The majority of group work I do nowadays involves grief and loss. Folks who attend these groups, are usually seeking answers to many questions they have struggled with for a long time prior to making a decision to deal with their loss in a group setting. Over the years, I’ve noticed that there are some questions and themes that come up consistently in groups and in the course of the next few months I’ll be writing about these one at a time.
When it comes to reaction most folks, at least in theory, buy into the “everyone grieves in their own way” way of thinking about it . I subscribe to that idea but it becomes somewhat problematic in the treatment of grief. “Everyone grieving in their own way” speaks to a person’s natural support system remaining flexible, compassionate and available during the grieving process. It also speak to systems being aware and accepting of the fact that people will express and deal with loss differently and hit acceptance at varying points. It doesn’t mean that problematic reactions to loss should not be acknowledged or addressed and that a person’s supports shouldn’t express concern, in an empathic way. In other words there is a difference between a normal and healthy grief reaction and one that is not – being honest about that isn’t a judgement on the person who is grieving it’s simply an acknowledgement that additional support may be needed in the latter situation to help a person cope.
This sort of “hands off” thinking has crept into the debate surrounding the removal of the exclusionary criteria involving grief in the diagnosis of depression. There is a school of thought that argues that the removal of the exclusion somehow monetizes or pathologizes grief. I have a hard time understanding that position given the research that demonstrates depression as the result of loss looks no different from depression. I can’t really say it any better than this –
The DSM-5 provides the clinician with some important guidelines that help distinguish ordinary grief — which is usually healthy and adaptive — from major depression. For example, the new manual notes that bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they remember the deceased. Their very understandable anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually the case in major depression.
The normally grieving person typically maintains the hope that things will get better. In contrast, the clinically depressed person’s mood is almost uniformly one of gloom, despair, and hopelessness — nearly all day, nearly every day. And, unlike the typical bereaved person, the individual with major depression is usually quite impaired in terms of daily functioning.
Furthermore, in ordinary grief, the person’s self-esteem usually remains intact. In major depression, feelings of worthlessness and self-loathing are very common. In ambiguous cases, a patient’s history of previous depressive bouts, or a strong family history of mood disorders, may help clinch the diagnosis.
Finally, the DSM-5 acknowledges that the diagnosis of major depression requires the exercise of sound clinical judgment, based on the individual’s history and “cultural norms” — thus recognizing that different cultures and religions express grief in different ways and to varying degrees. link
The reason that this is important is that it gives providers and clinicians the go ahead in helping those who are struggling with depression as a result of a loss and/or during a loss as aggressively as anyone else who struggles with the same set of symptoms.
The process of grieving is another concept that can sometimes be misunderstood. Most people are aware of the stages of grief . I don’t necessarily subscribe to the idea that grief is experienced in the same way by everyone – not everyone goes through these stages and the stages speak more to a way of “being” than “doing”. I could go on about how badly the stages are misunderstood and the potential damage this misunderstanding can create but that’s for another post. Process, as I’m using it here, speaks to factors one can be mindful of and actions one can take in maintaining a healthy and adaptive approach to grieving.
Linda Lehmann, Shane R. Jimerson and Ann Gaasch have put out some really great work in the field and although much of their stuff is written for children and teens; it can be easily tweaked to make sense for adults. I’m mentioning them because their Grief Key worksheet really helped me conceptualize a piece of the approach I use and forms the basis for the factors listed below.
One step in the process involves remaining factual. Loss can cause us to call many things into question – our capacity, ability to move on, our actions prior the loss, our level of responsibility, adequacy, the kind of relationship we had with the person we lost etc. Remaining factual means remaining in the evidence of how the loss occurred when coming to conclusions about the loss and it’s meaning. This can help mitigate the occurrence of thought distortions, the impact that they have in our understanding of what happened, beliefs about ourselves and others. Family members, thought records and journals represent supports and tools we can use to help keep us anchored in evidence when thinking about a loss.
For example, individuals who lost a loved one as a result of addiction may feel and/or believe they should have done more to prevent the loss. In reality, they probably took the same steps as anyone else in dealing with their loved one’s drug use and addiction is not something that is managed by anyone other than the person with the addiction.
Another step involves remembering. Remembering allows us to make sense of the loss, desensitizes us to the “movie” of the loss but needs to be more than just about the loss. Some people have a difficult time remembering the person they lost beyond the loss event. Sometimes the relationship they had with the person is defined and driven, in their thinking and memory, by the loss. The work here involves broadening the memory of your loved one to include times when they were healthy – memories that are separate and apart from the loss event.
A third step involves being aware of changes that occur in your landscape as a result of the loss. Are you isolating more? Drinking more? Avoiding places and events that have a connection to the loss? Being aware of changes can help us shift reactions so that we don’t end up cutting off necessary supports while, at the same time, engaging in maladaptive coping skills that can lead to bigger, longer term problems.
Another step involves disclosure which includes identifying safe supports you can use to talk about and discuss the loss. This is a significant step as it can help us with everything listed here so far. Disclosure allows others to challenge distorted thinking, provides opportunities for more balanced memory recall and can be another set of eyes that can give us a heads up if we’re not doing well.
If you are struggling with any of these areas, particularly if you are noticing behavior changes that are harmful and difficult to stop; seeking professional help is advisable. Therapy can offer a safe environment to discuss the loss while offering interventions that seek to increase safety and maintain functioning during the grieving process. Don’t be afraid to explore pharmacological options with your GP or psychiatrist either; medications can provide relief in ways that can make adaptive grieving more realistic.