Resolutions for the Grieving

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bereavement, death, death and loss, grief, grief and bereavement, grief and loss, grief work, new year's resolutions

I came across this list of Gentle Resolutions for the Grieving which were adapted from Adapted from New Year’s Resolutions for the Grieving by Ronnie Walker.  As we enter the new year, thinking about the things we want to change, for those confronting the realities of loss and grief, the following list might inspire one to take a different approach to the challenges that a death can bring for the mourner.

Gentle Resolutions for the Grieving

 By IMAGINE

December 26, 2016 at 6:54 PM

How can we cope and take care of ourselves in the midst of trauma and loss.  As we move through this holiday season with all of its expectations and commitments, please remember to be gentle with yourself and practice good self care.  Here are some resolutions to consider… 

I resolve…

– That I will grieve as much, and for as long, as I feel like grieving, and that I will not let others put a time table on my grief.

~That I will grieve in whatever way I feel like grieving, and I will ignore those who try to tell me what I should or should not be feeling and how I should or should not be acting.

~That I will cry whenever and wherever I feel like crying, and that I will not hold back my tears just because someone else feels I should be “brave” or “getting better” or “strong.”

~That I will talk about my loved one as often as I want to, and will find people who know how to listen.

~That I will not blame myself for my loved one’s death, and that I will constantly remind myself that I did the best job I could possibly have done. But when feelings of guilt are overwhelming, I will remind myself that this is a normal part of the grief process and it, too, will pass.

~That I will communicate with my loved one in whatever way feels comfortable and natural to me, and that I won’t feel compelled to explain this to others or to justify or even discuss it with them.

~That I will try to eat, sleep, and exercise every day in order to give my body the strength it will need to help me cope with my grief.

~To know that I am not losing my mind and to remind myself that loss of memory, feelings of disorientation, lack of energy, and a sense of vulnerability are all normal parts of the grief process.

~To know that I will survive and heal, even though it may take a long time.

~To let myself heal and not to feel guilty about feeling better.

~To remind myself that grieving is a process and that I may not make steady upward progress. There will be good days and bad days. When I find myself feeling stuck, I will remind myself feeling that way is normal.

~That I will reach out at times, and try to help someone else, knowing that helping others will help me cope with my grief and grow more resilient.

~That even though my loved one is dead, I will opt for life when and as I am able.

 Adapted from New Year’s Resolutions for the Grieving by Ronnie Walker 

Imagine is a free year-round children’s grief support center that serves NJ children age 3-18 and young adults 18-30 who are grieving the death of a parent or sibling, or who are living with a parent of sibling with a life-altering illness. Imagine also provides grief education and training for thousands of teachers, parents, coaches, youth and other adults annually.

The opinions expressed herein are the writer’s alone, and do not reflect the opinions of TAPinto.net or anyone who works for TAPinto.net. TAPinto.net is not responsible for the accuracy of any of the information supplied by the writer.

Why people tend to avoid helping others in grief

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bereavement, grief, grief and bereavement, grief and loss, grief and mourning, grievers, loss, loss and grief, mourners, mourning

One of the blogs I follow in my professional work, griefminister.com, shared some months back a list of Eight Reasons We Don’t Help Grievers.  He reflects on how his own mourning experiences taught him people we think will be there sometimes turn the other way.  As we can see from this list, much of the avoidance is tied into feeling that if I don’t know, then I would rather avoid than make a mistake.  His list is a lesson to realize that the goal is to support the mourner, be present and not allow one’s fears to stand in the way of giving to others.

Eight Reasons We Don’t Help Grievers

Posted on June 26, 2014by griefminister

Mourners need other people to support, comfort and encourage them as they go through grief.  As a mourner myself, I remember the times I felt really alone.  Unfortunately,  I found that some of the  people I thought would be there for me were not…for one reason or another.

There can be many reasons why those around a mourner don’t reach out to help.  The reasons can include:

• Feeling uncomfortable around mourners.   One of my most painful memories is of a close friend avoiding me during my early grief. I had just returned to church services a few days after the double funeral for my wife and two-year-old daughter in May 1993. As I walked down the church hallway, I saw a friend not far away. As I approached him, he saw me, then his eyes darted side to side nervously and he took off in another direction. His avoidance of me at that moment heaped more pain into my already breaking heart. I felt shunned, devastated and alone. I knew what C.S. Lewis meant in his book A Grief Observed when he wrote, “Perhaps the bereaved ought to be isolated in special settlements like lepers.”Everybody can feel uncomfortable when confronted with the harsh realities of dying, death and grief. Mourners need others to step out of their comfort zone into the world created by their loss. Remember, when you feel uncomfortable it’s not about you; it’s about the mourner and his or her needs at that time. When you enter into and are present in the painful world of the mourner, your presence, availability and support can lighten the mourner’s grief load at that moment and bring significant results.
• The fear of doing or saying the wrong thing for the mourner. The worst thing that can be done or said to a mourner is NOTHING. So don’t let your fear of causing more pain in the mourner’s life keep you from doing anything at all. The most important thing to remember is that you’re not obligated to say or do much of anything at all to provide the mourner with the support, comfort and encouragement she or he needs. In fact, the best thing you can do for the mourner is to simply be present, available and listen without judging or giving any unsolicited advice. The ministry of presence in someone else’s grief lets the mourner know that there is someone who cares and is there for him or her. Listening ears, an occasional nod, and a simple “I love you” or “I am so sad to see you hurting so much” can go a long way to make the darkest times in life seem a little more bearable.
• Not wanting to be intrusive in the mourners’ personal time. Respecting the mourner’s privacy is important, but many friends and family members use this excuse to not do anything at all…or to just cover up their fear of dealing with a potentially emotional situation. The truth is that mourners need occasional solitude but they also need others around them to form a support system to help them through the grief journey.So fight your fears and your discomfort and reach out to the mourner. Don’t be surprised, scared away or take it personally if your efforts are met with rejection or hostility. If the mourner lashes out in anger, remember she or he is not angry at you. The mourner is angry at the situation and life at that moment. Respect their space, apologize and return at a better moment to be there for the mourner.
• A lack of understanding of the grief process or experience.   Often those around the mourner have no idea of what a person in grief is going through. Maybe they have never had a major loss in their lives. Maybe they are simply not very good at dealing with emotional stuff.Show the mourner that you want to help and honor their story by listening to them and what they are experiencing. You don’t have to have a Ph.D. or counseling license to help a grieving person. Mourners can teach you important life lessons about grief…especially about their grief experience. Make sure they understand that you need them to tell you what they want or need. Be present, listen and do things that will show you care for them.
• An inability to deal with the expression of emotions. Many of us find it difficult to express our emotions and to hear others express their feelings and thoughts. Again, an uncomfortable situation with a mourner is not about us, it is about them and their needs. Sometimes in life it is our turn to receive from others: sometimes it is our turn to give. Now is your turn to give back to mourners the comfort that others have given to you when you struggled in a life crisis (2 Corinthians 1:3-5).
• The friend or family member is grieving too. On occasion the people around a mourner may be grieving the same loss or another loss in their life. If that happens to you, be honest with the mourner as you spend at least some time for them. Explain to them you want to be there for them and that you will be, but sometimes it may become too painful for them to deal with. Most mourners will understand and appreciate your honesty. If you simply avoid them to avoid further pain without telling them why, you run the risk of inflicting additional pain on the mourner.
• What culture and our family has taught or not taught us about dying, death and grief. Many of us have learned from culture and our family that grief is a short process that must be gotten over quickly and should be talked about as little as possible. Therefore, we can have little tolerance when a mourner’s grief process is “too long” and all that the mourner wants to do is talk about their loss and its effects on his or her life.We can often think that if grief goes longer than “normal” there must be something seriously wrong with the mourner.The truth is that grief takes as long as it takes and has no timetable other than its own. Every grief is unique to the mourner and his or her relationship with the loved one who died. Also healing in grief involves dealing with painful emotions and thoughts needing to be expressed to others in some way. Be present, patient and understanding with the mourner, allowing them the time and space they need process, express and heal in their grief.
• A lack of empathy and/or compassion. I think that I can safely say that if you have read this far into this article, you don’t deal with a lack of empathy or an inability to be compassionate with those who are going through grief. A bit of wise advice is that if you know someone like this, be kind, courteous, empathetic, and compassionate toward them because of their situation or nature. Mourners would be wise to spend more time in places and with people that make them feel safe, supported and cared for.

Written by Larry M. Barber, LPC-S, CT author of the grief survival guide “Love Never Dies: Embracing Grief with Hope and Promise”  and the Spanish version “El Amor Nunca Muere: Aceptando el Dolor con Esperanza y Promesa” available online at Amazon, Barnes & Noble and http://grief-works.org/book.php . Also available for Kindle and Nook. Larry is the director of GriefWorks, a free grief support program for children and their families in Dallas TX http://grief-works.org.

10 Common Emotional Experiences in Grief

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chaplaincy, death and dying, emotions, grief, grief and bereavement, grief and loss, grief and mourning, grief counselor, grief minister, Larry Barber, loss, loss and grief, pastoral care, psychology, spiritual care

When working with those dealing with loss, we tend to see certain commonalities in the emotions of those with whom we work.  The following is one grief counselor’s list of 10.  As he indicates in his introduction, this is not to suggest that we can ever pigeon hole anyone into these categories.  Additionally, I would add my common challenge to all counselors, chaplains, pastoral care providers, etc, that it is our responsibility to always remember that even when we think we have seen a pattern we must still work with the person as if this is the first person dealing with these issues.

10 Common Emotional Experiences in Grief

Posted on March 19, 2014by griefminister

Although every grief is unique and unpredictable, there are many common emotional experiences that can happen in any grief due to the death of a loved one or significant person in your life.  Some of them are:

• A state of shock:
  When sorrow and the pain of loss come flooding in initially, we instinctually shut down our emotions in order to anesthetize ourselves from the grim reality we face in grief.  This initial phase of grief protects us from going into emotional overload – experiencing the full impact of the loss before we can completely accept what has happened to our loved one and to us.
• Overwhelming pain & emotions:
  When the shock phase begins to fade, the reality of the loss hits us.  The result is overwhelming pain and emotional turmoil.  As we realize how dreadful the loss is, emotional release begins to be expressed, often without warning.  The grief emotions inside turn into observable mourning.  (Remember mourning is simply grief gone public).
  Immense sadness and loss usually is expressed in uncontrollable and unexpected crying.  Our first instinct may be to stifle tears because we feel out of control or embarrassed.  The truth is though that crying opens the way for us to acknowledge and express all grief emotions helping us to progress through grief and toward healing.
• Depression & loneliness:
  Feelings of utter depression and isolation are common.  Grief causes us to question our deepest held beliefs – especially our beliefs about God and how He works in the world.  It might seem as if God is no longer in control in His heaven – almost as if God does not care and is not present in their lives.  Such depression and feelings of being all alone are normal, healthy grief responses.  These feelings and thoughts will pass as we refuse to be overwhelmed by our feelings or thoughts and progress through grief.
• Physical symptoms of emotional distress:
  The continued emotional stress of grief can manifest itself in all sorts of physical maladies—real and/or imagined.
• Experiencing panic/fear:
  The emotional turmoil of grief can be overwhelming to us.  Because the emotional experience is often greater than anything else we have ever endured, a sense of fear and panic is common.  We begin to question our sanity and if we are doing grief “right.”   An overwhelming sense of deep despair causes us to also question if we will be able to endure what lies ahead and if we will ever experience joy and happiness again.
• Experiencing guilt about the loss:
  We can feel real or imagined guilt for what we did or did not do for the person when he/she was alive.  Guilt can develop into neurotic guilt which is all out of proportion to the reality of the involvement and control we had in the happenings surrounding the loss.  Acknowledging and expressing this guilt, voicing regrets and “asking” forgiveness for perceived wrongdoings can move us toward healing from these grief wounds.  We must also work toward forgiving ourselves for what we did or did not do.
• Feeling anger & resentment:
  These “negative” emotions are normal.  However, we must admit to ourselves to acknowledge anger without giving into destructive behaviors.
• Resisting a return to life:
  Something inside keeps us from going back to usual activities.  Perhaps it is the desire to keep the memory of the tragedy alive as a way to honor the life of the loved one lost.  We fear that smiling, laughing, and experiencing joy or pleasure somehow signifies that the life of the deceased is not being honored or remembered.  Since the pain of grief is a reminder of the emotional tie we have to the deceased, we become comfortable in grieving and fearful that everyone has forgotten our pain.  This causes us to become stuck in our grief—failing to move on toward healing.
• Realizing hope
  One day “the clouds part and the sun shines in” for us.  It becomes possible for us to experience joy and pleasure once again.  There is a realization that there are moments when grief does not dominate our thinking.  There are still bad moments, bad days and bad weeks, but they happen less and less often.  There is an overwhelming feeling of “I can make it after all.”
• Struggling to affirm reality
  As we move through grief, we realize that we have been changed by the experience.  The deceased’s influence in our life changed us, making us better people.  The loss of the person has also changed us—making us either healthier and stronger in spirit or sicker.

Compiled by Larry M. Barber, LPC-S, CT author of the grief survival guide “Love Never Dies: Embracing Grief with Hope and Promise”  and the Spanish version “El Amor Nunca Muere: Aceptando el Dolor con Esperanza y Promesa” available online at Amazon, Barnes & Noble and http://grief-works.org/book.php . Also available for Kindle and Nook. Larry is the director of GriefWorks, a free grief support program for children and their families in Dallas TX http://grief-works.org.

 

For the Bereaved, 10 Tips for Getting Through the Holiday Season

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bereavement, chaplaincy, coping during the holidays, grief and bereavement, grief and loss, holiday season, holidays, pastoral care, psychology, spiritual care

The following is a reminder about ways to cope with the holidays in the midst of one’s grief and bereavement.  A loved one not being physically present for a holiday, especially the first series of holidays after death, creates challenges which we need to know how to face.

by Jeanne Dennis

Senior vice president, VNSNY Hospice Care

Posted: 12/20/2013 1:41 pm

City sidewalks, busy sidewalks, dressed in a holiday style can be very alienating for those who have recently lost a loved one. “I walk around the streets of New York — the Santas, the shopping, the bell-ringing — and I feel like I’m looking at a picture,” says Lisa, whose husband died in August.

“The themes over the holiday season are gratitude, light and hope for the year to come,” says Vince Corso, bereavement and spiritual care manager at the Visiting Nurse Service of New York. “Those three things are rarely in the vocabulary of the bereaved. How you’re feeling contrasts so sharply to the culture around you that many people tell me — and I felt this when my own father died — they just want to go to bed on November 1 and wake up January 2.”

Over many years of working with people in mourning, Vince has developed several strategies for navigating the holidays after the loss of a loved one, especially during the difficult first year of bereavement.

1. Write out your schedule ahead of time. Rather than dreading an amorphous and anxiety-filled week, write a concrete schedule for yourself over the holidays. Include active and down time, time alone and time with others — and be specific. “Often when bereavement groups reconvene in January,” says Vince, “people note that the anticipation was worse than the holiday itself. It helps to see what you’re facing.”

2. Mark the loved one’s presence and absence. After his father died, Vince’s children set the Thanksgiving table and included a place for their grandfather, marked with a candle. Other families set a photograph at the table or a bouquet of her favorite flowers. Vince also recommends looking through photographs of the loved one that go back in time. This helps the family celebrate the life and share the loss together.

Joan, whose husband Bill died recently, sent out this year’s Christmas card with a family photo — herself and the couple’s two children — along with a note of gratitude from each, thanking friends and family for support during Bill’s final days.

3. Reimagine gift-giving. Lila and her husband always exchanged one special gift over the holidays. Last Christmas, after his death, she shopped for that one special gift — then donated it to a charity organization.

For young children, activities help to process grief. Over the holidays, make an activity out of gift-giving in honor of the person who died. Bake cookies and deliver them to the hospital that cared for the parent or grandparent. Or plant a tree in the person’s favorite spot in the back yard.

Here’s an activity for children and adults alike: On a piece of paper, note the lasting gifts the deceased has given you over the years — gifts in the broadest sense, from a home to learning forgiveness. On the other side, write the gifts you have given him or her. Wrap the paper in some way, in a decorative envelop or a small box, and include it in your holiday gifts, perhaps on or under the tree.

4. Accept at least one invitation. While difficult, it is important to put yourself among people during the holidays. Be selective, however, and do not feel obligated to accept every invitation. Vince suggests listing two or three people who have been most supportive through your grief and making a specific request of them over the holidays — whether it is to accompany you to church, to join them for Christmas Eve, or to go for a walk in the park New Year’s day.

5. Take people up on offers of help. Often, people want to help but are not sure what you need. When Carol lost her husband of sixty years, she wanted one thing over the holidays: to get a ride to his gravesite, since she didn’t drive and he was buried outside the city. She decided to accept a general “if there’s anything I can do” offer of help from a close neighbor and asked for a ride to the cemetery. “She was more than happy to do it,” Carol reported. “The anxiety was my burden.” They now make the trip every month.

6. Don’t try to do too much. Break holiday tasks such as cooking, shopping and card-writing into smaller chunks, delegate to others, or allow yourself a break from them this year. For siblings coming together after the loss of a parent, be especially sensitive to dividing cooking and chores. After Vince’s father died, his mother — “who could bake for an army” — no longer wanted the holiday-cookie assignment, so she delegated to other family members.

7. Don’t forget to ask the kids. Doug was consumed with anxiety over how he and his teenage children were going to spend the first holiday without their mother, but he didn’t want to burden them further. It wasn’t until his older son, who had done community service in school, suggested they serve meals in a homeless shelter on Christmas that a family conversation took place. “It was the best way we could have gotten through the day,” he said afterwards.

8. Take care of yourself. Grief and the caregiving that often precedes the death of a loved one take a great physical toll. Take care this holiday season to get enough sleep and eat wisely (including alcohol and sugar in moderation). “A body in grief requires a lot more attention,” notes Vince. “There’s greater susceptibility to illness, greater requirement for nourishment and rest. Especially for someone coming off a caregiving role, give yourself the gift of a doctor’s appointment.”

9. One holiday season at a time. The pull of tradition is especially strong around the holidays, but give yourself the liberty of taking one year at a time. Whatever you do this does not need to be repeated next year, when you may feel very differently. Leslie has decided to take her two children to Aruba for Christmas, the first after the death of her husband. “They just want to avoid the whole thing,” says Vince. “Nothing wrong with that, and nothing that says they have to do it again next year.”

10. Love does not end in death. During the holidays and throughout the year, we keep our loved ones alive by the way we live our life, buoyed by their memories, fortified by their values and shepherded by their love.

Drive-by shiva

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bereavement, comforting the mourner, grief, grief and bereavement, Jewish mourning practices, mourning, pastoral care, religion, shiva, spiritual care

For many people, visiting someone or trying to support someone who is in mourning the loss of a loved one can be a difficult proposition.  We are plagued with trying to figure out what to say, how to act and perhaps we ourselves are in pain and don’t have the emotional strength to be present with someone else who is living in sadness.  The following story and description is an interesting perspective on what visiting someone sitting shiva, or for that matter anyone mourning a loved one, as it emphasizes the impact of just showing up.  Showing up can sometimes in itself be the truest of expressions of empathy with a mourner.

by David Mandel

At first the words ‘drive by shiva’ seemed offbeat even a touch offensive.

A friend told me he was paying a shiva call, and the person sitting shiva excused himself and walked onto his terrace for a brief moment.

When he returned, he explained that he lives in a densely populated neighborhood famous for its congested streets and nearly no on street parking.

Another friend of his had called him from his car to explain that he had rounded the block several times and could not find any parking spot. No surprise to anyone familiar to the neighborhood. He said he didn’t want to leave without at least talking to him to pay his respects even over the phone.

The person sitting shiva immediately asked him to drive back to the front of the house.

He said he’ll walk out on the terrace so his friend could at least step out of the car, ‘see him’ and say the sentence ascribed to mourners that G-D should comfort the mourners amongst Zion and Jerusalem which is an important part of the visit.

And so he did. He paid his respects in person however brief seeing and talking to him from his terrace. The mourner was properly consoled and a parking spot was spared.

This may all sound amusing of course, yet it may be a proper alternative to some of the inappropriateness that too often takes place in a shiva house.

People asking wholly inappropriate questions of the mourner(s), laughter and gaiety as if it’s a sorority, staying endlessy long thus preventing others from entering a congested room to pay their respects.

When Rabbi Yisroel Reisman, Rav of the Agudah of Madison was sitting shiva for his father A’H he went to great lengths to teach those who came to pay their respects the proper way to do so. Recalling what he had learned from his Rebbe Rav Pam, A’H he explained the purpose is to talk about the niftar, the deceased. A visitor should always wait for the mourner to speak first or acknowledge you in some way. If the visitor knows the deceased you should repeat a good story about him or her. Talking about that person in a good way is a comfort to family members who are mourning.

If you didn’t know the deceased say to the mourner, I didn’t know your _____ well please tell me a good story about him.

Listen to the story, the mourners talking is meant to be cathartic and comforting and after a few additional minutes leave.

Sitting shiva is an emotionally and physically  difficult time. As it should be.

It is a time to cry, to remember, for introspection, and to feel a sense of loss. Some mourners may sit alone and only have few visitors. In those situations your remaining awhile may be the best gift you can give them especially if they ask you to stay. In a mourners home that has a large uninterrupted number of visitors, paying your respects properly and briefly is also a gift you bestow. It enables more people to come through, to talk or listen about the deceased and to repeat the important phrase May G-D comfort you…

There are many situations where a telephone call is the only way to pay a shiva call. No doubt most if not all of us have done this when we live a great distance away.

A drive-by shiva sounded funny and even inappropriate when I first heard the term.

Once I understood the circumstances that the mourner considered it more meaningful to ‘see’ his friend albeit momentarily from his terrace than a phone call it seemed perfectly reasonable.

The total time one spends in a mourner’s house to pay his respects should in many cases be less than finding a parking spot in some neighborhoods. It may be a good frame of reference to keep in mind.

Defending against loss

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bereavement, buddhism, chaplaincy, chaplains, grief, grief and bereavement, grief and loss, grief and recovery, loss, mindfulness, pastoral care, psychology, spiritual care, tara brach

The following provides an interesting look at how grief can continue to exist within us for years if we don’t confront and recognize it.  We often misplace our grief behind other emotions in an attempt to avoid confronting our pain. Here is a class from a psychologist with an influence from Buddhist thought.

The Buddha taught that we spend most of our life like children in a burning house, so entranced by our games that we don’t notice the flames, the crumbling walls, the collapsing foundation, the smoke all around us. The games are our false refuges, our unconscious attempts to trick and control life, to sidestep its inevitable pain.

Yet, this life is not only burning and falling apart; sorrow and joy are woven inextricably together. When we distract ourselves from the reality of loss, we also distract ourselves from the beauty, creativity, and mystery of this ever-changing world.

One of my clients, Justin, distracted himself from the loss of his wife, Donna, by armoring himself with anger. He’d met her in college, and married her right after graduation. Donna went on to law school and to teaching law; Justin taught history and coached basketball at a small urban college. With their teaching, passion for tennis, and shared dedication to advocating for disadvantaged youth, their life together was full and satisfying.

On the day that Justin received the unexpected news of his promotion to full professor, Donna was away at a conference, and caught an early flight back to celebrate with him. On her way home from the airport, a large truck overturned and crushed her car, killing her instantly.

Almost a year after her death, Justin asked me for phone counseling. “I need to get back to mindfulness,” he wrote. “Anger is threatening to take away the rest of my life.”

True Refuge, published Jan 2013. Available at Amazon.com and Amazon.co.uk.

During our first call, Justin told me that his initial response to Donna’s death was rage at an unjust God. “It doesn’t matter that I always tried to do my best, be a good person, a good Christian. God turned his back on me,” he told me. Yet his initial anger at God had morphed into a more general rage at injustice and a desire to confront those in power. He’d always been involved with social causes, but now he became a lightning rod for conflict, aggressively leading the fight for diversity on campus, and publicly attacking the school administration for its lack of commitment to the surrounding community. 

His department chairman had previously been a staunch ally; now their communication was badly strained. “It’s not your activism,” his chairman told him. “It’s your antagonism, your attitude.” Justin’s older sister, his lifelong confidant, had also confronted him. “Your basic life stance is suspicion and hostility,” she’d said. When I asked him whether that rang true, he replied, “When I lost Donna, I lost my faith. I used to think that some basic sanity could prevail in this world. But now, well, it’s hard not to feel hostile.”

The pain of loss often inspires activism. Mothers have lobbied tirelessly for laws preventing drunk driving; others struggle for legislation to reduce gun violence; gay rights activists devote themselves to halting hate crimes. Such dedication to change can be a vital and empowering part of healing. But Justin’s unprocessed anger had aborted the process of mourning. His anger might have given him some feeling of meaning or purpose, but instead he remained a victim, at war with God and life, unable to truly heal.

Loss exposes our essential powerlessness, and often we will do whatever’s possible to subdue the primal fear that comes with feeling out of control. Much of our daily activity is a vigilant effort to stay on top of things—to feel prepared and avoid trouble. When this fails, our next line of defense is to whip ourselves into shape: Maybe if we can change, we think, we can protect ourselves from more suffering. Sadly, going to war with ourselves only compounds our pain.

A few months after my first phone consultation with Justin, his seventy-five-year-old mother had a stroke. His voice filled with agitation as he told me about the wall he’d hit when he tried to communicate with her insurance company. They couldn’t seem to understand that her recovery depended on more comprehensive rehab. “There’s nothing I can do to reach this goddamned, heartless bureaucracy … nothing!”

Justin was once again living in the shadow of loss, and gripped in reactivity. We both agreed that this was an opportunity to bring mindfulness to his immediate experience. He began by quickly identifying what he called “pure, righteous anger” before pausing, and allowing it to be there. Then, after a several rounds of investigation, he came upon something else. “My chest. It’s like there’s a gripping there, like a big claw that’s just frozen in place. And I’m afraid.”

“Afraid of what?” I asked gently. After a long pause, Justin spoke in a low voice. “She’ll probably come through this fine, but a part of me is afraid I’m going to lose her too.”

We stayed on the phone as Justin breathed with his fear, feeling its frozen grip on his chest. Then he asked if he could call me back later in the week. “This is a deep pain,” he said. “I need to spend time with it.”

A few days later, he told me, “Something cracked open, Tara. Being worried about my mom is all mixed up with Donna dying. It’s like Donna just died yesterday, and I’m all broken up. Something in me is dying all over again . . .” Justin had to wait a few moments before continuing. “I wasn’t done grieving. I never let myself feel how part of me died with her.” He could barely get out the words before he began weeping deeply.

Whenever we find ourselves lacking control of a situation, there’s an opening to just be with what is. Now that Justin had once again found himself in a situation he couldn’t control, he was willing this time to be with the loss he’d never fully grieved. Instead of rushing into a new cause, he spent the next couple of months focused on caring for his mom. He also spent hours alone shooting hoops, or hitting tennis balls against a wall. Sometimes he’d walk into his empty house and feel like he had just lost Donna all over again. It was that raw.

Justin had finally opened to the presence that could release his hill of tears. Six months later, during our last consultation, he told me that he was back in action. “I’m in the thick of diversity work again, and probably more effective. Makes sense . . . According to my sister, I’m no longer at war with the world.”

By opening to his own grief instead of armoring himself with anger, Justin was finally able to start the healing process. His grief had never gone away; it had just been hidden. Once he was willing to open to it and feel it, his own sorrow could show him the way home to peace. As Irish poet and philosopher John O’Donohue tells us:

All you can depend on now is that
Sorrow will remain faithful to itself.
More than you, it knows its way
And will find the right time
To pull and pull the rope of grief
Until that coiled hill of tears
Has reduced to its last drop.

About Tara Brach

Tara Brach is a leading western teacher of Buddhist meditation, emotional healing and spiritual awakening. She has practiced and taught meditation for over 35 years. Tara is the senior teacher and founder of the Insight Meditation Community of Washington. A clinical psychologist, Tara is the author of 
Radical Acceptance: Embracing Your Life With the Heart of a Buddha and the upcoming book, True Refuge: Finding Peace & Freedom in Your Own Awakened Heart (Bantam, February 2013). You can subscribe to Tara’s blog here. For more information, visit www.tarabrach.com or to join our community, go to facebook.com/tarabrach. Read more articles by Tara Brach.

Passover: The Four Children…of Grief and Recovery

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bereavement, chaplaincy, grief, grief and bereavement, grief and mourning, grief and recovery, grief and the holidays, haggadah, Jewish holidays, Passover, pastoral care, religion, spiritual care, spirituality, yizkor

The following is a very moving sermon I came across in researching online for a talk on grief during the holidays.  The sermon was written for Yizkor on the Eighth Day of Passover and it relates the four sons found in the Haggadah to the process of grief.

PAS Home · The Four Children…of Grief and Recovery

The Four Children…of Grief and Recovery

April 06, 2010
Rabbi Elliot J. Cosgrove

Passover 5770, Eighth Day

In every generation, at every Passover seder, we return to the iconic passage of the four children. Four children: wise, wicked, simple, and the one who does not know how to ask. In every reading, we know that these children represent far more than first appears, and have been interpreted differently throughout the ages. Some interpretations draw on educational theory – that the four represent four Jewish approaches to learning: a posture of submission (the wise child), of criticism (the wicked), simplicity, and ignorance. Rabbi Yoseph Schneerson once explained that the four children represent four generations of the American experience: the wise child with roots in the European shtetl; the wicked child brought up in the American melting pot – cynical to his parents’ generation; the next generation, confused by his grandfather’s reverence and father’s irreverence, and then the fourth generation who, as a consequence of his mixed-up pedigree, has woken up not even able to formulate a question. Israeli Haggadot have similarly adopted the template of the four children with respect to attitudes towards the Zionist dream; women’s Haggadot have used the iconography of these children to portray the changing face of feminism. A simple passage, but not so simple – one that continues to resonate to different effect year in and year out.

This morning, as we arrive at Yizkor, reflecting on the absence of our loved ones and the storehouse of memories that we are about to open, I want to draw on the image of the four children one last time during this festival. Not as a meditation on assimilation or feminism, but on the process of loss and recovery, how a person receives the blow of the death of a loved one, and then journeys forward. I want to share with you a modern midrash if you will, as to how the four children represent the manner by which we may reconstitute our own lives in the face of grief, as we walk through our own valleys in the shadow of death.

We work backwards from the fourth child, the one who cannot speak. When death occurs, this is the first step. The punch to the stomach, the gasp for air, the realization that our father, our child, our brother or sister or life partner has died. There is a numbness. As in Edvard Munch’s famous painting “The Scream,” we open up our mouths, but nothing comes out. At the moment when Aaron received the news of the death of his sons, he did not cry, yell, or scream, he was silent: Vayidom Aharon. The tradition notes the similarity between Vayidom and the Hebrew word for blood, dam, explaining that upon hearing of their death, it was as if the blood was drawn from him. He was cut loose from his moorings, hit by a tidal wave of despair. So many questions. Why? How could such a thing come to pass? Why not me? According to Jewish law, you do not become a mourner, an avel, until after burial, only then do you say kaddish. The period from the news of death until burial is called aninut. Catapulted into death, you cannot be consoled, grief is inexpressible – comfort or healing is altogether premature. This is the one who cannot speak. This is the bottom rung from which we must climb.

And climb we do, because however painful, whether death happens suddenly or after prolonged illness, all of us know, on some level, that we are mortal. Even as we rend our garments, feeling that which is dearest to us being torn away, we know that there is a simple truth, the third child, embedded somewhere in our collective consciousness. From dust we come and to dust we go. Everyone has a limited number of years on this earth. We realize that we are not the first to have lost a parent. There is another who has felt this pain – mourning after all is one of the very few experiences shared by all of humanity. So we allow for a hug, we allow for a kind word, we are brittle, but we are willing to let ourselves be touched by our family, by our community, for in that contact comes the restorative reminder that we are still alive. It is actually Jewish law that when you return from the cemetery you must eat a meal. Why? Because it reminds us that we are still alive. We are not yet ready to move on, we hurt, but we must recognize that it is not we who have died. Our questions are simple, fumbling inklings that we are aware of our world. Mah zot? What is this? What is this world that we have woken up to – as a widow, as an orphan? There are questions to which we know we will never receive full answers, but at least here and now, in this stage, we are able to find our voice, to shed tears, tears that may just plant the seeds for fruit to be reaped another day.

As anyone who has grieved will tell you, however, just as there are steps forward, there are steps backward. As Elizabeth Kübler Ross explained in her book On Death and Dying, there will be a time for anger, resentment, and depression. The second child comes in all forms, but it all reflects the same impulse – a refusal to accept this narrative as your own. This is not the story as it should have happened; it wasn’t supposed to be this way. We say: “The physicians didn’t do enough. Maybe I didn’t do enough. The rabbi wasn’t there when I needed him. My loved one didn’t hold on long enough. Where are my friends now? Where did everyone go after shiva ended? How dare people plan their future when I can’t see the next day? The resentment of the second child is not good or bad, wicked or otherwise, it is just resentment, pure and simple. We are frustrated, we are alone, we are in pain, we are alienated from everyone who doesn’t know our hurt and we are angry. As the poet wrote: “We read the world wrong and say that it deceives us.” (Tagore, Stray Birds, LXXV) We are the second child.

The stage of the second child may last for a long time or for a little. Our constitutions are inherently different, loss follows no set recipe. Each of us proceeds at his or her own pace. But we know, here on Yizkor, that we aspire to be the wise first child, with the possibility of acceptance, the child of hope. Haham, “wise” is a carefully chosen word. Nothing is whitewashed, our grief remains, but somewhere along the way we have chosen to leverage our loss towards understanding and growth, towards asking the questions that we couldn’t ask upon the news of death, that can’t be asked simply, that we rejected in our anger. Now we know that we must learn to reflect on legacy, to think back and consider how the values, qualities, and high ideals of our loved ones transcend death and how they inform our lives. We wonder how we are shaped by them, as an extension of and reaction to the generations that came before. It is not for any of us to change the past; our relationships with our loved ones had their strengths and weaknesses. But we the living have been entrusted and empowered to craft and draft our own narratives of memory, to tell the story to ourselves and to those around us – after all, it is Passover. The wise child knows that given the fragility of life, the acute awareness of our mortality wrought by the loss of those we love, we here in this room must live lives worthy of remembrance. The stage of wisdom is hopefully not so much any one stage or destination, but rather a philosophy of existence reflecting resignation and acceptance, anchors of memory and breezes of hope all mixed together.

Anyone who has studied the Haggadah knows that ultimately, the most important thing to say about the four children is not about one or the other, but about the four of them together. They are not necessarily discrete individuals; rather they are four aspects of all of our beings. Each one of us has elements of the four. The point, we know, is that no matter how wise, how wicked, how simple, or how introverted, each one has a place at the table, and they are all seated at the seder.

It would seem that what is true for the seder table, is true for this moment of Yizkor. We who are gathered here recognize the continuum of grief. On any given day we may find ourselves to be at one stage or another. But when we say Yizkor, every emotion is present and accounted for. We are at a loss being reminded of the death of our loved one; we grieve in the context of a community, finding comfort in the knowledge that we are not alone; we resent, as is our right, our losses; and we are not afraid to bring that emotion into this sanctuary. We also seek wisdom – to draw from the well of memory in hope that it provides sustenance for the years ahead.

One final thought – perhaps unexpected but also a bit inevitable. Maybe, just maybe, the point of the four children is not the children themselves, their qualities, and what they represent. Maybe the point is the one thing, or better yet, the one person, that all of them have in common – the parent who greets them all at the seder table. I have often thought that the real lesson of this passage is to reflect on the role of the parent, that divine personality, who created a seder table capable of seating everyone, responding to everyone, no matter who they are and what burdens they bear. So, too, for our service of Yizkor. We sit at this seder of Yizkor with our Father in Heaven, avinu sheh-ba-shamayim, at its head. None of us are the same, nor need be. Though joined by loss, each of us exists somewhere different on this path of grief and recovery. The promise of Yizkor is the promise of the seder; no matter who we are, there is a place for us waiting, a makom with our name on it – barukh ha-makom – a blessed God of nehama. Hamakom yenahem etkhem. The table is set, the moment of Yizkor has arrived.

Our Unexpected Passover Guest

Tags

bereavement, chaplaincy, grief and bereavement, grief and loss, grief and mourning, Jewish holidays, Passover, passover seder, pastoral care, religion, spiritual care, Tablet Magazine

The following story really touched me, both personally and professionally.  When we enter the holidays, we can’t help but remember all those who have died in our lives and how much they are missing from our celebration.

Nobody expected my grandfather to show up at my apartment for Passover—two months after he died

By Rebecca Klempner|March 18, 2013 12:00 AM

 The first Passover after my grandfather died, my family knew that our grandmother would need us all to be together for the holiday, but we also knew she wouldn’t be able to host everyone. So Grandma, Mommy, and my 7-year-old brother squeezed into the two-bedroom apartment in Los Angeles where I lived with my husband, whom I’d married just one year earlier. My sister, who lived nearby, came over for the Seder and other meals throughout the holiday, and several other friends joined us as well. It was crowded but festive, like the crush at a happening party.

And then, on the sixth night of Passover, we got an unexpected visitor.

After kissing my mother and grandmother goodnight, I headed to the bedroom I shared with my husband, carefully stepping over my brother’s open suitcase and circumnavigating the sharp corner of the sleeper-sofa. My husband already lay in bed, curled on his side, breathing deeply. I lay down beside him with a book, drifting off after reading just a page or two.

As I slept, my grandfather, dressed entirely in white, entered my bedroom. He glowed with peace and holiness. Eyes twinkling, he beamed his usual vivacious smile. The vigor he’d possessed during my childhood had returned.

Grandpa’s presence was palpable, as if I could reach out and touch him, and—strangely—the sensation lingered even after I awoke with a start. Electricity charged the atmosphere in my room. Enthralled, I felt Grandpa’s benevolent but alarming manifestation emanating from a specific corner of the room.

Certainly, I would not be going back to sleep.

I crept from the room to go get a drink of water. When I entered the living room, I discovered Mommy sitting at the foot of the sleeper-sofa where Grandma was lying, speaking animatedly. She kept her voice was low to avoid waking my brother, still sleeping nearby. Grandma, who appeared agitated, listened intently.

“What are you doing awake?” I whispered.

“I had a dream,” my mother told me. “Of Grandpa. He came to comfort us.”

“And I had one, too,” Grandma added.

I flopped down into a chair. “Whoa.”

My mother turned to me, her eyebrow arched. “What’s wrong, honey?”

Before I had a chance to explain, my husband emerged from our bedroom. “I dreamed that Grandpa came to visit,” I said. “And it feels like he’s still in there.”

“In where?” my mother asked. I gestured over my husband’s shoulder into our bedroom.

“In that corner?” he asked, pointing to a specific area of our bedroom.

“How—how did you know?” I stuttered.

“I just felt something, something there,” he said.

The blood draining from my face, I nodded silently. Mommy and Grandma rushed over. But as everyone approached, the presence dissipated.

***

Grandpa had been more than a grandfather to me. He had acted as a substitute father after my parents divorced when I was 5 years old.

In my eyes, he’d been tougher than Muhammad Ali. He regularly lifted my sister and me high into the air when we were little, one in each arm. Every summer, Grandpa schlepped my sister and me from our home in Columbia, Md., to the beach in Ocean City and bought us frosty Popsicles on hot days. When Lee’s Ice Cream in Baltimore introduced cookies-and-cream ice cream, Grandpa mixed his own version for us at home with kosher Hydrox cookies instead of treyf Oreos. Grandpa fried crispy latkes at school with me at Hannukah and celebrated all my triumphs, large and small, with his booming voice and contagious grin.

When my sister and I grew up and left for college, Grandpa wrote us long letters in an almost indecipherable scrawl. He battled cancer during my first year at college, but triumphed. When we returned home, he pulled us close and said, “Are you still growing? So tall! So beautiful!”

Life was unpredictable, but Grandpa’s love never was.

***

On a Shabbat evening the February before he died, I had worried about Grandpa. The doctors had concluded that they could no longer fend off his cancer, which returned from remission shortly after my wedding. A hospital visit in January had left us with little hope—Grandpa, who’d once been so strong, had withered to a specter of his former self. My husband had held one of Grandpa’s hands while I had held the other. It had become unimaginably soft, his calluses faded from months lying in bed. Like the hand of newborn.

Now Grandpa had returned home, awaiting the inevitable.

In a dream that Friday night, I entered a wedding hall draped in white tulle and festooned with flowers. A groom approached the chuppah, the Jewish wedding canopy. Grandpa sat across the aisle from me. We stood as the bride entered, radiating joy and light. Just as my eye caught Grandpa’s, I awoke and sat up.

Grandpa had told me as a child, “My mother believed that if you dream of a birth or a wedding, it foretells death.” Shaken, I noticed the time—a few minutes past midnight. I knew with great certainty that my grandfather had passed to the next world.

In the morning, I quietly confided my dream to my husband. Not wanting to dampen the joy of the Sabbath, I said no more about my secret knowledge, but I walked around all day with a lead weight on my heart.

Our phone rang immediately after havdalah, the service that marks the end of Shabbat. Grandpa had died at home, surrounded by his wife and children, a few minutes past midnight.

As Passover approached just a couple months later, I wondered what the holiday would be like. Grandpa’s Seders had always opened a door to a magical reality, completely distinct from the quotidian world I inhabited the rest of the year.

We had always read the service all the way through from my grandparents’ art deco Union Haggadahs. With a booming voice, Grandpa had told the story of the slaves in Egypt as though it were his own personal drama. My young mind never once questioned the miracles of the Exodus—their reality had been handed down to me by my grandfather, who’d received it from his, and so on for more than 3,000 years.

Year after year, Grandpa had hidden the afikomen, undetected. His sleight of hand was worthy of Doug Henning. By the time the gefilte fish arrived on its china plate, Grandpa would have me on the edge of my seat, wondering where he’d hidden the matzoh.

In our youth, my sister and I balked when we were sent to the front door late in the Seder to invite in Elijah the Prophet. To us, Elijah the Prophet could be no one but the Boogey Man. After all, hadn’t Grandpa told us that the Boogey Man lingered by the front door at night?

As a child, I was greatly relieved when Elijah would fail to appear. Now, as an adult, I grieve.

***

Twelve years have passed since Grandpa died. My husband and I still live in the same tiny apartment, now (thank G-d) crammed with kids. When I begin to prepare for Passover, I inevitably think of my grandfather, who never met my children and would have taken such pleasure in them. Nevertheless, my husband and I try to make our Seders as magical as possible for them. I don’t think we have quite the same flair as Grandpa, but the kids look forward to Passover with as much anticipation as I did.

I don’t expect Grandpa to visit us again this year. When he appeared to us that first Passover, he knew we needed him. Today, we still miss him. We still wish he were here. But we no longer need reassurances of his unconditional love. His one final visit gave that to us.

***

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Rebecca Klempner is a wife, mother, and writer in Los Angeles.

Self Talk That Keeps Mourners from Healing

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bereavement, chaplaincy, denial, grief, grief and bereavement, healing, mourners, pastoral care, spiritual care

As we grieve, we often try to minimize our grief. This can lead to increased challenges with finding healing as we mourn the loss of a loved one. Here is a piece offering some common modes of denying our need for grieving.

Self Talk That Keeps Mourners from Healing
Posted on January 16, 2013 by griefminister

These are common beliefs shared with me by grief counseling clients and grief group members that prevent mourners from healing and steal their hopes of progressing in healthy ways through grief:

Expressing my grief emotions shows weakness.

Giving into grief and expressing it just makes me sadder and doesn’t make anything better.

There is nothing I or anyone can do or say to change things.

Crying in front of others will make others see me as weak or out of control.

My loved one wouldn’t want me to grieve.

I shouldn’t be sad. I should be happy for my loved one (who is in a better place, because he is no longer suffering)

No one wants to hear about my problems.

I don’t want to be a burden to others.

No one will allow me to grieve.

My grief comes from my selfishness in wanting my loved one back.

Mourning is throwing a pity party for myself.

I am a private person when it comes to feelings and I cannot let others know I am grieving.

I don’t have time for grief.

Once you give into grief you will not be able to get out of it.

If you have the right perspective, there is no need to struggle with grief.

Since I am a Christian and believe thatI will see my loved one again, I won’t grieve.

Death is part of life. I just need to forget and get over it.

Written by Larry M. Barber, LPC-S, CT, author of the grief survival guide “Love Never Dies: Embracing Grief with Hope and Promise”

Bereavement Does Not Immunize the Grieving Person Against Major Depression

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bereavement, chaplaincy, depression, Dr. Ronald Pies, DSM - IV, DSM-V, grief, grief and bereavement, major depressive disorder, MDD, psychology

The following article is some food for thought on the usage of the Diagnostic Statistic Manual in relation to grief and depression. As has been widely reported, bereavement was pulled from the major depressive disorder diagnosis, allowing for the potential of diagnosing depression outside of grief. As the article below indicates, there is positive and negative to this decision. On some level, I think it boils down to the question of going with one’s intuition or going by the textbook. I find myself agreeing with the author, especially about the potential problems that could arise.

Bereavement Does Not Immunize the Grieving Person Against Major Depression

This is a guest post by Dr. Ronald Pies in response to this week’s GeriPal post about the removal of the Bereavement Exclusion from DSM-5.

Dr. Pies is the Editor-in-Chief Emeritus of Psychiatric Times, Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, and Clinical Professor of Psychiatry at Tufts USM.

Dr. Widera is quite right: ordinary grief is not an illness, has adaptive value, and does not require professional treatment. But grieving persons are not immune to major depressive disorder (MDD), and, indeed, bereavement is a common trigger for MDD. There are, nevertheless, substantial differences between grief and MDD, and experienced clinicians will be able to tell the difference. The elimination of the bereavement exclusion from DSM-5 will not change that. Let’s consider the following scenario:

Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc—really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. Sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”

Though it’s still early after his wife’s death—and some clinicians may want to defer a final diagnosis for another week—all clinicians should be very concerned about Mr. Smith. He easily meets DSM-IV (and now, DSM-5) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the present DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because Mr. Smith doesn’t have the DSM-IV features that allow the clinician to “override” use of the BE; namely, severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. It’s important to note that the DSM-IV exclusion rules did not apply to any other type of loss, such as losing one’s job or becoming homeless. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM-IV rules!

Many of us who have specialized in the treatment of mood disorders found the DSM-IV criteria not only illogical, but also inimical to good clinical care. We were concerned that many bereaved patients like Mr. Smith–who meet all symptom and duration criteria for MDD, but who happen to have lost a loved one within the past two months– would be shunted out of the mental health care system. In the view of many (though not all) mood disorder specialists, the risk of overlooking MDD, with its high potential for suicide, far outweighs the less serious risk of “over-calling” MDD—the so-called “false positive” scenario.

The elimination of the bereavement exclusion (BE) by the DSM-5 does not mean that “grief is now a mental disorder,” as some have claimed. Nor does it mean that anyone who is grieving within two weeks of a loved one’s death—i.e., most people!—will be diagnosed with major depressive disorder. (Two weeks is the minimum duration required for MDD, under DSM-IV and DSM-5 criteria). First of all, studies have shown that most bereaved persons will not meet full DSM-5 criteria for MDD. Second: it would be extremely rare, in clinical practice, for a bereaved person to seek psychiatric care within two weeks (or even a month) of the death of a loved one, unless something very unusual or dysfunctional were going on—for example, the bereaved person has developed a psychotic-level disturbance; is severely incapacitated; or has become suicidal–in which cases, the bereavement exclusion would not apply anyway. And, contrary to the strident claims of some, nothing in the diagnosis of MDD will prevent bereaved patients with MDD from receiving the love, support, and solace of family and friends.

To be sure, physicians and other health care workers need a much better understanding of the key differences between ordinary grief and major depression. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day. The bereaved individual usually maintains a strong emotional connection with friends and family, and often can be consoled by them. The person suffering a severe major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Dr. Kay R. Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.” My colleagues and I are now developing a screening questionnaire (the PBPI) based on these distinctions. We don’t yet know the final wording of the DSM-5 text, which we hope will emphasize and clarify the distinctions between ordinary grief and major depression.

I would urge readers of GeriPal to take a look at the excellent piece by Dr. J. Sloan Manning, in the September 7, 2012, Psychiatric Times, from which I provide a few excerpts. Dr Manning is Co-director of the Mood Disorders Clinic at the Moses Cone Family Practice Center in Greensboro, NC. Here is what he wrote:

“I write this as one in the midst of bereavement, having lost my dear mother several months ago… During the last year of her life (in rehab facilities and briefly in a nursing home) we were never closer. I still avoid driving by the nursing home. I still wake up at night occasionally tearfully thinking of her. I cook a lot of pot roasts in the old cast iron Dutch oven she made famous. I am converting a home office to a guest bedroom filled with family memories. I am not ill. I am grieving. It doesn’t look like illness. It doesn’t need to be treated like illness. I can’t believe anyone would mistake it for illness, especially an experienced clinician. But if I were ill and grieving, I would expect my health care providers to understand that the two concepts are not mutually exclusive, and I would expect them to offer help for my illness . . .Part of my practice is in a mood disorders clinic in a family practice residency…I cannot remember a single instance in this setting where the [bereavement exclusion] saved the day, preventing the unnecessary use of medication for a non-illness. In situations in which previous ill episodes were absent, symptoms were mild, and cognition and function were preserved, we would always choose the path of supportive and cognitive psychotherapy, and bibliotherapy or other non-pharmacological means as primary interventions. However, in patients with severe symptoms or those with documented histories of Axis I illness, we would never ignore the reality that intact affective control systems are a requirement for successful negotiation of grief.”

In conclusion: eliminating the bereavement exclusion means essentially this: the death of a loved one–a common precipitant of major depression—-will no longer be a “disqualifying” factor in diagnosing MDD, within the first few weeks after bereavement. This emphatically does not mean that we should be starting everyone with bereavement-related MDD on antidepressants! Some depressed and bereaved patients will heal and recover with “tincture of time”; some will benefit from cognitive, supportive or grief-oriented psychotherapies. More severely depressed, grieving patients–those, for example, with melancholic features or pronounced suicidality–may require concurrent medication and psychotherapy.

No, indeed: we must not “medicalize” normal grief. But neither must we “normalize” major depression, simply because it occurs in the context of bereavement.

by: Ronald Pies MD
SUNY Upstate Medical University, Syracuse, NY
Tufts University School of Medicine, Boston

For further reading:
Pies R. Was the bereavement exclusion originally based on scientific data? World Psychiatry. 2012 Oct;11(3):203.
Pies R. Bereavement, complicated grief, and the rationale for diagnosis in psychiatry. Dialogues Clin Neurosci. 2012 Jun;14(2):111-3.
Zisook S, Pies R, Corruble E. When is grief a disease? Lancet. 2012 Apr 28;379(9826):1590.
Zisook S, Corruble E, Duan N, et al: The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43.
Lamb K, Pies R, Zisook S. The Bereavement Exclusion for the Diagnosis of Major Depression: To be, or not to be. Psychiatry (Edgmont). 2010 Jul;7(7):19-25.
Zisook S, Simon NM, Reynolds CF 3rd, Pies R, Lebowitz B, Young IT, Madowitz J, Shear MK. Bereavement, complicated grief, and DSM, part 2: complicated grief. J Clin Psychiatry. 2010 Aug;71(8):1097-8.
Zisook S, Reynolds CF 3rd, Pies R, Simon N, Lebowitz B, Madowitz J, Tal-Young I, Shear MK. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010 Jul;71(7):955-6.
Pies RW. Depression and the pitfalls of causality: implications for DSM-V. J Affect Disord. 2009 Jul;116(1-2):1-3.
Pies R: How the Public is Being Misinformed about Grief. Psychcentral. http://psychcentral.com/blog/archives/2012/02/28/how-the-public-is-being-misinformed-about-grief/all/1/
Manning JS: Debate: Let the Bereavement Exclusion in DSM-5 Die. Psychiatric Times, Sept. 7, 2012. http://www.psychiatrictimes.com/mdd/content/article/10168/2101417?CID=rss
Dunlop BW: Debate: Is It Worth Saving the Bereavement Exclusion in DSM-5? Ringing the Bell to Save the Bereavement ExclusionPsychiatric Times, September 7, 2012 http://www.psychiatrictimes.com/mdd/content/article/10168/2101460
Pies R: After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI: A Potential Assessment Tool. Psychiatric Times. February 21, 2012. http://www.psychiatrictimes.com/mdd/content/article/10168/2035804
Jamison KR: Nothing Was the Same. Knopf, 2009. Also: an excellent video with Dr. Kay R. Jamison explains some of the key differences between grief and depression: http://bigthink.com/ideas/16707

Acknowledgments: Thanks to Laura Dunn, MD and Sidney Zisook MD, for suggestions on earlier drafts of this blog; however, the views expressed here are my own.

Disclosure statement: Dr. Pies reports no financial or other conflicts of interest with respect to the content of this piece. He has had no official role in the DSM-5 development process, or any formal connection to the DSM-5 committees. He receives no monies from any pharmaceutical companies. A formal disclosure statement may be found at: http://www.psychiatrictimes.com/editorial-board