Grief teaches all of us that life is vulnerable, but also that life has tremendous potential. You may grieve the absence of what could have been possible if you hadn’t suffered the trauma of your loss, but growth need not be absent from your journey through grief. Let this book guide you as you transform into the best “you” you can be, even if this looks very different than the person you would have liked to be, and even in the absence of your loved one.
Chapter 1
Identifying Your Grief
We are all different. All of our relationships are unique. All of our losses are also unique. Grief will find each of us at some point in our lives, perhaps many times. There is no shame in that. Our feelings are unique, and each of us has different ways of managing our feelings. Just as the relationship you had with your loved one was unique, so too is how you experience the loss of your loved one.
Everyone grieves, but no two people follow the same path in grief. What you are experiencing after your loss is not something anyone has ever experienced before. Every grief is unique. The language we use to talk about grief, such as “getting over it,” “getting through it,” or “moving on,” doesn’t feel accurate or appropriate for everyone. Those who find that grief is persistent may feel as though there is something terribly wrong with them—that they are broken, weak, and maybe even unfixable.
Grief unfolds over time. Often, it is not something you move on from, get over, or get past. It has nothing to do with strength or weakness. It slowly becomes part of who you are. Despite what others may have told you, for many people grief is something to figure out how to live with, sometimes for a very long time. Although some people do seem to have an almost innate ability to adapt to extraordinarily difficult circumstances, not all of us can easily deal with the suffering life deals us.
This book is meant to help you figure out how to be healthy on your journey through a grief that feels as though it doesn’t have an end. Your grief may feel relentless, a constant intrusion into your daily life. You may feel immobilized by the intense emotions that come up. When grief persists and doesn’t seem to be going anywhere, you need to figure out how to deal with it to try to regain some sense of empowerment in your life.
Understanding Grief and Prolonged Grief
You should know that many of us who practice psychotherapy feel that we don’t have an adequate vocabulary for or realistic understanding of what you’re going through, even though grief has always been part of the human experience. Current researchers are working hard to figure out how to better understand grief, and some of their latest work is highlighted in this book. We have some ideas of how to describe and map the journey. These ideas may fall short, but they are the best that we have to work with at this time, and they are constantly being revised to reflect what people actually experience. However, even though we have some fairly detailed maps of the process of grief, that is not the same as knowing how it feels or how to cope with those feelings. This book will help bridge that gap for you—the gap between being able to describe what we know about the emotional states that accompany grief and how to live with grief.
Prolonged Grief
An experience of grief that persists is called prolonged grief. We used to call it “complicated grief,” but I think this changed because people realized that grief often isn’t simple. Prolonged grief means emotional distress related to the loss of a loved one that persists for longer than six months. For many people, six months doesn’t feel prolonged at all. It may feel like just the beginning.
Why does it matter what your type of grief is called? The reason you need to understand how best to classify your grief and how you’re feeling and living is because that’s how information about how best to help you is organized. Once science has a particular term to accurately describe what people are experiencing, researchers can better identify how to help most people who are feeling that way. They can sort out the most relevant treatments and more confidently recommend which have a good chance of helping you.
Techniques or strategies that work well for one condition may not help a different one as much. For example, if I can fix a car, that doesn’t necessarily mean I’m good at fixing an airplane. Just as different types of vehicles may require different types of mechanics, different emotional states sometimes require different solutions.
Stages of Grief
You may have heard about the five stages of grief, a theory pioneered by Elisabeth Kübler-Ross (1969). It stated that people move through five stages in the grief process: denial, anger, bargaining, depression, and acceptance. Kübler-Ross didn’t conceive of these as distinct stages; rather, she felt you could move back and forth in between them. However, ultimately the goal was acceptance of the loss.
Although this is a popular theory, I haven’t found it to be very accurate for the people I see in therapy. In fact, one study found that it was accurate for some people, but that study only used people who were already coping pretty well and excluded people from participating if they were too distressed by their loss (Maciejewski et al. 2007). Other researchers noticed that the study found that the people who participated in the study tended to have a high degree of acceptance from the beginning, casting further doubt on the value of thinking of grief in these stages (Bonanno and Boerner 2007).
In my experience, the only stages that most of my patients consistently feel are “up” and “down.” Those are the only two stages that seem accurate for most people.
Different Diagnoses in Grief
In the mental health field, we organize information about different types of emotional states using a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). Over the years, this manual has been revised several times to reflect new research and cultural norms. As I write this book, most therapists are using the DSM-IV-TR, the revised fourth edition (American Psychiatric Association 2000).
The DSM is used primarily to establish categories that help us organize symptoms into clusters that we can connect to particular diagnoses. For instance, if you go to see a therapist, he or she will typically ask you a number of questions about how you’ve been feeling and if you’ve been able to do the things you need to get done. The purpose of these questions isn’t to shame you or make you feel inadequate; rather, it is to figure out which treatments will work best for you.
These questions can also provide a sense of validation by helping you see that you are not alone in what you’re feeling. For example, people who have panic attacks often feel a strong urge to get away from wherever they are. Many people assume that they are alone in having this sensation until someone who is trained in mental health asks them if they ever felt that way. All of a sudden it can feel normal, and you can feel understood instead of ashamed of or frightened by your feelings.
As is the case for many people, grief may be only a part of what you’re going through. You may also be suffering from other conditions that affect your mental health and well-being. In the following sections, I’ll describe the diagnostic criteria for grief, and also some conditions that commonly afflict people who are experiencing grief. You may or may not have any of the other conditions, but reading through them will help you consider the possibility. Being informed about the nature of your pain is a necessary part of the healing process.
I encourage you to consider the diagnostic categories I’ll be sharing with you with the same attitude you’d have when seeing a doctor for the flu. You probably don’t feel guilty or ashamed about getting the flu. We all get it sometimes, often through no fault of our own. You may have been on a crowded airplane during flu season, or maybe you spent too much time around someone who had it. Sometimes there’s no obvious reason. You wake up one day feeling a bit under the weather, and it turns into the flu before you know what happened.
Although psychological conditions can’t be transmitted like the flu, I think it is helpful to think of receiving a particular diagnosis with the same attitude as if it were the flu. Feeling guilty, angry,
ashamed, or stressed about fitting into one or more of these diagnostic criteria definitely won’t help you feel better. However, knowing which patterns your feelings are organized around can certainly help you focus on which techniques can help with which symptoms. This is the crucial first step in the journey toward healing prolonged grief, even though you may feel like your journey with grief has already covered a thousand aimless miles.
Bereavement
The DSM pays some attention to grief itself in the diagnostic category called bereavement (American Psychiatric Association 2000). According to the diagnostic criteria for bereavement, the loss must have occurred within the past two months. If more than two months have passed, then major depression or another diagnosis may be more accurate. Bereavement, therefore, is diagnosed if the loss happened in the past two months and all of the following are true for you:
You feel guilty.
You think about death frequently.
You feel completely worthless.
You’re having a hard time moving around or feeling motivated.
There has been a noticeable and major decline in your ability to work, take care of yourself, or do simple tasks.
You see or hear things that are not there.
There are a few important considerations with this category. The first involves guilt. It’s considered normal to feel guilty about things you did or didn’t do when your loved one died, so the diagnostic criteria doesn’t refer to this kind of guilt. Second, it’s also considered normal to wish you had died instead of your loved one. This is like survivor’s guilt. It’s also considered normal to see or hear your loved one, so the last item in the list above refers to seeing or hearing things other than your loved one. One of the most common experiences I hear about is people feeling their loved one sitting or lying on the bed next to them. This is a fairly normal experience and isn’t included in the diagnostic criteria.
Now let’s look at the time frame. Two months hardly seems like a very long time to grieve an important relationship. For the hundreds of grieving people I’ve worked with, two months feels like the blink of an eye. Frequently, there’s still a lot of bureaucracy to get through two months after someone close to you dies. Changing names on bank accounts, dealing with insurance policies, legal issues, and burial plots—all of these things often take much longer than two months to sort out. This sort of failure to reflect real-life conditions is one of the shortcomings of rigid diagnostic criteria.
Prolonged Grief Disorder
We don’t normally think of grief as being prolonged until at least six months after the death of a loved one. The time between the two-month maximum for a diagnosis of bereavement and the six-month mark may be better explained by another mood disorder, such as depression or anxiety. The following criteria for prolonged grief disorder have been submitted for consideration in the next revision of the DSM (Prigerson et al. 2009).
According to several grief researchers and experts, you may have prolonged grief disorder if six months after the death or loss of a loved one you long for that person daily or to the extent that it is disabling. To fit the criteria, you must also experience at least five of the following symptoms daily or to a disabling degree:
You feel confused about your role in life or feel a diminished sense of yourself, as if a part of you has died.
You’re having a hard time accepting the loss.
You try to avoid reminders of the reality of the loss.
You don’t feel like you can trust other people since the loss.
You feel bitter or angry about the loss.
You can’t do the things you used to do, can’t make new friends, or are uninterested in things you used to enjoy.
You feel like you have fewer feelings or as if you’re numb.
You feel like life is unfulfilling, meaningless, or empty since the loss.
You feel stunned, dazed, or shocked by the loss.
These feelings get in the way of your daily functioning and are not better explained by a different diagnosis, such as major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder.
Regarding the last item in that list, these other conditions are fairly common in people suffering from prolonged grief, and all are described below.
Major Depressive Disorder
For many years, it has been recognized that the pain of grief often is tied to what we normally think of as depression. A lot of people think depression is just another way of saying that you’re feeling sad. However, feeling sad is only the tip of the iceberg in depression. This condition has a huge overlap with grief, and people with prolonged grief typically also experience depression. In order to be diagnosed with major depression, or major depressive disorder, you have to meet the following diagnostic criteria (American Psychiatric Association 2000).
You experience five or more of the following symptoms over a two-week period, including either the first or second symptom:
Your mood is depressed most of the day, most days, and this is noticeable to you or other people.
You’ve lost interest or pleasure in almost all activities and experience this nearly every day.
Your weight has changed by more than 5 percent (gain or loss), or your appetite has changed such that you’re eating much less or a lot more every day.
You sleep too much or too little or wake up frequently at night.
You feel restless or slowed down to the extent that other people notice this.
You feel tired or lack energy most days.
You feel worthless or guilty for things you have no control over most days.
You have difficulty focusing mentally, more than before.
You have recurring thoughts or feelings of not wanting to live.
For a diagnosis of major depression, these symptoms must cause significant distress or hold you back with friends, family, or work or in other important areas of your life. If these symptoms are due to the effects of a drug, medication, or another illness, major depression is not diagnosed. In addition, these symptoms can’t be part of what’s called a mixed episode, meaning a combination of mania and depression most of the day every day for a week. Finally, the symptoms must occur or continue two or more months after the loss of a loved one. If these symptoms occur within two months of a loss, bereavement may be a more accurate diagnosis.
In my clinical experience, major depression frequently accompanies prolonged grief. Mindfulness meditation and mindfulness-based techniques seem to be well suited to treating depression, especially in people who have had it before (Teasdale et al. 2000). I will explore these tools in depth throughout this book.
Post-Traumatic Stress Disorder
Depending on the circumstances of how your loved one died, you may wish to review the criteria for post-traumatic stress disorder (PTSD). You might think that PTSD applies only to combat experiences. I’ve observed that many grieving people whose loved ones died after prolonged or traumatic stays in a hospital fit the diagnostic criteria for PTSD. Particularly intense medical interventions, such as witnessing or experiencing a bone marrow or organ transplant or attempts at resuscitation can result in PTSD for surviving caregivers. Motor vehicle accidents or acts of violence that resulted in severe injury or the death of someone you know can also lead to a diagnosis of PTSD. A diagnosis of PTSD may make it much more likely that people experience prolonged grief.
According to the DSM (American Psychiatric Association 2000), you may have PTSD if you experienced, witnessed, or were faced with a situation where you or someone you were near faced actual or near death, injury, or a bodily threat and you reacted with intense fear, helplessness, or horror. While this event sets the stage for potential development of PTSD, the diagnostic criteria include several other categories of symptoms.
First, you must also reexperience this event in one of the following ways:
Images, thoughts, or perceptions of the event replay in your mind.
You have recurring dreams about the
event.
You act or feel as though the event is happening again.
You experience intense distress when something reminds you of the event.
You experience a physical reaction when you think about the event or when something you see reminds you of it.
Second, you try to avoid having anything to do with the event by doing three or more of the following things:
You try to avoid thoughts, feelings, or conversations associated with the event.
You try to avoid people, places, or things that make you remember the event.
You can’t remember something important about the event.
You’ve lost interest in or don’t participate in important activities.
You feel estranged from or unconnected to others.
You can’t feel a normal range of emotions, like you did before.
You feel like you won’t live long or be able to meet your life goals.
Finally, you’re also more keyed up or on alert more than before, as evidenced by two or more of the following symptoms:
You can’t sleep.
You experience more irritability and anger than you used to.
You can’t concentrate.
You’re always hypervigilant.
You startle easily.
To be diagnosed with PTSD, this cluster of symptoms must persist for more than a month and get in the way of your normal life and activities. To date, there is no gold standard for PTSD treatment. A variety of techniques are used to work with people who have experienced trauma and all seem promising, but none are universally accepted as preferable. The evidence base for using mindfulness meditation and mindfulness-based techniques with PTSD is growing, and the research looks very encouraging (Kearney et al. 2012).
Generalized Anxiety Disorder
Mindfulness for Prolonged Grief Page 2