The Grief FAQ- Avoidance

driving through desert foothills

Back in November I wrote about how the field is shifting its thinking on complicated grief and some of the controversy surrounding the changes to grief as an exclusionary criterion for depression in the DSM. I still agree that the change was a step in the right direction and with that in mind, we’re going to look at how CBT can be useful in addressing avoidance behaviors within the context of complicated grief.

Individuals who struggle with complicated grief may engage in avoidance behaviors as a way of dealing with the distress caused by situations connected to the loss. Behaviors may include avoiding family gatherings, isolating during certain times of the year, avoiding certain family members, avoiding places that have a connection to the loss – the list can be long or short. Avoidance behaviors carry two big price tags, the first being that they make the distress related to the situation worse in the long run. To understand why this happens it might be useful to understand the culprit behind the behavior namely, faulty thinking.

Avoidance behaviors are generally driven by catastrophic hypotheses . By engaging in the avoidance behavior we get immediate relief from the distress because we avoid whatever catastrophic event we believe may happen if we were to confront or face the situation- this is the hook. In avoiding the situation we rob ourselves of the opportunity to test the hypothesis. Because negative thinking surrounds the situation we are seeking to avoid, our beliefs about the situation become more catastrophic as more time passes between the present and our last successful exposure to the situation. This increases the likelihood that we accept the hypothesis as fact without evidence.

Let’s say a hypothesis someone may have looks something like,

“If I attend a family function I will go crazy.”

Things get even more complicated if the last exposure to the situation actually did involve an unpleasant or uncomfortable experience; there may be historical evidence to support the belief that the hypothesis is correct. So…

“If I attend a family function I will go crazy.”

Feeds into or is based on…

“Last time I went to a family event I had a panic attack and embarrassed myself in front of everyone.”

By not accepting the invitation, the distress associated with the invitation probably drops down rather quickly. However, the long term impact may involve an increase in the distress they experience when thinking about or faced with the prospect of attending family functions in the future. As this spiral progresses, negative core beliefs the person has about themselves in relation to the loss may either get reinforced or introduced…

“I’m a bad [uncle, cousin, son] because I abandoned my family after the loss.”

Which brings us to the second price tag; sometimes avoidance behaviors cause us to push away from supports and activities that can actually help us through the grieving process. By burning both ends of the candle through avoidance, increasing the distress associated with triggers connected to the loss  AND isolating from supports that can help us cope with the loss, we are significantly reducing our overall capacity to adaptively grieve.

The most effective way to reduce the distress associated with triggers is to test the hypothesis but that may be a tall order and, in some situations, even counterproductive for someone who experiences really high levels of distress. One small step that may increase comfort and motivation to change the behaviors is to really examine history.

True, there may have been times when things did not go well when confronted with a situation connected to the loss but can you think of other times when things did not turn out so poorly?

What could you learn from the “bad exposures” that may be helpful to you in future exposures?

Were there other circumstances contributing to the negative exposure that no longer exist?

On the whole, in what ways are you better now than you were then?

What are the real costs and benefits to keeping things the way they are?

What are the real costs and benefits to changing?

Even if the worst happens how can confronting the trigger still be beneficial?

Would you judge someone you cared about as harshly as you are judging yourself?  What evidence do you have to support the belief that your family members are any different?

Hopefully, examining  the record of history and putting the “worst” in perspective will help reduce the amount of anticipatory distress to a point where you feel capable of taking a few more steps forward.

One tool that can help you cope with avoidance is a fear ladder which can break down the event you are avoiding into small pieces. Each piece will trigger different levels of distress; the trick is to begin confronting those aspects of the situation that bring up the least amount of distress. So a person who isolates may begin by emailing family members they have been avoiding. Typically friends and family members will be glad to hear from the person and the feedback received may test the hypothesis further or challenge the core belief. As you work on the lower rungs you may notice that the pieces on the higher rungs may also shift down.

Something else to keep in mind is that the anticipatory distress of a triggering situation usually drops off after a period of time during the exposure.  Sure, there may be a bit of a spike from anticipation to exposure but eventually the distress drops below the level prior to the exposure as a result of testing the hypothesis and/or surviving the situation despite it not going as well as you would have wanted.

Although we used family gatherings as an example throughout this post we can really apply this thinking and skill set to anything we avoid as a result of the loss – photo albums, restaurants, sections of town, etc.  Although exposure is effective, it is not advisable for every situation.  For example, I would never encourage an individual who struggles with a gambling addiction to hang out in a casino.  Also, it is very important to remember that exposure can make matters worse if not done correctly and so if there are concerns about safety or fears that exposure may lead to a worsening of symptoms, it is probably best to seek professional assistance.

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.

Timing
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.

Suffering

Suffering becomes beautiful when anyone bears great calamities with cheerfulness, not through insensibility but through greatness of mind. –Aristotle

When entering therapy some folks view treatment as something that can remove suffering whether the suffering is caused by a mood disorder, addiction or life event.  While treatment (therapy and/or medications) can certainly help mitigate suffering, the idea that suffering will disappear as a result of treatment often sets clients up to view coping skills and/or medications as ineffective. This becomes problematic when working with addictions as immediate gratification is usually a large component of the disease.

Regardless of your beliefs with regard to whether there is an inherent purpose to suffering, purpose can be derived from suffering.  It is not possible for us to avoid suffering but wholly possible for us to use and/or work through suffering in a way that advances a higher ideal that we hold in relation to ourselves and the environment we live in. Suffering is not in and of itself a noble endeavor but we can make it so.

Running away from suffering (denial) or creating a life that seeks to avoid the onset of suffering (detachment) will probably create more suffering. The former although useful in the short term has potentially harmful consequences in the long run. Eventually, we will have to implement extraordinary measures to perpetuate a state of denial (substance use, isolation).  The latter leads to distant relationships that fail to meet the emotional needs most of us posess in relation to love, accountability and friendship.

Suffering is an unavoidable part of life; therapy and medication are not going to take all of that away, right away.  Therapy can help one tolerate and work through suffering in ways that are more adaptive and protective.  It can help ease suffering or work to address unreasonable beliefs or ideas associated with it.

The quote may come across as Pollyanna but Aristotle was anything but.  Aristotle lost his father before he hit adolescence, his mother before he turned 18 and his wife 10 years into their marriage. Aristotle was not arguing that the acts or demonstration of emotions associated with suffering were bad or wrong.  To the contrary; he believed that these were not only appropriate but that their absence was evidence of a problem.  Suffering, he would argue, is not in and of itself “beautiful” but adds to the beauty of noble action and that noble actions create a greater potential for happiness.

Loss, Families and Acceptance

In thinking about loss we tend to focus on the impact it has on an individual but loss can present as a significant crisis in a family system. As with any crises; the event can act as a catalyst for positive or negative change. Many times a loss can create the emotional push and motivation that is needed in helping folks become more open to working old grievances and issues out; allowing bygones to be bygones because the loss can act as a reminder of the importance that family has in our lives.

However, if a family system tends to be near an extreme on the spectrum it can act as a catalyst for entrenchment in maladaptive patterns or soft abandonment (withdrawing from the family without formal declaration).

Enmeshed families tend to foster extremely close relationships among members and place a priority on the family system over the individual. While they appear to be supportive, they can be stifling and harmful to the individual members that exist within them. One feature of enmeshed families is the presence of rigid roles. These roles aren’t necessarily assigned titles (although sometimes they are-patriarch, matriarch etc) and they can come from different arenas (cultural, clinical, societal). Roles are the product of a person’s function within the system and are tied to certain spoken or unspoken expectations. Many times rituals and other processes within enmeshed families center or place a high value on certain roles.

Disengaged families value the individual over the system and tend to have an open door to outside influence. Relationships within these families appear disconnected and members may have stronger relationships with friends than those whom they live with. Roles are typically diffuse and seem to only exist in times of crisis. Roles aren’t necessarily assigned, rather they are taken and are usually short term- ending when the crisis is over or someone else takes ownership of the “problem”. Naturally, rituals tend not to be an important part of the disengaged family’s experience.

Loss presents as a challenge to both types of family systems; the more extreme the family is in relation to the spectrum the more difficult it can be to overcome these challenges.

For enmeshed families a loss presents as problematic because it creates a vacuum in the structure of the family. As a result of the system’s rigidity, ideas surrounding the value of a role may cause the family to give up on rituals. Many times this is because the role that lent value to the ritual(s) no longer exists. The challenge for enmeshed families resides in accepting that rituals and relationships have a value and importance that is independent of the person the system lost-that relationships within the family do not have to depend on the presence of one member. Enmeshed families can successfully negotiate a loss by challenging the emphasis they place on roles and acting beyond them to maintain relationships between the individuals that still remain.

Another challenge within enmeshed families is allowing individual members to grieve at their own pace and in their own way. Loss can generate very strong feelings and individual members may either resent or begin to feel disconnected from the family as a result of how the loss is handled and their perception of what is “permissible” for them to say, do or feel during the grieving process.

Enmeshed families who have difficulty in negotiating a loss may engage in “turf wars”;  there is a greater risk for perceived insult or injury if other members stray away from what the system holds as “right” or proper”. This can even come about as a result of a member not demonstrating the appropriate level of emotion during a ceremony. “Why aren’t you crying?” may be a question that is asked of a family member who does not appear to fall in line with how others are reacting. That difference can also be material for backroom discussions around the inappropriateness of a member’s behavior and can call their love of the family member who passed into question.

Enmeshed family members run the risk of breaking away from the larger system while maintaining most aspects that define the system as enmeshed within their own family or the part of the family they choose to maintain a relationship with.  The loss turns what was once whole and cohesive into something fractured or siloed.

Disengaged families typically find gaining support or empathy from their loved ones during the loss a difficult task due to the already existing feeling of disconnectedness members feel towards one another. Being able to process the loss with someone who can relate to their experience and completing many of the tasks associated with adaptive grieving may be difficult to come by. Part of the issue, as discussed, is the lack of ritual. Ritual plays an important role in helping people suffering a loss make sense of it, feel like they have permission to talk about it and giving folks the opportunity to honor the loss in a way that makes sense for them. Because of the lack of precedent, the rituals that disengaged families participate in to speak to the loss may feel inauthentic,  empty or meaningless to individual members. The fact that disengaged families need proximity in dealing with a loss may seem odd but a disengaged family still has proximate relationships, they just lack consistency and overall form.

The challenge for disengaged families resides in individual members making a conscious and determined effort to maintain an awareness of each other’s needs while making efforts to meet those needs. They can draw purpose from the loss by using it as a catalyst for taking healthy relationship risks with one another.

Disengaged families run the risk of glossing over the loss and willfully distancing themselves further from the system in order to avoid the discomfort of what the loss means to their family system and the relationships that exist within it. Members may become frustrated at an individual’s inability “to get over it” because the need and emotion that person is willing to communicate to the family challenges the structure in a manner that may feel too uncomfortable for the rest of the system to tolerate.

The potential barriers for growth and improvement after a loss, or any crisis for that matter, may be best understood through the concept of Radical Acceptance. Radical Acceptance is acknowledging that we cannot always change the cause of the crisis but that we can address the crisis in ways that are good for us and the system(s) we operate in. It is a choice between willfulness and willingness.

Willfulness means sticking to the old ways even if it doesn’t make sense or is harmful. Willfulness is the result of an emotional desire to avoid the discomfort of confronting the fact that things have changed.  Willingness means accepting that we don’t have full control over what happened but in order to adapt, things cannot remain the same. Willingness is the result of authentic analysis and the desire to engage in right action.

Acceptance does not have to be an emotional state; we don’t necessarily have to feel comfortable or authentic in making changes we know are for the best.  Just making these changes, behaving from a place of acceptance may be what we need to do to feel as if we are closer to acceptance.