Monday, April 30, 2012

Can Grief be Brief? By: Dr. Ursula Weide

When I received the phone call that my 47-year old husband had died of a heart attack, I was pushed into a dimension of existence I had been unaware of so far. I was unable to eat or sleep for three days and nights, running on something unknown inside of me. Once fitful sleep returned for a few hours each night, I fought waking up in the morning, knowing that something dreadful was going to overwhelm me once I would become fully conscious. During my waking hours, I felt locked into a concrete cell of pain which I was unable to escape. Only death would provide relief, as I knew.

Talking with friends and family, I was amnesic – forgetting in the middle of a sentence what I had intended to say, and never sure whether I was not repeating an earlier part of the conversation which I no longer remembered. I would get into my car to drive to a specific destination and, half an hour later, found myself in a completely different location without any recollection of how I had gotten there. Often, I was standing next to myself, watching me, the robot, wondering how it managed to function.

At times, I had to force myself to even move in slow motion, and the uttering of every sentence required a superhuman effort. The world around me seemed unreal, and I had angry outbursts at what I would have considered insignificant before. Never given to colds, I suffered through an endless series of sore throats and laryngitis. Gastritis seemed to be my chronic companion, causing frequent stomach pains. I had no appetite and lost weight but managed to eat at least some of my favorite foods to keep my body functioning. Eventually, I developed excruciating back pain, tentatively diagnosed but never confirmed as a herniated disc.

Today I know that I was experiencing a combination of the typical symptoms of post-traumatic stress syndrome and major depression, as described in the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, the DSM-IV, the basis for all mental health care. Since our country has lived through numerous tragedies over the past several years such as the Oklahoma City bombing, September 11, the wars in Afghanistan and Iraq, and the Katrina hurricane, we now have a much greater awareness of trauma and the acute mental health needs of survivors.

What continues to go unrecognized, however, is that the survivors of any traumatic death often exhibit identical symptoms, also benefiting from specialized mental health interventions to assist with working through the trauma, to prevent longer-term emotional and physical after-effects, and to build a "new" life.

What is traumatic bereavement? It is the loss of a spouse or partner, child, sibling, parent or other loved one which is sudden, untimely or violent through an accident, suicide or homicide. It is also the traumatic experience of watching a loved one suffer and die of a terminal illness, observing the person change from their prior self to a body or mind withering away, participating in the person’s terminal care, or observing treatment in the intensive care unit. It is any kind of death which strips away forever our denial that this could ever happen – at least not to us. A death which leaves us feeling vulnerable to the same kind of fate, now that we know that it is real.

Currently, bereavement is listed in the DSM-IV for information only. But the DSM-V, to be published in the near future, in all likelihood will have the new diagnosis of "complicated grief". Insurance will then cover specialized treatment by qualified licensed mental health professionals, society will finally become more attuned and sensitive to the needs of the bereaved, recognize the exceptional state survivors find themselves in, learn more about it, and accept complicated grief as a condition amenable to specialized interventions. The survivors, in turn, would be enabled to be more assertive about their condition, feel more comfortable to ask for care at an earlier stage, and have fewer reasons to be fearful of inappropriate, hurtful reactions by an unwitting environment.

The future DSM-V complicated grief diagnosis hopefully will also lead to the extinction of “grief counseling certification programs” which, for a steep registration fee, promise anyone (!) the acquisition in four days of all the skills required to help grievers “recover” from any loss, ranging in one breath from “death to the break-up of a romantic relationship.” Survivors will then have an incentive to seek out specialized mental health professionals to obtain appropriate information and care. And more mental health professionals will add the expertise needed to work successfully with the traumatized survivors.

Until the new edition will be published, we should make every effort now to understand that, when we, as a family member or friend, physician, mental health professional or member of the clergy, are facing someone who is grieving after a traumatic death, more than comforting phrases (and psychotropic medication such as anti-depressants...) is needed to treat a dimension of pain and trauma we are unable to gauge unless we have been there ourselves. Recent advances in neuro-science indicate both functional and structural changes in the brains of traumatized individuals, most of them temporary only. These changes are shared by many exposed to the traumatic death of others and/or threats to their own lives and safety. Traumatically bereaved individuals would be well-advised to seek assistance by a qualified mental health professional to receive helpful information, reassurance as to the course of complicated grief, and for an evaluation of present symptoms of trauma, depression (including thoughts of suicide), anxiety, and concurrent mental health conditions. Establishing a thorough history of prior and recent mental and physical health is also essential. Pre-existing or newly-developed physical conditions – elevated blood pressure, heart rate and cholesterol levels, cardiac, gastric or orthopedic symptoms, thyroid disorders, none of them unusual as a reaction to the extreme physiological and emotional stress of trauma - require the referral to a primary care physician or a specialist. (Research has shown that the incidence of illness among the bereaved is three times the population average.) A family history of childhood abuse or neglect, emotional or addictive disorders, and a history of prior adult trauma predispose survivors to more prolonged traumatic reactions – and need to be considered when choosing the proper treatment approach.

A range of treatments is available such as supportive counseling in combination with cognitive-behavioral therapy (focusing on thoughts as influencing feelings and actions) and psychodynamic therapy (understanding the origins of thoughts, emotions and behaviors). Relaxation techniques and retelling the extreme traumatic experience can also help to rob the memories of their vivid impact. At the same time, much needed coping skills will need to be developed. EMDR and structured exposure therapy are not recommended.

Symptoms of trauma may persist for a year or more, accompanied by depression and possibly anxiety, then followed by demoralization and exhaustion as complicated grief continues to recur in waves, at times seemingly out of the blue, but often triggered by the sight of an object, a sound, a smell, or the taste of a particular food, bringing forth repressed memories. Holidays, anniversaries, birthdays and special occasions can be especially difficult times for a survivor of traumatic death because the absence of the deceased is felt like a gaping wound. Also, as time goes by, symptoms of trauma yield to an increasing awareness of what the loss of our loved one means for the remainder of our lives. Hence, working through trauma and loss is a long-term process, there are no ninety-day miracles, no matter how much our environment wants us to “get on with it.”

Where am I today? I have turned my own experience of trauma into an instrument for assisting others, to convey the understanding that complicated grief is a natural reaction to an abnormal experience - please do not tell us that “Death is part of life!” - and that it can be survived. That we were forced into a dimension unimaginable to others and from which there is no return but which links us by a common bond. That we have to live with questions which have no answers but that eventually we can find meaning in our experience. And that eventually we learn to live better with our loss. But no – grief is not brief!

Dr. Weide has been a Licensed Psychologist and a National Certified Counselor in private practice in the Washington, D.C. area for twenty years. Dr. Weide is also certified as a Fellow of Thanatology (by the Association for Death Education and Counseling), specializing in complicated grief, bereavement and trauma therapy.

Ursula Weide, PhD, JD, NCC, FT Licensed Psychologist, National Certified Counselor Fellow of Thanatology 801 N. Pitt Street, Suite 113; Alexandria, VA 22314 Tel. 703-548-3866 4400 East-West Hwy., Suite 329; Bethesda, MD 20814 Tel. 240-229-1893 (Five minutes from Bethesda Metro)

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