Bernards Voices

Today’s letters to the editor in the New York Times on grief are informative.

Gordon Livingston writes:

To set two weeks as the time allocated to mourning the loss of a loved one before receiving a diagnosis of major depression — as proposed in the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — is ridiculous.

This is illustrative of one type of reaction. But it misses the point. Sadness isn’t depression. Loneliness isn’t depression. Mourning and major depression do not mean the same thing. Conflating the 2, by either side of this argument, is a disservice. Depression, that persists two weeks, diagnosed by a psychiatrist or psychologist, a trained professional, should be treated.

In the original op-ed piece, “Good Grief,” Allen Francis (Francis was chairman of the DSM-IV taskforce.) writes:

Grievers with severe and potentially dangerous symptoms–for example, delusional guilt over things done to or not done for the deceased, suicidal desires to join the lost loved one, morbid preoccupation with worthlessness, restless agitation, drastic weight loss or a complete inability to function. But people with such symptoms are rare, and their condition can be diagnosed using the criteria for major depression provided in the current manual, the D.S.M. IV.

I have sympathy with that point of view–just use major depression as the diagnosis–but I don’t support the earlier parts of his op-ed designed to inflame the debate.

Below is also a common argument for inclusion in the DSM–health insurance, then, has a mechanism to help offset the expense. This is valuable. Elena Lister writes:

It is precisely because of my respect for the necessity of the grieving process that I can support its recognition in the diagnostic manual. The only way that many patients can afford therapy is with insurance — which covers only certain mental health diagnoses, and even then in very limited ways.

This debate is being waged by well-meaning people. And if words like “ridiculous” were left out … it might serve an additional useful purpose of raising awareness.

I’ve posted on the DSM5 debate before. You can access these posts by cliking on DSM5 in the right sidebar under Tags. I really like the (yes it lasts 1 hour) This American Life podcast on the DSM referenced towards the end of this post.

Dr. Gail Giacalone spoke this morning on grief.  I’ve been seeing Gail for 3 1/2 years, but I learn new things each time I see her. I’ll start with the new for me.

Loss doesn’t just mean death. Divorce, loosing a job, a pet, one’s youth … all involve grief. A person will grieve the same way.

Parents should talk about death with their children.  Starting as early as ten weeks old.  There should be small things, in your everyday life, that can prompt the conversation.  A plant dies in the house.  A gold fish dies.  A pet dies.  Or more significantly … a parent gets sick.  Discuss this with your children.  Talk about life having a beginning and an end.

Pets grieve, too, for their lost owner.

Tears of grief have salt. Tears of joy/laughter have no salt. Listen to your body. Your body won’t lie.

Complicated grief:

• high, ambivalent feelings toward the deceased
• poor resolution of previous loss
• deep-rooted, unresolved business with deceased

Other topics which I’m very experienced with:

• everyone grieves their own way, in their own time (the DSM only allows the bereavement diagnostic code for 3 months)
• healthy ways of moving your grief through: walking, cleaning your closet, swimming, conversation, reading
• 7 stages of grief — but don’t consider this a sequence — shock, volatile emotions, disorientation, guilt, loneliness, relief, re-establishment
• grief, not dealt with, will surface somehow.  physical problems like rheumatoid arthritis, GI track inflammations, cancer … can happen.  Losses not properly grieved for may wait dormant, each new loss piled on top of another … only to be toppled over when kicked by a loss later in life

In the February 1, 2010, The New Yorker, Meghan O’Rourke asks if there is a better way to be bereaved.   O’Rourke frames her piece around Elisabeth Kubler-Ross, the Swiss psychiatrist, who in 1964 started lecturing on death.   “Death, [Kubler-Ross] felt, had been exiled from medicine.”

Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance.

I’ve been in grief therapy for more than three years. I’m not as hung up (or put off) by the grief stages as others. I understand them as useful metaphors. In my therapy, Dr. Gail Giacalone, talked about 7 stages–the first three of which are shock, confused thinking, emotional tumult. I’m paraphrasing. I was taught that these three phases can occur on top of each other–which my experience confirms.   I don’t recall what the other 4 stages are any more.

O’Rourke writes:

Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve. It pervades pop culture—the opening episodes of this season’s “Grey’s Anatomy” were structured around the five stages—and it shapes our interactions with the bereaved.

Scientists have found that grief, like fear, is a stress reaction, attended by deep physiological changes.   Levels of stress hormones like cortisol increase.   Sleep patterns are disrupted.   The immune system is weakened.  Mourners may experience loss of appetite, palpitations, even hallucinations.  They sometimes imagine that the deceased has appeared to them, in the form of a bird, say, or a cat.  It is not unusual for a mourner to talk out loud—to cry out—to a lost one, in an elevator, or while walking the dog.

Additional studies suggest that grief comes in waves, welling up and dominating your emotional life, then subsiding, only to recur.  As George A. Bonanno, a clinical psychologist at Columbia University, writes in “The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss” (Basic; $25.95), “When we look more closely at the emotional experiences of bereaved people over time, the level of fluctuation is nothing short of spectacular.”  This oscillation, he theorizes, offers relief from the stress grief creates.  “Sorrow . . . turns out to be
not a state but a process,” C. S. Lewis wrote in 1961. “It needs not a map but a history.”

This “grief comes in waves” idea was very useful to me.   When I saw the six, nine foot swells cresting, it was useful for me to know that it would pass, recede.   When you body surf you lose if you fight the water.  You can’t possibly be strong enough to stop it.   It was equally useful for me to know the wave would come again.

O’Rourke continues:

To say that grief recurs is not to say that it necessarily cripples.

Even Bonanno, trying to offer a neutral clinical description of grief, betrays how deeply he has bought into the muscle-through-it idea when he describes a patient who let sad feelings “bubble up” only when she could “afford to.” Many mourners experience grief as a kind of isolation—one that is exacerbated by the fact that one’s peers, neighbors, and co-workers may not really want to know how you are. We’ve adopted a sort of “ask, don’t tell” policy. The question “How are you?” is an expression of concern, but mourners quickly figure out that it shouldn’t be mistaken for
an actual inquiry.

Another thing Dr. Giacalone made sure I understood: “Bill, no one walks in your shoes,” “everyone grieves in their own way, in their own time.”  Some people would be good at showing sympathy, others would be awful.  Some wouldn’t be able to engage at all.   In my case, some close friends took more than a year to get past the cliche.  There are others, even today, who haven’t spoken to me.   I know the silent ones were hurting, may still hurt.

Meanwhile, the American Psychiatric Association is considering adding “complicated grief” to the fifth edition of its DSM (the Diagnostic and Statistical Manual of Mental Disorders). Certainly, some mourners need more than the loving support of friends and family. But making a disease of grief may be another sign of a huge, and potentially pernicious, shift that took place in the West over the past century—what we might call the privatization of grief.

This is a topic I would love to discuss with O’Rourke.  I want to make sure we know what is the forest and what are the trees.  Grief therapy is useful.  If having a code for it in the DSM helps medical insurance cover it, that is good.   That is not the same thing as making it a disease.  Well-baby visits are covered by insurance.  Getting your teeth cleaned every six months is covered.   There should be mechanisms in place to encourage preventative care.

The other point O’Rourke is making in the quote above, and probably the one more important to her, is the “privatization of grief.”   Here I agree.  Community, friends, family are very important.   Even as the bereaved is wanting isolation, and is pushing people away, it is still a comfort to know there are people in the next room.   One of the more special things friends did for me was to bring me dinners for months afterwards.

Even a good death is seldom good for the survivors …. In [Emily Dickinson's] poem “I Measure Every Grief I Meet,” the speaker’s curiosity about other people’s grief is a way of conveying how heavy her own is:

I wonder if It weighs like Mine—
Or has an Easier size.

I wonder if They bore it long—
Or did it just begin—
I could not tell the Date of Mine—
It feels so old a pain—

I wonder if it hurts to live—
And if They have to try—
And whether—could They choose between—
It would not be—to die.

Listen to O’Rourke talk about her piece with The New Yorker’s Blake Eskin:

Libby read Naomi Shihab Nye’s poem, Kindness, at Jack’s memorial service.   Here’s a link to Kindness from Garrison Kieller,s Writers Almanac on NPR. I’ve excerpted this:

Then it is only kindness that makes sense anymore,
only kindness that ties your shoes
and sends you out into the day to mail letters and purchase bread,
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you everywhere
like a shadow or a friend.

I have to say I don’t like Kieller’s voice reading the poem, so you can skip that.