I ran into neighbors the other day as they were about to attend a funeral of a close friend. One of them, a fellow physician, said, "I hate this death thing." I had to agree.
Except for those who die too young, grief is an unavoidable and normal experience. But it can take intense and disturbing forms that surprise a bereaved person, including forms that in other circumstances would be called a psychiatric disorder. In some cases, psychiatric treatment may help.
Up to 50% of widows and widowers have symptoms typical of major depression in the first few months. They may also have hallucinatory experiences — imagining that the dead are still alive, feeling their presence, hearing them call out. These symptoms, upsetting as they may be, are usually normal responses to the loss. They call for comforting and sometimes explanation, but not treatment. But if the symptoms linger and become increasingly debilitating, the condition turns into what is now being called unresolved, protracted, traumatic, or complicated grief. It has features of both depression and post-traumatic stress disorder (PTSD).
Risk factors for complicated grief
The risk of developing complicated grief depends on both the immediate circumstances of the death and the background against which it occurs. PTSD is more likely to follow a traumatic experience if the person who undergoes it regards his reactions as a sign of weakness, believes that others are not responding helpfully or sympathetically, fears that he will lose his sanity if he thinks too much about the experience, or ruminates about how he or someone else could have prevented it from happening. These are also risk factors for complicated grief, and the disorder is more likely to occur after a death that is traumatic — premature, sudden, violent, or unexpected.
But even normal bereavement can produce complicated grief. Whether that happens depends on how a person copes, not just with trauma, but with loss. A person with a history of depression, anxiety disorders, or a personality disorder is more likely to suffer complicated grief after bereavement, as well as PTSD after a traumatic experience.
Treatment
Treatment of complicated grief often relies on the idea that grieving is an experience to be worked through. Some people are thought to be stuck and unable to free themselves because of problems arising from emotional instability, previous losses, or difficulties in their relationship with the person who has died. Different kinds of therapists may tackle complicated grief with different methods:
- A psychodynamic therapist may try to help by identifying past losses that were never fully mourned and discussing their connections with the present loss. The therapist may also gently point out feelings about the deceased that the survivor may be defending against, helping the mourner come to terms with them.
- Cognitive therapists help people reinterpret the loss, partly by re-experiencing it in imagination.
- Interpersonal therapists help patients develop new social relationships and activities.
- A promising treatment called traumatic grief therapy uses cognitive behavioral methods for traumatic symptoms and stress relief, along with interpersonal techniques to encourage re-engagement with the world. Patients tell the story of the death repeatedly and listen to tapes of the recitation. They learn to confront thoughts and situations they may have been avoiding. They evoke memories of the deceased, especially happy memories, and hold imaginary conversations with him or her under a therapist's guidance, exploring regrets or resentment. They are encouraged to think about how to enjoy other activities rather than dwell on the loss.
No matter how or when, confronting the death of a loved one or close friend is, indeed, an inevitably painful part of life. No one likes this "death thing," which may paradoxically make it harder to get treatment that might provide relief. But if the pain takes a form that is paralyzing, I think it's a great idea to get extra help.
Have you had an experience of grief that went beyond what was manageable? Have you known anyone else in that situation? What were the obstacles to getting help? Or, what kind of help was most effective?
Understanding Depression
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Dr. Michael Miller has been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.
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Comments: 7
Sometimes they aren't hallucinating, I am into paranormal investigating- I have listened to countless EVP's - some responding to our questions. I have many photos with abnormalities in them....so in some cases, the loved one really might still be lingering around. Just another theory.
It is very common for people to feel angry after a loss. Very few relationships in life are uncomplicated. And anger is often part of close relationships, either because you are angry at the person who died, or because you're angry about the death. That makes it more difficult, in a way, to mourn. A good therapist can help you come to terms with the anger, and help you accept whatever complicated feelings come up.
Death in modern society has moved out of the family and into institutions, like hospitals or nursing homes. We are luckier than our ancestors because we have a much longer life expectancy. For illnesses that seemed untreatable when I was a child, life extending treatments are now available. I am therefore grateful to live in a time where good treatments are available and there is so much promise for even better treatments in the future.
But no matter how good treatment gets, death is inevitable and we all must face it.
Perhaps the one advantage people from prior generations had is that they saw death more and so had a greater familiarity with it. But my bias is not to romanticize those times. I'm sure grief has been quite painful in every era.
And yes, as Bert points out, often the hardest part for a grieving person comes after the first few weeks, when the formal ceremonies end. You give good advice — people in mourning need us for a long time after they lose a loved one.