Sometimes grief is accompanied by conditions that have anxiety at their core, particularly generalized anxiety disorder and panic disorder. The following criteria are used to diagnose generalized anxiety disorder (American Psychiatric Association 2000):
You experience intense anxiety and worry most days for at least six months about different things (friends, work, money, and so on).
You can’t control the anxiety or worry.
In addition, you must experience three or more of the following, with at least some of these symptoms occurring more days than not during the previous six months:
You feel restless, keyed up, or on edge.
You are easily exhausted.
You can’t concentrate, or your mind goes blank when you don’t want it to.
You feel cranky or irritable.
Your body is tight or tense.
You aren’t sleeping well.
The focus of your anxiety isn’t about having a panic attack, being embarrassed in public, being contaminated by germs, being away from home or close family members, or gaining weight (these are symptoms of other conditions, such as phobias, obsessive-compulsive disorder, or eating disorders). Additionally, the anxiety isn’t about having a lot of physical problems or a serious illness, or isn’t part of PTSD.
The anxiety, worry, or physical symptoms get in the way of work, friendships, or other important areas of your life.
The symptoms aren’t caused by something you take, such as medicine or recreational drugs, aren’t caused by an illness, and aren’t part of any other DSM diagnosis.
Panic Disorder
Another type of anxiety that many people suffer from is panic disorder, which is characterized by severe, recurring panic attacks. We all have times when we feel really stressed-out. This doesn’t necessarily mean having a panic attack. Mental health practitioners use the following DSM criteria to diagnose a panic attack (American Psychiatric Association 2000). A panic attack is a specific period of intense fear or discomfort in which four or more of the following things happen and peak within a ten-minute period:
Pounding or racing heart, or a feeling of the heart skipping beats
Sweating
Trembling or shaking
Feeling like you can’t breathe
Feeling like you’re choking
Pain or discomfort in the chest
Nausea or stomach pains
Feeling dizzy, like you’re going to faint, or unsteady and light-headed
Feeling like you’re outside yourself or like things don’t seem real
Fearing that you’re going crazy or losing control
Fearing that you’re going to die
Numbness or tingling sensations
Chills or hot flushes
When some people have panic attacks, they feel an urgent or almost uncontrollable desire to get away from where they are, or at least to know that an easy escape is possible. People who have frequent panic attacks may try to avoid any situation where they’re in a crowd, traveling, away from home alone, or even on bridges. When this is only due to concerns about having a panic attack, as opposed to something like obsessive-compulsive disorder or PTSD, it’s called agoraphobia.
A diagnosis of panic disorder with agoraphobia is made if you have the panic attack symptoms described above along with agoraphobia.
A diagnosis of panic disorder without agoraphobia is made if you have recurrent panic attacks and, as a result of at least one of the panic attacks, experienced one of the following symptoms for a month or more:
You were continuously concerned about having another panic attack.
You continuously ruminated about the implications of the panic attack, worrying about losing control, having a heart attack, and so on.
Your behavior changed significantly after the panic attack.
Additionally, for a diagnosis of panic disorder without agoraphobia to be made, the panic attacks can’t be a result of another psychological condition, such as social phobia, or because of taking a drug or another substance.
When You Should Get Help
Again, my intention in presenting these lists isn’t to make you feel worse, but to help you better identify what you’re going through. Having a better understanding of your symptoms will help you know what you need to work on. However, if you found that many of the symptoms of one or more of these conditions seemed to apply to you, please consider seeing a qualified mental health professional in addition to using this book.
You should also consider seeking the help of a trained mental health professional if you have limited support. For example, you may not have a lot of opportunity to talk about your feelings or organize your thoughts. A therapist can help you do that. I recommend that you work with someone who has experience in working with grief, trauma, and other end-of-life situations. The type of therapy with the most research supporting it for a wide variety of conditions is cognitive behavioral therapy, and that approach is what this book is based on. Cognitive behavioral therapy helps people understand how their thoughts, feelings, and behaviors are related. I believe mindfulness is a crucial part of cognitive behavioral therapy. If you decide to pursue therapy, make sure you choose a therapist who is trained in cognitive behavioral therapy.
You should definitely seek professional help if you’re thinking of hurting yourself or someone else. If this is a thought or impulse that seems to dominate your thoughts, I recommend that you get help immediately, before using any of the techniques and practices in this book.
When You Should Consider Medication
Current research suggests that many of the conditions described in this chapter will improve with psychiatric medications. The most commonly used antidepressants, called SSRIs (selective serotonin reuptake inhibitors), are often used for depression, PTSD, and several anxiety disorders.
For a long time, it’s been well-known that antidepressants and psychotherapy in combination are often superior to either approach on its own (Cuijpers et al. 2009). However, the benefits may be at least partially influenced by personal preference; in other words, the form of treatment you prefer may be most effective for you, if for no other reason than because you’re more likely to comply with the treatment (Kwan, Dimidjian, and Rizvi 2010). A comprehensive review of antidepressant research suggests that SSRIs are most helpful for severe depression (Shelton and Fawcett 2010). Severe depression is characterized by uncontrollable crying much of the time, being almost unable to move, and persistent rumination about suicide or death. SSRIs are also used for PTSD, often in combination with antianxiety medications and tranquilizers.
I’ve found that not everyone needs medication, but if you feel like you may benefit, you should have a conversation with your doctor about which medication may be most appropriate for you. And if your condition is severe enough to warrant medication, I recommend that you also engage in psychotherapy. This book can certainly help, but it might be only a part of what you need to do to help yourself.
If you elect to take medication, take it as prescribed. You should never suddenly stop taking SSRIs without the supervision of a physician. As an aside, psychiatrists and other MDs can prescribe psychiatric medications. In most of the country, psychologists, licensed social workers, and other mental health care professionals cannot prescribe.
Summary
Grief unfolds differently for each of us. The pain of grief may manifest in different ways and is sometimes expressed as an identifiable set of emotional conditions. You can better treat the pain of grief if you identify how it’s interfering in your life. If you meet the diagnostic criteria for other mental and emotional conditions, it’s important to get appropriate help. If this is the case, this book can be a part of your way forward, but it shouldn’t be used as a substitute for personalized, professional guidance.
Now that you have a better understanding of the different types of grief, various conditions that may coexist with grief, and how to get professional help for them, let’s explore how mindfulness can help you
in your journey with grief.
Chapter 2
Mindfulness Meditation
The strategies and techniques in this book are well researched. The approach of mindfulness meditation and other mindfulness-based techniques is several thousand years old. Now, modern scientific methods have been applied to researching mindfulness and have corroborated what millions of people have experienced over these past millennia: mindfulness has the power to heal many different kinds of suffering. Mindfulness may not prevent future losses from happening, but it can become a cornerstone of your well-being.
practice: Blue Sky Visualization
Imagine the sun in a clear, blue sky—radiant, life-giving, warm. Now clouds move in on a cold wind, covering the sky in a gray blanket. Above the clouds, the sun continues shining, unconditionally, indifferent to the presence of clouds.
Above the clouds, the sky is still blue.
Notice how you feel when you think of the dark clouds.
Now notice how you feel when you think of the light of the sun shining high above it all.
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For many thousands of years, spiritual teachers have taught that part of our minds is like the sun. The mind, however, is also like clouds. Both coexist with each other in the same space. Sometimes your awareness is absorbed by clouds, and you feel down, sad, and frustrated. Your mind doesn’t feel like the sun at all. In intense and prolonged grief, it can be difficult to believe that the sun is shining anywhere.
Over the years, many traditions around the world have come up with mental and physical exercises to help our minds feel more centered and identify with the sun rather than only with the clouds. Many of these exercises are what we have come to know as meditation. There are hundreds, if not thousands, of different types of meditation and meditative activities. With the right intention and practice, almost any healthy behavior or action can become a meditation.
Origins of Mindfulness
Since the 1970s, a few forms of meditation have been studied extensively by scientists. These days, mindfulness meditation seems to show particular promise, and the evidence base behind its uses is extensive. This particular form of meditation comes to us from the Buddha, who lived in India around 2,500 years ago. However, please don’t think you need to be Buddhist to practice this very helpful technique. Thousands of people have benefited from mindfulness meditation practice while observing other religious and spiritual traditions, or even without any religious or spiritual belief.
As you will learn, mindfulness has ancient ties to coping with grief and attempts to wrestle with the big question of why we suffer so much in our lives. You may have an impression of the Buddha as a humble, superspiritual monk who was born enlightened or was in some other way completely different from the type of person that you are. This may make you feel as if you have little in common with him, or with anyone who meditates. However, before the Buddha became a monk, he was a regular person, although very sheltered by a life of privilege. I like to think that if the Buddha were born today, he would be raised in an affluent suburb or elite gated community. He would probably have all the latest gadgets and might even make an appearance in the pages of tabloids, like a celebrity.
At the time of the historical Buddha’s birth, a holy man told his father that the boy was destined to become either a powerful ruler or spiritual master. His father wanted his son to become a powerful ruler, so he raised him in a sheltered home away from the ordinary and common sufferings of life. At the age of twenty-nine, the Buddha went on a series of covert outings, sneaking out of the house to see what he was being sheltered from. He was confronted by the realities of life: a sick person, an old person, a corpse, and finally a monk, who seemed to be the most centered.
The sights the Buddha saw, especially the sick and dying, overwhelmed him completely. Nothing in his background had prepared him for any of these harsh realities of human life. He realized that the body he took so much pleasure in was doomed to become wrinkled, maybe even deformed, before succumbing to illness and, ultimately, death. Furthermore, no one was exempt from this fate. All life was made mortal, and all humans were guaranteed a measure of grief on their journeys with other beings.
“Why?” the Buddha asked. Why are loss, aging, and death the universal experience? Why must we all lose those we love and care about? Why will they lose us? Why must we suffer like this? What can we do about it?
Overwhelmed with the sudden knowledge that his pleasurable existence was incredibly precarious, the Buddha resolved to leave behind his sheltered life and become a monk. Ultimately, the Buddha, like Job from the Bible, found that the answers to our suffering are neither easily available nor easily understood. He realized that answers would be available only if he could alter his preconceived notions of pleasure and pain, right and wrong, good and bad. He also found that a great deal of our suffering arises from the mind’s tendency to crave.
Understanding Your Grieving Mind
What do we all crave? We crave having control in any way we can over the uncontrollable twists and turns of the life journey. You may avoid the realities of your grief in an attempt to control the pain, but it probably just feels like your suffering gets worse each time you do this. Your mind is trying to control an uncontrollable world—a world that can often feel crushingly indifferent. To do this, your mind, like most people’s minds, makes certain key underlying assumptions that run contrary to the nature of our existence.
Craving Control and Permanence
Your mind, like everyone’s, craves permanence. Although the world, including all of your relationships, thoughts, and feelings, is in a state of constant change and transformation, your mind is trying to grasp things the way they have been or used to be. Your mind may be resisting changes to the familiarity of your life as it is now, even though your current situation may be very unpleasant. I’m sure you’ve experienced how hard it can be to try to do something that might make you feel better—your first thought is probably to not do it.
Your grief is a contradiction to the part of your mind that assumes that it’s in control or that life is predictable. Your mind is never in full control of reality—none of us are in control of reality. The mind’s attempt to control things is always doomed to fail, and grief is the most painful reminder of this hard truth.
The notion that we crave permanence might sound strange to you considering how much pain you must be in and your intention to try to ease that pain, in part by reading this book. Surely the desire for permanence doesn’t mean you want to always feel this way! I don’t believe it does.
What the desire for permanence does mean is that, even though you may be experiencing emotional pain, your mind finds comfort in the stability of the pain. It doesn’t matter all that much to your mind whether you’re feeling well or unwell. As with addiction, your mind doesn’t want to have to work at trying to figure out what comes next. Pain has become guaranteed, stable, and seemingly permanent. You may find that your mind struggles against participating in some of the exercises in this book. It is much more content to stay put or find something else to do—anything but change, even if that means continued suffering.
Luckily, this assumption of permanence is false. Everything is impermanent, and the circumstances of your grief are the unfortunate proof. But doesn’t this mean that the experience of your grief is also impermanent, or at the very least subject to change? There is hope, not just suffering, in the law of impermanence that your mind is struggling to come to terms with.
Intolerance of Empty Space
Part of the mind’s assumptions about permanence is the misconception that the future can be predicted, and that if everything in your life is stable, it should always stay that way. Part of what happens in grief, especially prolonged grief, is the stress of confronting a future that’s completely unexpected. Where you had plans, ideas, assumptions, and fantasies about what life would hold, now there’s a wall of empty space. Even if you saw the loss you suffered coming, the emotional realit
y probably wasn’t something you could imagine.
Now your mind is trying to control this unpredicted and uncertain future. To accomplish this, your mind is constantly telling and retelling a story of your past and trying to predict your future, even if it’s a future you can’t see. The future you assumed you’d have—a future with your loved one in it—has fallen away. Your mind can’t tolerate what feels like empty space where your hopes once were. It fills up this wall of empty space with chatter, rumination, and emotional pain.
In my clinical practice, I’ve found that for people who are experiencing depression or symptoms of post-traumatic stress in their grief, their mental chatter is dominated by recollections of the past, and it is very difficult for them to see or anticipate the future. If this is your situation, you may be replaying memories of your loved one, such as his or her final moments or days or certain conversations and experiences the two of you shared. This may come at the price of not being able to attend to your day-to-day activities and responsibilities. Rather than confront the uncertainty of the present, your mind finds comfort in the known memories of the past.
For people who suffer more on the anxiety continuum of grief, there is a great deal of mental chatter concerned with uncertainty about the future. If this is your situation, you might also be reminiscing and replaying memories, but you’re likely to spend a lot of time worrying about what will become of you. The dominant chatter in your mind might be How can I possibly go on? You may also be asking yourself, How will I meet my obligations and fulfill my responsibilities? Perhaps your loved one was the primary wage earner or did certain tasks for you, such as paying bills, preparing taxes, doing home repairs, planning social activities, cooking, or cleaning. Your mind may be fixated on your uncertainty about how to do these things, rather than focusing on taking steps to address these tasks. It may find other things to do, rather than working on what needs to be done. This is called avoidant coping. I’ll address this type of coping extensively throughout the book.
Mindfulness for Prolonged Grief Page 3