The Grief FAQ- Anniversaries

In the first article of this series we discussed the differences between adaptive and maladaptive grieving, remembering being one of several areas we covered. We are going to get into remembering a bit more today paying particular attention to anniversaries. I’m using the term anniversary to refer to a range of events – holidays, birthdays, the date of the actual loss – as each of these may present with its own unique set of challenges for individuals and family systems. Some of these challenges can include,

– The obligation the individual who is grieving may feel to the family to remain “active” in the festivities of the holiday.

– The anticipatory distress of an upcoming anniversary and how an individual is going to “be”.

– Feeling an obligation to comply with cultural, familial or individual expectations surrounding ritual or formal remembrances and being unsure about the capacity to “perform” appropriately.

– Fear of being or feeling alone.

– Fear of losing control and engaging in maladaptive behaviors.

Planning can be helpful in tolerating and working through the distress of anniversaries. Prior to developing strategies, it’s important to consider where you’re at in the grieving process. If safety issues exist and/or memories or triggers relating to the loss leave you vulnerable to relapse (addiction/mental health) then strategies could center on safety, distraction and structured, purposeful and time limited exposure to memories or events surrounding the loss. If you feel you are in a position to honor the loss willingly, safely and feel closer to a position of acceptance; strategies could be more assertive in honoring the loss and celebrating memory. photo_29849_20131130

Since I tend to work with folks who have complicated grief reaction or struggle with a co-existing condition in addition to a grief reaction; I’m going to focus more on conservative planning. Denial and avoidance get beat up pretty bad in the public discourse surrounding how folks should deal with problems and this can creep into people’s thinking about what they need to do in order to deal with the loss. I think it’s important to consider that denial and avoidance behaviors exist for many reasons; not all of them are bad. Sometimes, denial and avoidance can be protective and may work to increase resiliency while helping an individual maintain functioning. Like anything else, it comes down to the degree and length a person resides in these states or strategies that will determine whether they are ineffective.

I’m not saying folks should be encouraged in maintaining denial or avoidance strategies only to be aware of the purpose that they serve in helping individuals through the grieving process. With that in mind let’s go through some strategies that can help mitigate the impact of anniversaries in ways that nudge us closer to acceptance.

Many times the anniversary date isn’t the only thing we need to plan for; some individuals require support a week or so in advance. The fall and winter can be really difficult because of the seemingly back to back reminders that pop up. Parents who have lost a child, as an example, have to deal with back to school in September, Thanksgiving in November, Christmas in December and New Years in January. The point here is that the development of an anniversary plan should account for the anticipation of the event, the event itself and, perhaps, the time after the event.

Available Supports
Anniversary plans should include trusted and helpful loved ones who are willing to provide the individual with support by phone, by engaging in activities with the individual or as a resource an individual can go to during an event that is expected to be difficult. The more supports an individual has the better, as a larger pool can help prevent individuals who have agreed to take on this role from being “burned out”. To the extent possible, responsibilities should be delegated according to the strengths and resources each support has.

Scheduled Activities
Structure and activity can be key to safety as distraction can act to mitigate difficult emotions and thoughts.  Use of supports can be very helpful in developing structured activities.  Having a full schedule during the anniversary period allows supports to plan ahead which works to make their role easier. A schedule can also help to hold the individual who is grieving to their plan. Not all activities can be planned so creating a list of activities that can be done on the fly (short to long term) can help individuals who are grieving through difficult periods when informal supports are not available or not necessary.  If you’re having difficulty with creating a list, the DBT folks have developed a list that may be helpful.

Make Some Activities Meaningful but  Safe
Activities can also help folks honor the loss in safe and indirect ways that they are able to tolerate; I’ve written before about how contribution, ritual and structured remembrance can play a significant role in providing folks with a variety of opportunities along these lines.  Family members can play a significant role helping the system and individual members remain connected to each other while creating opportunities for adaptive grieving (Masses/Services in honor of the deceased, family Reunions during the anniversary period to specifically honor the member, etc.)

Strong anniversary plans can help individuals and families safely grieve a loss while  creating opportunities for stronger relationships within a family system. Just by virtue of their existence, plans can reduce the anticipatory distress of an anniversary because it answers the “what am I going to do?” question.

By the way, if you missed the first post of this series you can check it out in the related articles section below. Thanks for checking in.

The Grief FAQ – “Am I doing this right?”

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.

photo_1069_20060213-1 A common struggle many folks identify is trying to figure out how grieving is supposed “to go” and whether they are doing it “right”.  “Doing it right” usually has two meanings for the person struggling with a loss. The first has to do with reaction – many folks spend a good deal of time trying to figure out whether how they are feeling in relation to the loss is normal.  The second has to do with process – a desire for a blue print on how to go about grieving.

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.

Time and Attention

Chance The past or future can be hot spots for people who are in treatment as a result of a loss (death, career, marriage, identity) or trauma.  In the grief and loss groups I facilitate, I spend a few sessions on the subject because attention away from the present can be a barrier to adaptive grieving.

Living in the past, or rather, replaying it over and over again, typically leads to sadness, anger and regret.  Focusing exclusively on the future typically leads to anxiety and fear. The former has to do with guilt and inadequacy while the latter centers on safety and predictability. To be clear, there is a difference between reminiscing (past), planning (future) and ruminating on the two.

While we encourage remembering in our work with clients; not all remembering is good- it depends on how you go about it.  “Remembering”, to assign responsibility or “undo” the event in our thinking is generally harmful because it can create a series of movies that act as evidence to our “mistakes”.  While reasonable and focused planning is necessary, constantly being on guard against future losses or harm is the product of or can lead to hypervigilance; we prioritize safety in a way that disproportionately affects other parts of our lives.

Folks who struggle with loss and trauma sometimes play the “what if” game. Having behaved differently before or in response to the loss or trauma may or may not have produced a different result.  Even if the result were different it may not have been more desirable. Survivors of sexual trauma may struggle with having  “given up” during the trauma – feeling ashamed and inadequate about the fact that they did not fight long enough. In reality, not fighting after being overpowered may be a reasonable choice a survivor makes during the traumatic event as it represents a shift in strategy from trying to stop the act to surviving the act.

Other survivors may struggle with the position they feel they placed themselves in just before the trauma; feeling “stupid” or responsible for the act. Most acts of sexual trauma (90+%) are committed in environments familiar to the survivor by a person known to the survivor.   To have expected the event would have required more than hypervigilance; like having a sixth sense.  Survivors of trauma who hold on to this expectation in their understanding of the event may be more prone to hypervigilance or re-enactment – placing themselves in unsafe situations as way of gaining mastery over the original trauma.

It’s unreasonable to expect someone to just turn the thinking off in the early stages of treatment . The ability to turn it off is a desirable mid- long term goal; but in the short term objectives may have more to do with shifting attention away from the past and future or thinking about each in ways that do not consume time, impact functioning or trigger unsafe behaviors.

With regard to grief, one strategy involves creating time in your schedule to remember a loss while allowing yourself permission not to think about the loss until your appointment with it. The appointment can include  journaling, art, prayer, looking at photo albums with family members, a church service, a therapy session or support group – anything that is action oriented, time limited and most people would describe as healthy and reasonable. Anticipatory anxiety about the approach and the distress involved with tolerating the activity can be mitigated by engaging in activities such as attentive breathing or exercise before, during and after the activity.

With regard to physical or sexual trauma, “thinking” about it should probably be handled in a context that prioritizes safety with access to expertise or help readily available.  Support groups or therapy  can be the appointment that provides opportunities to work through the trauma. In our practice, work involving trauma occurs within a framework of a highly structured and guided process that seeks to mitigate the risk of unsafe emotional escalation.  It begins with increasing capacity to tolerate memories of the event by learning and reinforcing coping skills then, when a person feels ready, directly addressing the event through some form of exposure therapy.

The “appointment” with the loss or traumatic event allows survivors access to a credible holding ground – it gives them a receptacle they can use to contain the material when it’s not safe or convenient to think about.  Thinking about therapy or any other safe activity in this manner can help increase the credibility clients give to attentional coping skills like mindfulness or “stop’ techniques because we are speaking to their desire to address the events while giving them “permission” to get relief from the material.