The Grief FAQ- Avoidance

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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.

Time and Attention

Chance Agrella-freerangestock.com 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.

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.