Coming to Grief

After fourteen years of deliberation: consensus, conflict and continuing debate, the latest version of The Diagnostic and Statistical Manual of Mental Disorders (DSM) has finally been released into the world, and with it, a Pandora’s Box worth of controversy. Changes regarding grief-related diagnoses have been the source of some of the most heated disagreement, with extensive media attention given to the ongoing debate about what constitutes normal grief, how grief differs from depression and other issues relating to diagnosis and treatment.

Anyone who has experienced grief, personally or professionally, knows that people who are grieving are often extremely sad, weepy, confused, exhausted and otherwise distressed. These behavioral manifestations of deep emotional pain are present, to one degree or another, in most of the people we see in treatment. As difficult as grief can be to bear, for many of our clients the acute pain of loss will subside, and with a little help, the bereaved individual will gradually integrate the loss and be able to re-engage with life. But what about the people for whom this is not the case? What about the client whose behavior falls outside the norm of grief? How do we identify people whose grief has gone off course, and how do we help them?

Deliberation concerning how to address grief in the DSM 5 (APA, 2013) revolved around this group, the estimated 10 to 15 percent of grievers whose grief is problematic, in terms of duration, intensity, or both. Two issues generated substantive and heated debate, the first concerning the creation of a formal diagnosis for problematic grief, “Persistent Complex Bereavement Disorder” and the second, elimination of the “bereavement exclusion” according to which neither adjustment disorders nor depression was to be diagnosed in the immediate aftermath of a significant death. The committee ultimately decided not to add a diagnosis for problematic grief at this time, although they did elect to include the proposed criteria as an appendix in the DSM for future consideration. They did, however, eliminate the bereavement exclusion from the descriptions of depression and adjustment disorders, a change that has been met with responses ranging from enthusiastic approval to vehement opposition. (Pies, 2013).

Critics of the change warn that removal of the bereavement exclusion will result in an increase in the frequency of diagnoses of depression among people who are bereaved, with an accompanying increase in the use of anti-depressant medication in this population. Advocates of the change argue that it reflects an acknowledgement that bereavement is a “severe psychosocial stressor that can precipitate a major depressive disorder in a vulnerable individual” and that in these cases delaying treatment “adds an additional risk for suffering feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder“ (APA, 2013b, p. 5). Thus, although the committee did not adopt a diagnosis for problematic grief, they acknowledge that grief can become chronic and disabling. The point of the change, in other words, is not to increase the diagnosis of depression, but to encourage clinicians to consider the possibility that a bereaved person may be clinically depressed. In these cases, delaying treatment may result in significant complications and prolonged impairment of functioning.

So what does the DSM offer by way of guidance for clinicians who provide counseling to the bereaved?

Implications for practice

Although much has been made of the changes in the DSM-5, the impact of these changes remains to be seen. The elimination of the bereavement exclusion allows clinicians to make a diagnosis of major depression even when someone has suffered a loss, but this may or may not make much of a practical difference. Experienced clinicians know that two months is only the beginning of grief for many mourners; they also know better than to think that all of these people should be diagnosed with depression. On the other hand, some people who are bereaved may also be depressed. They may have been depressed for some time prior to the loss, or the loss may have triggered a depressive episode.

While there is no question about the inadvisability of prescribing medication for everyone who is grieving after two months, it would also be a mistake to assume that medication is never indicated. Whether, in the clinician’s judgement, a recently bereaved person is exhibiting signs of grief, depression, or both, in cases where the severity of the client’s symptoms raises concerns about the possibility of self -harm, or where functioning is significantly impaired, medication can be considered, and the potential benefits discussed with the client. Again, the important point here is that the decision as to whether or not to suggest a referral for evaluation of the need for medication should be made based on the severity of the client’s distress, regardless of whether or not that distress can be definitively diagnosed.

Recognizing complicated grief

Although the new DSM (APA 2013) does not include a diagnosis for complicated or problematic grief, it does incorporate, in the appendix, criteria proposed by the working committee regarding such a diagnosis. These criteria define a range of problems that can arise in response to significant loss, and that can cause the mourner persistent and significant emotional distress, as well as impaired social and work-related functioning if not addressed in a timely manner. Symptoms include relational problems (“Bitterness or anger related to the loss[b]”, p.790); cognitive issues (“Maladaptive appraisals about oneself in relation to the deceased or the death, e.g., self blame”, p. 790); disruption of identity (“Difficulty or reluctance to pursue interests since the loss or to plan for the future”, p.790). There is also a suggested specifier for traumatic bereavement, characterized by “persistent, frequent distressing thoughts, images or feelings related to the traumatic features of the death” (p.790). Clinicians are encouraged to take note of the proposed criteria, which constitute a thoughtful and well- conceived set of principles for the treatment of problematic grief.

Intervening with complicated grief

While many people who are bereaved want to know how long it takes to heal from a loss, or whether the extent of their emotional pain is “normal,” these are not easy questions to answer. The experience of losing a loved one cannot be reduced to a set of parameters, nor can its course be predicted with certainty for a single person or for bereaved people on the whole. That being said, clinicians need to be able to identify the significant number of bereaved whose grief, by virtue of its severity, persistence, or some combination of both, appears to fall outside the range of what is considered normative.

Many bereaved people question their ability to go on with their lives in the wake of a significant loss, yet we know from experience that most do. But for some people, the passing weeks and months bring no relief, no change in how they feel. The longer they remain in this state, the more likely it is that their sadness will be compounded by frustration and a sense of personal failure. That frustration, and the emotional drain imposed by prolonged grief, can easily lead to a sense of hopelessness. Thus, an important part of the bereavement therapist’s role is to identify these clients, and to intervene before hopelessness sets in.

A number of explanations have been offered for the complications that interfere with resolution of grief. It is generally recognized that traumatic loss is predictive of problematic grief ( Stroebe, Schut, Boelen, and van den Bout, 2012) and that certain features of personality or attachment style are evident in many people who struggle after a loss ( Burke and Neimeyer, 2013). There are likewise a multitude of approaches and techniques for addressing problems in healing from loss. Two relatively new models, !e Dual Process Model developed by Stroebe and Schut, and Rubin’s Two Track Model, take a broad view of the causes of problematic grief and of how to help move a bereaved person forward. Stroebe and Schut’s model emphasizes that normal grief is characterized by an oscillation between a loss orientation and arestoration orientation. In this view, healing requires that a bereaved person be able to move flexibly between an awareness of the loss and the feelings associated with it, and a continuing involvement with the people, activities and roles that are still part of their lives. Problems arise when there is a lack of oscillation, as when a person is unable or unwilling to recognize and work through feelings, or alternatively, when feelings become a quicksand from which no escape or respite is possible. !e role of the bereavement therapist in these cases is to help the client engage in whichever part of the process appears to be missing, for example, encouraging someone who has become socially isolated to begin to reconnect with friends.

The Two Track model posits that grief presents the mourner with two distinct and complex sets of tasks, the first having to do with their biopsychosocial functioning (Track I) and the second having to do with the nature of their relationship with the deceased (Track II). What distinguishes the two track model from earlier characterizations of grief and loss is that it combines the psychodynamic and interpersonal view of loss, which emphasizes the loss of the relationship with the living person, with an appreciation of the potential impact of loss on biological, behavioral, cognitive and emotional processes (Rubin, Malkinson and Witzum, 2011). In this model, the isolation of the person mentioned above would be seen as a biopsychosocial factor impeding resolution of grief. As this example suggests, although the focus of this model is different, the clinical implications in many cases will be the same.

Therese Rando argues that when mourning is not progressing it is almost always because of the mourner’s inability to accept some truth relating to the relationship or the death. A son may be unable to accept the truth that he was never able earn his father’s love. A wife may not be able to accept the truth that her marriage was not what she dreamed it would be. The survivor of a family member’s suicide may not be able to accept the person’s decision to take his/her own life. In all of these cases, the bereavement therapist’s role is to help the client identify the unrecognized or unacceptable truth, and to come to whatever resolution is possible, so that emotional energy can be redirected from suppression or denial to engagement and restoration (Rando, 1993).

Early attachment, affect regulation and adjustment to loss

With regard to our understanding of complicated grief, we note that there is increasing recognition of the role of early trauma and lesser forms of problematic early attachment in the etiology of a range of psychological problems, including problems in bereavement (Lanius, Vermetten and Pain, 2010). Fifty years ago, Bowlby identified the instinctive need of human beings, at every stage of life, to establish and sustain connection with other humans, and their propensity to experience distress when significant connections are lost (Bowlby, 1969). Bowlby believed that the quality of early attachment had a direct effect on how well such disruptions were tolerated, an idea that was successfully tested by American psychologist Mary Ainsworth. Based on her observations, Ainsworth extended Bowlby’s model to address the impact of abuse or neglect on attachment security, and identified a group of infants who became extremely dysregulated or shut down in response to separation from their caregiver (Ainsworth, 1978). Ainsworth attributed the response of these infants to the unpredictable and non-contingent behavior of their mothers, a high percentage of whom were found to have been abused or neglected as children. Subsequent investigations have validated the lasting impact of early maternal care and the persistence of regulatory deficits in children and adults who do not receive adequate caregiving (Schore and Schore, 2012). Thus, it is not surprising to find that insecure attachment is associated with complicated grief (Lobb, et. al., 2010) and that early mistreatment is reported by many of our clients who struggle with bereavement.

Treatment of bereaved clients who have problems relating to early attachment, including difficulty in tolerating strong emotion, requires particular sensitivity on the part of the bereavement therapist, who in effect functions as a transitional attachment figure. Special consideration must be given to the difficulties inherent in working at the edge of what the client can tolerate with regard to emotion in order to avoid treatment failure or premature termination of treatment. While the challenges of establishing a strong therapeutic bond with clients who have a history of abuse or neglect are not insubstantial, the potential rewards, for the therapist as well as the client, are considerable. For these clients, the loss of a loved one may be the catalyst that moves them to embrace a deeper and ultimately more satisfying emotional life. The opportunity to do this kind of work with people who are at the juncture between who they were before and who they will be in the future brings light into our professional lives and a clarity of purpose that encourages us, as well as our clients, to carry on.

References

Ainsworth, M.D.S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, N.J.: Erlbaum.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Author: Washington, DC.

American Psychiatric Association (2013b). Highlights of Changes from DSM IV-R to DSM V. Author: Washington, DC.

Bowlby, J. (1969). Attachment and loss, Vol. 1: Attachment. New York: Basic Books.

Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. New York: Routledge.

Burke, L, and Neimeyer, R. (2012). Prospective risk factors for complicated grief: A review of the literature. In: M. Stroebe, H. Schut, and J. van den Bout (Eds.) Complicated grief: Scientific foundations for health care professionals (pp.190-203). New York: Routledge.

Greenberg, Gary (2012). Not diseases, but categories of suffering. The New York Times, Jan. 9, 2012.

Lanius, R., Vermetten, E., and Pain, C. (Eds.) (2010). The impact of early life trauma on health and disease: "e hidden epidemic. New York: Cambridge University Press.

Lobb,E., Kristjanson,L.,Aoun,S., Monterosso, L.Halkett,K. and Davies, A. (2010). Predictors of complicated grief: A systematic review of empirical studies. Death Studies 34 (8) pp.673-698.

Mikulincer, M.,and Shaver, P. (2008). An attachment perspective on bereavement. In: M. Stroebe, R.Hanson, H. Schut., and W. Stroebe. (Eds.). Handbook of bereavement research and practice: 21st century perspectives (pp. 87-112). Washington DC: American Psychological Association.

Pies, R.(2013). How the DSM-V got grief, bereavement right. Retrieved on December 20, 2013 from http://psychcentral.com/blog/

Prigerson, H.G., Vanderwerker, L.C., & Maciejewski,P.K. (2008). A case for inclusion of Prolonged Grief Disorder in DSM-V. In M. Stroebe, R. Hansson, H. Schut, and W. Stroebe (Eds.). Handbook of bereavement research and practice: Advances in theory and intervention(pp. 165-186). Washington DC: APA.

Rando, T. (1993). Treatment of complicated mourning. Champaign, IL.: Research Press.

Rubin, S., Malkinson, R., and Witzum, E. (2011). The two track model of bereavement. In R. Neimeyer, D. Harris, H. Winokuer, H., & G. Thornton, (eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 47-56). New York: Routledge.

Schore, A., and Schore, J. (2012). Modern attachment theory: "e central role of affect regulation in development and treatment. In: A. Schore (ed.) The science of the art of psychotherapy (pp. 27-51). New York: W.W. Norton.

Stroebe, M., Schut, H., Boelen, P. & van den Bout, J. (Eds).(2012). Complicated grief: Scientific Foundations for health care professionals. New York: Routledge.

Phyllis Kosminsky, PhD is a clinician in private practice and at the Center for Hope in Darien, Connecticut. A Fellow in Thanatology, she is the author of Getting Back to Life When Grief Won’t Heal, and with John Jordan, and she is currently writing a book about attachment and bereavement.