Greg Thorkelson, MD with Ryan Reagan, PhD(c), LPC

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It can easily be one of the most wretched of human experiences. There is no textbook for it, and therefor no right or wrong way to do it.  If there was, you would simply buy the book and follow the necessary steps and then it would be finished.  But it never exactly finishes does it?   It just hurts differently. Grieving is a process and sometimes it needs revisited. This distinguishes it from other complaints routinely treated within the mental health system.  The term “complaint” is used here because grief is not a mental illness.  Yet, it can be every bit as disruptive, painful, and debilitating as a major depressive episode (MDE).

In fact, grief shares a broad overlap with the symptoms of depression.  Depending on the characteristics of the loss those symptoms can range in intensity.  With depression one of the two symptoms need to be present to make a diagnosis: a pervasive depressed mood state accompanied by sadness and hopelessness; the other symptom is anhedonia, or an inability to experience enjoyment. These symptoms must occur for most of the day and be present for at least two weeks. In the cases of an unanticipated, traumatic loss, grief can easily produce intense feelings of sadness and an inability to experience joy.

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Along with the two symptoms above, mental health professionals diagnose depression based off an additional collection of symptoms—changes in appetite, sleep, feeling fidgety and restless or the opposite, feeling slowed down.  Again, it is not uncommon with an intense grief to see these symptoms as well.  It is also not uncommon to encounter the most serious symptom—passive death wish or suicidal ideation, especially when the loss is an intimate partner e.g. “I don’t know how to go on without…”

Despite the commonality in symptoms, there is one feature that tends to differentiate grief from depression. It concerns how we feel about our self.  Along this dimension, people that are experiencing depression often report feelings of low self-worth.  Individuals who are grieving on the other hand, report feelings of emptiness.  This makes sense, we are talking about loss.  If the intensity of the grief is enormous, you literally feel as if something has been removed from you.  

Mental health professionals who work with grief sometimes make the distinction between “complicated” or “carried” grief.  The latter terminology is probably preferable.  All grief is complicated because of its pervasiveness, it touches and invades multiple areas of our lives.  Depending on the relationship it can feel all-consuming. If the relationship itself was complicated or strained it adds to the complexity.  If the circumstances are traumatic, unexpected, or unusual it can add additional layers of complexity.  This can certainly make it more challenging to process the grief and move forward, which is what is meant by the term carried grief.

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Grief can persist well beyond what is typically regarded as average—6 months.  If you are suffering from an intense and unremitting grief it may be worth doing some therapy.  There are also grief support groups in most communities.  Therapy and medication cannot cure grief, but they can facilitate recovery and help bring down the intensity of the emotional pain.  Below are some coping strategies and skills that may help with the grieving process:

Distractions: grieving sometimes requires that you distance yourself from the intensity of the emotions. This is one of the reasons that people often resume routines and express a desire to be busy.  It’s like a hot burner that you must come back to when it cools. The cooling will never be as fast as we would like.

Allow yourself to feel whatever you feel: grief can bring a range of emotions other than just sadness. It can easily evoke anger and guilt. There are moments where you may feel an overwhelming and painful sense of joy and connection to the departed.  The important thing here is to acknowledge the emotion.  If you can label the emotion ask yourself “is it ok to experience (blank) if someone lost (blank)?”  For example, ask yourself “is it ok to feel angry if someone lost a parent?”  In this step you are validating the emotion you are experiencing. If a friend had said to you “I feel really angry about losing my mother.”  You would almost certainly acknowledge this is reasonable.  Sometimes in the suffering and conflicted emotions we forget to tell ourselves that it makes sense to feel this way.  

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These two skills form a bit of a two-step, walk away from the burner when it is unbearable, return when it feels cooler.  Provide space and time to do the second step as you can bear it. This may look like going to work and doing your absolute best with a zombified brain, barely functioning, just to come home and sob hysterically until you fall asleep. As a popular book on grief says “it’s ok to not be ok.”

Readers of this blog will know that we are a big fan of:

Meditation: you likely have noticed that meditation is everywhere now.  Despite its popularity we still have much to learn about the practice.  There are different pathways to meditating, including yoga, prayer, and the very popular “mindfulness” approach.  However, there has been some recent critique questioning whether “mindfulness” is the best approach for some. With grief one of the challenges is that we often end up ruminating.  This is the “should have, could have, would have” conversation on autorepeat. Its nothing more than the brain trying to close out the story.  The problem with ruminating in general is that time moves in one direction, we don’t get do-overs.  There is a line in a popular book on grief—“grief is an unfinished conversation.”  We hurt because we don’t get to continue the conversation.  Prolonged rumination actually keeps us stuck in a loop, and simply being mindful and aware of this fact may not help.  For rumination, a guided meditation or one that requires focused and sustained attention on a task might be a better match.  It snaps the mind out of mental wandering.

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In the book When Children Grieve the authors provide examples of how to write a completion letter.  There is an actual formula for doing this type of writing and many people find it cathartic when the moment arrives for this activity. The exercise is certainly applicable for adults as well.  The general outline is as follows:

Completion Letter:

[A] = Apologies

[F] = Forgiveness

[SES] = significant emotional statements that are not forgiveness or apologies but should be said. (really important or meaningful things)

[FM] = fond memories.

Here is an example of what this might look like:

Dear Nick,

I was sad to here of your passing.  I am sorry that we did not get to catch up in person. [A}  I really appreciated that you reached out a few years ago and that we got to joke about how much trouble we got into as children. [SES}. I remember you saying that your Mom was in the room and laughed when I mentioned what we put our parents through. [FM] Nick, I know that growing up we often did not get along. We were often cruel to each other. I forgive you for that, and I apologize for my behavior as well [F, A]. Our neighborhood was a rowdy bunch.  Despite that there were a hell of a lot of laughs. I will never forget the time you tried to have me ride your dirt bike and it got away from me, the trip to Hershey Park when that guy Ed yelled at us, hours of sledding, bike riding, etc [FM]. Thank you for that time when I fell and split my knee, you went and got my parents. [SES] There is a line at the end of Stand By Me that says something like “do you ever have better friends than you did at age 12?” I feel that today. A piece of those days has left me. I wish you peace my friend. Goodbye Nick.

Examples in the book are much more extensive.  There may be the need to do multiple drafts and rewrites. But as you can see there is a pattern here that helps to form a narrative structure that works toward closure. This can be repeated as often as necessary. With adults and those who struggle with complicated grief it may be helpful to apply this exercise during meditation.

Finally, many people find it helpful to do something to transform the grief.  It comes as no surprise that certain activities like gardening cross cultures—it symbolizes rebirth.  There is even research to support that gardening is highly therapeutic for depression, and while grief is not the same thing, symptoms do overlap.

Honoring: in addition to gardening there are other activities that can assist with the transformation of grief.  This may include donating to a cause that was important to the loved one. Families may dedicate spaces or objects in memory. Anniversaries are always difficult, but these can also be used to honor memories.

“Life will break you. Nobody can protect you from that, and being alone won’t either, for solitude will break you with its yearning.  You have to love. You have to feel. It is the reason you are here on earth. You have to risk your heart. You are to be swallowed up. And when it happens that you are broken, or betrayed, or left, or hurt, or death brushes too near, let yourself sit by an apple tree and listen to the apples falling all around you in heaps, wasting their sweetness.  Tell yourself that you tasted as many as you could.”

--Louise Erdrich

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