sometimes doesn’t heal on its own and it’s hard to know what’s normal and what isn’t. In this next article, I will discuss how to distinguish between normal grief and complicated grief and at what point treatment might be useful.
No two people go through mourning the same way. Despite Elizabeth Kubler Ross’s noble, and popular attempt to list stages of grieving, research suggests that there are no proven stages of mourning. We do know that people tend to do connecting and disconnecting behaviors. These are simple but important concepts. Connecting behaviors include gathering mementos of the person, thinking about them, going to the cemetery and talking to them, talking to other people who knew them, etc. Disconnecting is getting on with life, creating a life without the individual that is satisfying, doing things, volunteering, etc. Both are critical parts of bereavement but are not always necessary for everyone.
We are social animals and the majority of humans find their greatest joys and sorrows in relationships with other humans. Bereavement is complicated because it is not only the loss of the individual and their physical presence but their role in our life. Beyond that, there is also the loss of the sides of ourselves that only that person knew. The history that only they shared in and the roles we played with them. Thus, we not only lose the support and relationship, but also the opportunity to experience the parts of ourselves that only that person evoked.
Normal grief can include sadness, tearfulness, loss of appetite, fatigue, poor concentration, loss of interests in things previously enjoyed, erratic sleep patterns, anger, loneliness, anxiety, powerlessness and even mild suicidal thoughts. Bereaved people can show common stress reactions such as losing their keys, becoming forgetful and distracted or they may want to isolate themselves. It is also normal and common to feel the presence of the individual who has died or even hear or see the image of the deceased; this should not be confused with psychosis or depression.
Widows and widowers who lose their spouses while they are still young, aged 70 years and younger, tend to have the most trouble. Widows and widowers who describe their marriage as very fulfilling have a harder time than those for whom the marriage was just okay. People who blame themselves for the loss and are unable to forgive themselves, or who continue to rehearse over and over in their heads things they might have done differently, have great difficulty. People who lose loved ones to violence or suicide have a harder time.
The people who do better are the ones who forgive themselves if they ever blamed themselves for aspects of the relationship and those over 70 years old. People who quickly put the death behind them can recover quickly. There is a myth in our society that you have to work through loss, but some people can quickly move on, and that doesn’t mean anything bad. People who have said good-byes and made amends handle their grief more easily. Most of us fall somewhere in the middle between the extremes of these groupings.
In my own work with patients over the years, there are at least two major circumstances where treatment might be helpful. Sometimes grief doesn’t heal on its own and time doesn’t help. If the grieving person goes through the daily pangs of grief associated with deep guilt, lack of closure, and non-acceptance of the death for more than six months, the person might have complicated grief and can use therapy to process loss and hopefully learn to forgive themselves. Connecting with other people who are grieving can also be clarifying and helpful such as connecting them with local groups for the bereaved. Therapy can be lifesaving and curative in these situations because otherwise, the unresolved grief can put a person at risk for other medical problems and depression. In addition, I often recommend the book Seven Choices by Elizabeth Harper Neeld to patients, family, and friends who find mourning confusing and are looking for guidance. The book chronicles a map of the complete grieving process that Dr. Neeld developed after the loss of her young husband. Dr. Neeld’s message is to empower us by virtue of the choices we make--to determine the outcome of our grieving and at least see some kind of opening ahead.
The other circumstance that may necessitate treatment is when the loss of a loved one does trigger Major Depression. What distinguishes depression from grief is when the grieving person stays stuck in hopelessness, self-loathing, worthlessness, guilt, and feels like a burden. People who have a previous episode of Major Depression or a family history of Major Depression are particularly vulnerable. Depression makes everything worse and grief becomes even more difficult to get through. In situations like this, people can often benefit with some varying combination of therapy and medication. However, medication should not be a substitute for some form of therapy (individual, group, or bibliotherapy). Medication can be helpful but therapy is still important to help take away the pain of grief.
Finally, I believe it’s important for people to make meaning of their losses and find new reasons for living. Victor Frankl, an Austrian psychiatrist who was imprisoned in four different concentration camps during World War II, discovered, much to his surprise, that some young men, became quickly ill and died in the camps, while some old women lived. He was puzzled about this. He asked one old woman why she wanted to survive, and she said, “My grandchildren escaped to Switzerland over the mountains before the Nazis came, and I am going to see them.” Dr. Frankl discovered that the old woman had a reason for living, a why, a hope, a purpose. In a similar way, those who are unable to give up their grief are often those who can find no new why. The Chinese symbol for crisis is crisis and opportunity. Death is an ending and a beginning. Another way to look at this is to learn to seize the opportunity to go on by making choices that move us forward to create for ourselves a new future.