Patrick Kelly MIACP, BA (Hons) Counselling and Psychotherapy
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|Posted on April 3, 2013 at 3:54 PM|
In this essay I will explain the difference between the normal grieving process and pathological grieving or complicated grieving. I will then outline tasks or phases of grieving. By using these tasks one can identify if there is a complication to the normal grieving process, leading to pathological grieving, and I will demonstrate how this applies.
I am going to start by giving a rather clinical definition of grief: “a complex constellation of psychological, physiological, and behavioural responses that accompany the human awareness of an irrevocable loss…….Bereavement is the term applied to loss specifically through death” (Kennedy, E & Charles, S.C. 2001). I do not believe this definition provides us with an understanding of the depth of the emotional effect that grief can have on us. Kennedy & Charles go further to give us an insight into the profound effect normal grief can have “bereavement rubs us raw, assaulting us as a rapist might, bearing away by violence the kingdoms of our souls. Bereavement rips us, leaving us, as the dictionary definition puts it, desolate”.
The death of someone close to us is for everyone, at some stage of their lives, a fact of life. However not everyone has the same reaction to bereavement. Normal mourning can manifest in a variety of ways. We can be prone to experience certain feelings, physical sensations, cognitive processes and behavioural changes, all of which may seem abnormal and certainly strange.
Even though this process is quite normal it may seem confusing, the intensity of the feelings may be overwhelming, and there may be a regressive feeling of helplessness. One of the most confusing feelings can be anger. It is hard to imagine feeling anger towards someone you loved, and we live in a society where you do not speak ill of the dead. This anger may be caused by the upset of abandonment. This confusing anger can lead to a sense of guilt. One may indeed feel guilty that one did not do enough to prevent the death. Bereavement may cause anxiety. The bereaved may feel they cannot cope without the person they have lost or they may become anxious as the death may evoke their own sense of mortality. Loneliness without the other person is also a common feature, especially in the case of a bereaved spouse. The bereaved may tire easily. This can be a distressing feeling. There may be a feeling of shock especially in the case of a sudden death. One may pine for the deceased. This feeling can help to gauge what stage the bereaved person is at. Another confusing feeling can be emancipation. The person may feel they have more freedom because of the death. Alternatively some may feel relief for the deceased person especially in the case of a long standing degenerative illness. Finally numbness to feelings and emotions can occur as a defense against the overwhelming impact of the loss (Worden. 2001).
There are also many physical sensations associated with the grieving process. Among these are: hollowness in the stomach; tightness in the chest; tightness in the throat; oversensitivity to noise; a sense of depersonalisation; breathlessness; muscular weakness; lack of energy and a dry mouth (Lindermann c.f. Worden 2001). All of these symptoms are very similar to a stress response.
There may also be certain thoughts associated with the grieving process. There may be disbelief that the person has died. There may be confused thinking or inability to concentrate. The bereaved may be preoccupied with thoughts of the deceased person. The bereaved may cognitively believe that the deceased is still physically present.
There may also be some behavioural changes experienced by the bereaved. Normal sleeping patterns may suffer. So too can appetite. The person may become forgetful. There can be an inclination to social withdrawal. The bereaved may dream about the deceased. The content of the dream can indicate to the therapist where the person is in the mourning process. There can be an avoidance of items that remind people of the deceased. However the rapid disposal of items may indicate a complicated grieving process to follow. Conversely hanging on to things and keeping things as they were before the person died may also indicate pathological grief. Bereaved people may find themselves searching for or calling out to the dead person. They may also try to keep themselves as busy as possible to avoid having to dwell on the loss. This too could lead to abnormal grieving.
However all of these reactions to loss are normal and part of the healthy grieving process. In normal grief they dissipate over time. When these symptoms are prolonged or sublimated it can be an indication of pathological grief. Normal grief can be summed up as “the blues that healthy people sing when they suffer a major loss” Kennedy & Charles (2001).
There is almost a societal taboo to fully experiencing the grieving process “the Western world treats mourning as though it were a weakness rather than a functional and necessary human experience” (Kennedy & Charles 2001). It can take time to work through the process, while others close to you may try to distract you from thoughts of the deceased or believe it is time you got over it. This may explain why some people do not complete a normal grieving process. If we feel we cannot allow ourselves to experience the reactions to bereavement, these feelings may become repressed. This can lead to a state of complicated/delayed/displaced/pathological or abnormal grief.
Usually in pathological grief, a considerable amount of time has passed since the death. Clients may come to therapy with no idea why they need help. During the therapeutic process one may find a recurring theme of loss. The bereaved may be consciously aware that they have not dealt with the loss. On the other hand they may feel that it was so far in the past that they must be over it. Due to the circumstances of the death they may find it impossible to accept the fact that the person is gone. They may have a relatively excessive reaction to a current loss. These may be indicators of pathological grief.
Horowitz (c.f. Worden, 2001, p.89) describes abnormal or pathological grief as “the intensification of grief to a level where the person is overwhelmed, resorts to maladaptive behaviour, or remains interminably in a state of grief without progression of the mourning process towards completion……..[It] involves processes that do not move progressively toward assimilation or accommodation but, instead, lead to stereotyped repetitions or extensive interruptions of healing”.
There is a difference in how the grieving processes are dealt with in therapy. Grief counselling is used to facilitate the client to go through a normal grieving or mourning process. Worden (2001) tells us that the goal of grief counselling is to facilitate the tasks of mourning in the recently bereaved in order that the bereavement process comes to a successful termination. However grief therapy is applied in complicated or pathological cases of bereavement. The goal, of which, is to identify and resolve the conflicts of separation which preclude the completion of mourning tasks in persons whose grief is absent, delayed, excessive or prolonged.
I am now going to outline Worden’s (2001) tasks or phases of grieving. These tasks are in order but not necessarily sequential. These tasks can be used to resolve pathological grief and they can be worked through separately and revisited over time. When all these tasks are completed then the grieving process is over. If someone gets stuck at one or more tasks then complicated/pathological grief will result. By using these tasks we can see if there are unresolved issues around bereavement, leading to pathological grief. As stated previously usually a substantial period of time needs to elapse, since the death, before one is able to assess if the grief reaction is pathological.
Task I: To Accept the Reality of the Loss.
One of the reactions to death is not to accept the finality of it or to accept that a mortal event has occurred. This is represented by denial and an inability to accept the loss. During this phase the person goes through a period of numbness. The successful completion of this task will result in the bereaved accepting the intellectual and emotional reality of the loss.
If however there is some confusion around the issue of the death of the deceased or if the client is uncomfortable and resistant about talking about the dead person, this may indicate a lack of acceptance concerning the loss. People may use present tense. They may keep personal belongings, for years, in the (sometimes unconscious) hope the deceased will return. The opposite is also true; people may discard the deceased personal belongings to facilitate them in not having to face the reality of a loss. The way or location in which a person died can affect the resolution of this task.
Task II: To Work Through the Pain of Grief.
The pain of bereavement manifests itself emotionally and physically. In this task it is necessary to acknowledge the pain and feel it. However this experience may be at odds with societal conventions. If this task is unresolved people may carry this pain for life.
The therapist looks for signs of the person cutting off their feelings around the bereavement and hence denying the pain. People can also use their rationality to suppress the emotional pain. A person who intellectualises consistently may be a candidate for one who has not worked through the pain. As mentioned earlier anger can play a part in the normal grief process. One should look for signs of displaced anger. To feel this emotion towards the deceased may be too painful.
Task III: To Adjust to the Environment in Which the Deceased is Missing.
Firstly one needs to learn to function without the deceased. This may mean taking on roles that the deceased performed. Then one must evaluate your sense of self and who you are without the deceased. Then one needs to work through how the death affects one's spiritual assumptions about how the world is.
Pathological grief in relation to this task manifests itself in the person presenting as helpless, showing an inability to cope with life and or withdrawing from social responsibilities. The person finds it difficult or indeed does not want to move forward.
Task IV: To Emotionally Relocate the Deceased and Move on With Life.
To find a place for the deceased that will enable the mourner to be connected with the deceased but in a way that will not preclude them from getting on with life.
Pathology would take the form of a person having an inability to form new relationships. They may have a sense of guilt or unfaithfulness. An inability to love or find love again may indicate the non resolution of this task.
People may exhibit signs of clinical depression due to the normal grieving process. However the main distinction between depression and a grief reaction is that there is no loss of self esteem. It is possible that the person is clinically depressed if there is an associated loss of self esteem. Worden (2001) describes this as an exaggerated grief reaction. High levels of anxiety manifested by panic attacks and phobias may also indicate an underlying disorder. Agoraphobia or a generalised irrational fear of things or people may have to be treated by psychotherapy. If the person is manifesting alcohol or substance abuse, due to or exacerbated by the death, this will have to be treated. Due to the nature of a particular death, i.e. a traumatic or violent death, or indeed exposure to trauma or violence, the client may suffer from post traumatic stress disorder (P.T.S.D.) The classic symptoms of P.T.S.D. are: hyper arousal; constriction; dissociation (where one feels detached from the reality of ones life, like you are an observer looking at what is happening to yourself); denial and feelings of helplessness, immobility or freezing. (Levine, P. 1999). There is also an association of mania with grief. The main symptoms to look out for in the case of mania are: agitated or enthusiastic activity, a person always on the go, difficult to contain, and in their conversations are easily distracted and quickly shift the gears of content (Kennedy & Charles 2001).
I would like to conclude the essay by giving an example of prolonged or pathological grief from my own experience. My mother died when I was 20, from cancer. She spent her last 3 months in St. James Hospital. I watched her deteriorate physically from the cancer, mentally form the palliative drugs and emotionally from the fear of not knowing what was happening to her. I spent hours each day in the hospital with her. I was strong for her and for everyone else who saw her, as a person that they did not know. I was holding her hand at the time she died. Even though I saw and felt her die I could not accept what was happening. Even when the doctor brought my father and I into the tea room to confirm the death I was still in denial. My reality became very blurred. The funeral was another blur; I was numb, expressionless and emotionless. I comforted myself by remaining busy and organising the funeral. The only emotions I remember were my father handing me a cigarette as we drove over Rialto Bridge away from the Hospital). I also remember two teenagers, in heavy metal gear, waving goodbye to the hearse as we drove behind it along the canals on the way out of Dublin. I saw this as a sweet gesture.
I remember all the fine details about the funeral, but I couldn’t tell you how I felt. Why? Because I didn’t allow myself to feel, I didn’t allow myself to cry, I was numb. I remained like that for a long time, always participating but feeling nothing. I was haunted by recurring nightmares where my mother was neither alive nor dead. After these nightmares I found it very hard to tell fantasy from reality. Sometimes I would ring home expecting to talk to my mother and I found it very hard to convince myself that there was some reason that I couldn’t speak to her. Driving home on weekends I would have problems accepting that she was not in the house and I remember thinking thoughts like "did we move?" "Are my parents separated and no one is telling me?"
As I said this continued occasionally for about 7 years the intensity and frequency diminished over time to be replaced by new nightmares. Every time since, when someone I know has died or I experience loss I am revisited by that special numbness.
I worked through this in my own personal therapy. The first time I even allowed myself to cry was 15 years after the event. I have now learned to accept the loss, acknowledge and work through the pain, find my way without my mother and I will always have a place for her in my heart. However this process took me fifteen years.
Kennedy, E. & Charles, S.C. (2001). On becoming a counsellor. Dublin: Newleaf.
Levine, P. (1999). Healing trauma restoring the wisdom of the body. Boulder: SoundsTrue, Inc.
Worden, J.W. (2001). Grief counselling and grief therapy third edition. New York: Springer Publishing Company Inc.
Categories: General Writings