- Understanding Grief
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Key points
- We see the tragedy our clients experience but cannot be flooded by it, or we wouldn’t be able to do our work.
- Meaning-making is a stage of grief that helps us integrate grief into life purposefully.
- Grief and depression may coincide but may be mutually exclusive; clinicians need to be sensitive to this.
Dr. Kübler-Ross, in her 1969 book, On Death and Dying, offered for the first time a framework for understanding grief, based on her research with terminal patients. Her model is not linear, and individuals may cycle through or revisit as needed
Kübler-Ross, a psychiatrist, describes denial, the first stage of grief, as a defense mechanism where our minds numb us to the immediacy of the loss. The next stage is anger, where the denial gives way to feelings of anger at the pain experienced from the loss or at external circumstances brought about by the loss. The third stage is bargaining, where we might try to negotiate the pain of the loss away by perhaps imagining different outcomes. Then we may experience feelings of depression characterized by the weight of what has occurred, expressed with sadness, isolation, or hopelessness. The final stage is acceptance, which might be best described as learning to live with the permanent pain and changes it brings to how life was.
Dr. David Kessler, a grief expert, has added another stage he describes as meaning,which allows a person to move forward, honor the loss in some way, and find a way to integrate the experience into a purposeful life
The DSM-5-TR pathologizes grief by calling it Prolonged Grief Disorder, and it adheres to a caveat of more days than not and over a month of intense yearning and preoccupation with thoughts or memories of the deceased person. A person must exhibit marked disbelief about death and avoidance of reminders of the deceased, and experience three symptoms from a laundry list that includes identity disturbance, reminders of loss, intense emotional pain, and more
This historical development is presented as a long-term process culminating in the inclusion of valid, clinically relevant prolonged grief disorder criteria in diagnostic handbooks. Yet there are challenges to this dominant narrative. As stated in a 2023 article (Eisma, 2023): “[T]he developmental history of prolonged grief disorder has been nonlinear and…this yields questions on generalizability and problems with measurement.” Grief and depression may certainly coincide, but they also may be mutually exclusive, and we as clinicians need to be sensitive to this.
Grief may also tell us we lost something important that may not be a person, but something else. Grief informs us of the value of something we have received. As I work with individuals who suffer from severe and persistent mental illness, I witness loss often. The person who hears voices marching through their head or believes they are being followed may grieve the absence of quiet and safety
Individuals who have been sexually or physically abused as children, those who lack loving and committed parents, homeless or hungry persons, or those who suffer from a pervasive life-changing mental illness grieve for those losses they have experienced, yet they don’t have the luxury to grieve because their lives are filled with instincts to survive
Illegal immigrants who live in fear of being deported at any moment cannot grieve their loss of hope about the lives they believed they would have had. It is ever-present grief about the immediacy of impending loss
I believe grief also takes us to a darker side of life we would rather not see. For those of us in mental health care, we see the tragedy our clients have experienced routinely, but we cannot be flooded with grieving, or we would be unable to do our work
Grief is a multidimensional experience that all of us will experience or have experienced in our lives. Perhaps it is the experience that has allowed us to go deeper inside ourselves to serve others. It is a common occurrence that we don’t speak enough about
I had a client I worked with for 20 years. She suffered not only severe and persistent mental illness but also borderline personality disorder. I met her in a clinic I was working in and was able to accommodate her in my private practice following my leaving the clinic
- Understanding Grief
- Take our Depression Test
- Find a therapist to heal from grief
She was a unique human being, but she had spent her life cutting her arms and pushing people away and hearing voices when no one was around. She was a pacifist and often went to marches to proclaim nonviolence
Over time, she abandoned her cutting behaviors in favor of developing relationships with others and expressing her deep feelings openly and with less fear and intensity. Her favorite method of being pampered was being psychiatrically hospitalized at a few chosen sites. Not only a particular hospital but a designated floor
When she was 51 years old, she was diagnosed with lung cancer. When oxygen became necessary, she could not visit my office, so I decided to have our sessions at her house
She became less able to care for herself and did not have any care providers, so she moved into a nursing home where she would be able to be transported to a hospital for her chemotherapy and radiation. The rides became very painful. She needed to be wheeled into an ambulance and take the bumpy ride to treatment. After a few treatments, she elected to discontinue both. She was going to die
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I once again decided that I would conduct therapy where she was living, in a private room, which she was wheeled into. This continued for months as she weakened, but she was still committed to working in therapy
This process forced me to consider the purpose of psychotherapy and the surroundings in which it occurs
She had requested my attendance at her bedside as death approached. I remained one day when she passed. Having received verbal permission to speak at her funeral, I gave the eulogy
My grief was not like it was for other deaths I had previously experienced. It was a deep-felt awareness of my connection to someone with whom I had passed through different stages of her life. I felt a gratitude, a joy, a sadness, and privilege to have known someone who changed my life and helped me become a deeper, more compassionate, more skilled practitioner. It was David Kessler’s stage of meaning
Fifteen years later, her calligraphy hangs in my home, and her dream catcher hangs in a window
Eisma, Maarten C. Aust N Z J Psychiatry. 2023 Feb 6;57(7):944–951
