107 Ways to Help Others: Cope with Waves of Grief

A randomized controlled trial comparing CGT to standard interpersonal psychotherapy showed that the former performed better Participants were permitted to enter the trial on medication that had been prescribed for more than 3 months if they still met criteria for complicated grief. Compared to those not already taking medication, previously treated individuals appeared to derive modest benefits from the addition of psychotherapy and proved to be more likely to complete a full course of CGT.

Given these findings and the frequent occurrence of lifetime mood and anxiety disorders in individuals with complicated grief, it appears likely that combination treatment, including antidepressant medication and targeted psychotherapy, may be the most effective treatment approach Prospective randomized controlled trials examining the role of pharmacotherapy for the treatment of complicated grief with and without concomitant psychotherapy are indicated.

There have been numerous longitudinal follow-up studies of the newly bereaved. The majority of studies have focused on the widowed, although there are excellent studies of children who have lost a parent and of parents who have lost a child. Most studies have found roughly similar results, demonstrating a high frequency of depressive symptoms that diminish in frequency and intensity over time, but that may continue to occur at greater frequency than in non-bereaved controls for years after the death Irritability was common, while overt anger was uncommon.

Suicidal thoughts and ideas were rare and hallucinations were not uncommon. When asked, most widows and widowers reported that they had felt or had been touched by their dead spouse, had heard their voice, seen them, or smelled their presence.

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The misidentification of their dead spouses in a crowd was common. By the end of the first year, the somatic symptoms of depression had remarkably improved, although low mood usually associated with specific events or holidays , restlessness and poor sleep continued. The studies demonstrate that symptoms were consistent amongst the following variables: By one year, most bereaved subjects were able to discuss the dead person with equanimity.

He discovered that low mood, loneliness, and crying were the cardinal symptoms of bereavement, with loneliness persisting the longest. Seven percent were chronically depressed. In all of these studies, the best predictor of major depression at 13 months was depression at one or two months. According to the Zisook and Shuchter studies, a past history of major depression also predicted major depression at one year. In addition, bereaved persons are not only at high risk for major depression, but they are also at risk for lingering subsyndromal depressive symptoms.

Such symptoms, even in the absence of full depressive disorders, may be associated with prolonged personal suffering, role dysfunction, and disability Many clinicians are confused by the relationship between grief and depression and find clinical depression difficult to diagnosis in the context of bereavement. Bereavement is a major stressor and has been found to precipitate episodes of major depression, resulting in a diagnostic quandary that may have profound clinical implications 24 , Although there are overlapping symptoms, grief can be distinguished from a full depressive episode.

The principal source of confusion is the common occurrence of low mood, sadness, and social withdrawal in both bereavement and major depression. However, there are also clear differences between the two states. Grief is a complex experience in which positive emotions are experienced alongside negative ones. As time passes, the intense, sad emotions that typically come in waves are spread further apart. Typically, these waves of grief are stimulus bound, correlated to internal and external reminders of the deceased.

Furthermore, grief is a fluctuating state with individual variability, in which cognitive and behavioral adjustments are progressively made until the bereaved can hold the deceased in a comfortable place in his or her memory and a satisfying life can be resumed. In contrast, major depression tends to be more pervasive and is characterized by significant difficulty in experiencing self-validating and positive feelings. Major depression is composed of a recognizable and stable cluster of debilitating symptoms, accompanied by a protracted, enduring low mood.

It tends to be persistent and associated with poor work and social functioning, pathological immunological function, and other neurobiological changes, unless treated. This is as true of major depression after the death of a loved one as in non-bereaved individuals with major depression 34 , Moreover, untreated major depression after bereavement carries the extra burden of prolonging the pain and suffering associated with grief. The consequences, clinical characteristics and course of bereavement related major depression are similar to those of other, non-bereavement related major depression.

Documented adverse consequences of bereavement related major depression include: Symptoms of bereavement related major depression are usually severe and long lasting 30 , 31 , In addition, bereavement related major depression also has biological characteristics that reflect similarities with other depressions, such as increased adrenocortical activity, impaired immune function and disrupted sleep architecture Most information about bereavement related major depression is focused on death of a spouse, considered one of the most disruptive and distressing events of ordinary life Compared to married individuals, there is an increase in general medical consultation by depressed widows in the first year 42 after the loss.

In addition, there is an increased use of counseling, especially pastoral counseling 25 and significantly increased use of tranquilizers, hypnotics and alcohol Finally, it is likely that unrecognized and untreated major depression accounts for at least a portion of the increased mortality seen in bereaved populations The causes of deaths have varied in different studies, but almost always include suicide and accidents When a major depressive syndrome occurs soon after the death of a loved one, according to the ICD, it should be classified as major depression. Is the syndrome an illness, likely requiring treatment, or is it a normal phenomenon, requiring, at most, watchful waiting?

The DSM-IV states that, under most circumstances, bereavement within two months of the death precludes the diagnosis of major depression, but that major depression should be strongly considered when there is guilt about things unrelated to actions at the time of the death, pronounced psychomotor retardation, morbid feelings of worthlessness, sustained suicidal ideation, or prolonged and marked functional impairment. However, these features are also likely to be present in bereavement related major depression as in any other instances of major depression 36 , 38 , and several studies have found that bereavement related major depression is more similar to, than different from, other forms of major depression 35 , and that it responds to treatment in much the same way as other, non-bereavement related major depression.

Thus, we feel the DSM-IV convention of excluding the diagnosis of major depression within two months of bereavement no longer fits the best evidence and may have the undesirable consequence of preventing people with potentially life threatening illness, such as major depression, from obtaining the appropriate treatment. The key to successful treatment is the recognition that bereavement related major depression is similar to other, non-bereavement related major depression. However, clinicians remain uncertain regarding how to intervene with bereavement related major depression and sometimes question whether to intervene at all.

Medical professionals, as well as the public, tend to misattribute and normalize bereavement symptoms, leaving vulnerable grieving individuals exposed to the burden of untreated depression and the stressful demands of coping with their recent loss. Thus, we recommend treating bereavement related major depression as seriously and aggressively as when treating depression related to other life events, or unknown psychosocial precipitants. As with other, non-bereavement related major depression, key factors used to determine whether to treat are past history and the intensity, duration, and pervasiveness of the depressive syndrome.

Under certain circumstances, such as when there is a history of previous, severe major depression, prophylactic treatment to prevent the emergence of a new episode in the face of this predictably difficult period should be considered. On the contrary, if there is no past or family history of major depression and the syndrome is relatively mild in terms of severity, reactivity, and impairment, treatment may be delayed for at least the first two months, if not longer, but the patient should be monitored regularly.

The clinician may then initiate treatment with educational-supportive psychotherapy, using the same general guidelines as one would for non-bereavement major depression. If the depression does not fully respond to this kind of support, antidepressant medications should be used At present, there are no psychotherapy studies focusing specifically on bereavement related major depression which demonstrate efficacy, although there are no compelling reasons to believe that psychotherapy would not be as effective in bereavement related major depression as in non-bereavement related major depression.

While further research in needed to determine the potential effectiveness of psychotherapy for depression in the context of grief, we advocate for an integrated treatment method that includes individualized psychotherapy. Currently, there are six published studies on bereavement related depression demonstrating the efficacy and safety of a variety of antidepressant medications 47 , In each of these studies, grief intensity diminished along with amelioration of depressive symptoms, although improvement in grief was not as robust as relief of depression.

Inquiring about patient preferences and past personal successes or failures with various antidepressant trials can help guide a rational choice in medication.

If the depressive episode is relatively mild and not associated with suicidal risk or melancholic features, support and watchful waiting might be an appropriate initial choice. On the other hand, the more autonomous and severe the symptoms, the more antidepressant medications should enter the treatment equations. For severe or highly comorbid episodes, or where medication has been unsuccessful, combination treatment with multiple medications in addition to targeted psychotherapy may be needed.

One notable comorbid condition, unique to bereavement, complicated grief 8 , may require a very specific form of psychotherapy A treatment model that includes education, a supportive and individualized form of psychotherapy, and medication management maximizes the probability of a positive outcome Patient suicide is an occupational hazard for psychiatrists, since psychiatrists treat the most chronically and severely ill patients, utilizing treatments that are not perfect.

Thus, it is no surprise that patient suicide has been reported as one of the most frequent and stressful crises experienced by health providers around the world 54 , When a patient suicides, psychiatrists should consider the advantages and potential problems in providing care for the family of the deceased.

Many survivors will welcome contact with the treating clinician as they seek to make sense of the death and process their own grief Generally, clinicians should proactively offer to meet with family members after a suicide, unless there are clear reasons to not do so. The psychiatrist can provide support, help to normalize the reactions of family members, provide referrals to community resources and, within the bounds of confidentiality, offer a perspective on the suicide that may assist family members in reducing their confusion, guilt, or anger about the death.

Attendance at funerals and memorials are an individual matter, but often both the psychiatrist and the family find this restorative. Even when the psychiatrist does not personally know the close family survivors, condolence cards, expressing caring and sympathy, are usually received positively. When a psychiatrist loses a patient to suicide, personal reactions are as varied as in other survivors.

Low mood, poor sleep and irritability, for example, have been described Many studies have found high rates of problematic grief experiences in survivors, such as intense guilt or feelings of responsibility for the death, a ruminative need to explain or make sense of the death, strong feelings of rejection, abandonment and anger at the deceased, trauma symptoms, complicated grief, and shame about the manner of death 6 , Psychiatrists are not immune to these reactions when they, themselves, become survivors Postvention should be multifaceted and ideally should involve support from family, friends, and colleagues.

For some individuals and in certain cultures, healing may be facilitated by prayer and doing merit Psychiatrists who lose a patient to suicide should consider consultation from a trusted and experienced colleague who can serve as a sounding board and source of emotional support, while also consulting on the most helpful response to the survivors impacted by the death. After completing their education and formal training, psychiatrists may not be fully prepared to handle some of the most common clinical challenges they will face in practice.

Diagnosing and treating complicated grief and bereavement related major depression will undoubtedly rank high on the list of such challenges. It is important to realize that, while each individual grief process is unique, there is a form of grief that is disabling, interfering with function and quality of life. Go inside the Home upon Returning. Send Unexpected Surprises without a Name Attached. Otter to Stay after Family Leaves. Get Permission before Washing Laundry. Prepare a Personalized Healing CD. Give a Personalized Calendar. Create a Collage of the Deceaseds Lite.

Mind Your Nonverbal Communication. Remind the Bereaved to Document Phone Calls. Accompany the Bereaved to Businesses. Teach about Car Maintenance. Share in the Creative Activity. Suggest a Good Grief Counselor. Find the Good and Talk about It. What to Say or Write. Help Develop a Routine.

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Discourage Rushing into Changes. Make Positive Message Cards tor Him.

How to Heal a Grieving Heart

Help through the Holidays. Leave Your Phone Numbers by Phones. Remember the Children 1. Remember the Children 3. Remember the Children 4. Remember the Children 5. This Is Not the Time to Criticize. Homicide Victim to Seek Help. So you post today sank directly into my heart. Grieving the loss of my married self even though I am happy with my emerging single self. Appreciate this reminder a great deal. Lost my Dad in August. And I loved him. The sobs still erupt, and I let them. For more than you know. Thanks so much for this Kris.

Love to all in this process. Never on the best of terms — he was still my father……and I miss the sheer presence of him more than I ever thought I would.

Kris you remind us all of that impactful quote: Sometimes the only way out is through. Try to harness and consume the strength and breadth of this wind of devotion and care for you. I find this so helpful and beautifully written. Wishing you blessings and healing! I have been wondering why you did not do Crazy Sexy Miracles this year. I love that event so much and missed it this year.

This is true and so beautifully said. My husband passed 6 years ago and it was devastating but I grieved, I felt, I cried and eventually I healed, I laughed and I transformed! This process takes time, so be kind and gentle with yourself!

Grief and bereavement: what psychiatrists need to know

Thank you For sharing Kris:: Dear Kris, I just want to say thank you. You spend most of your time caring for others, teaching people how to care for themselves. We probably forget or take for granted that you need love and care too. Kris, Thank you for this. I lost a loved one 2 years ago and I too had to learn all this through a therapist. This was so helpful because I honored anything that came up for me and I set aside time for it.

After each crying session a small weight seemed to lift. It never ceases to amaze me that despite the cavernous grief I was in, once my tears started drying minutes later I could let some happiness in and actually feel a soothing glow. I am 65 yr old and have had my heart broken many times. Thanks for this post. I now envision my heart veined with gold. It is so true. When your heart breaks, there is always the opportunity to redefine, open, and fill the cracks with wisdom. Kris, your words are beautiful. I am marking this post to read again…and again.

January has started out rocky with scary sad news. I am so sorry you have experienced such loss and grief in the past year. Sending you my love. I am a huge fan of yours…you have helped me more than you know. May all the sentiments expressed here by those you have touched help you now. Kris, We all fell in love with your beloved Buddy. But then, he just seemed to vanish. It is my prayer that he is still with you. If not, it is my prayer that he is running free, without a harness, without pain.

Can you share an update? I just ask for some information—so that I can stop worrying..

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My sincerest condolences at your loss, Kris. May your memories be blessings that sustain you and inspire you. As you do for so many. You are brave, and wise, and beautiful. You are loved, and held, and cared for.

WHAT IS UNCOMPLICATED (NORMAL) GRIEF?

Keep shining your light! Either way, a beautiful thing to see the beauty in imperfection! What stuck out to me most was trust, Kris. Trust has been key for me. Trust things will work out. Trust that some things need to be let go and some things need to be brought in. Thank you for your words of inspiration. My daughter went to see you in NYC And always treasured your hug.