Life’s greatest pleasures can sometimes cause the greatest pain: a job loss because of company downsizing, a miscarriage after years of trying to have a baby, the death of a beloved spouse or parent. Regardless of the type of loss, traumatic events can lead to crying, insomnia, fatigue, confusion, deep sadness and a host of other symptoms. So how does a psychologist determine if symptoms have crossed the line and become something more serious than grief?
Jill Colman, Psy.D., a private practitioner in Cambridge, Mass., says, “In almost all clients, there is a layer of grief. What brings the client in is the starting point. The past will inform the way the person is grieving now, so personal and family mental history is important to have.”
“Some [clients] have bad relationships, others are dissatisfied in life and others are grieving what they didn’t get in life,” Colman says. “But the first layer is grief with loss.”
Just as the response to a grief situation varies from person to person, so, too, do treatment options, depending on the type of loss and severity of symptoms. “The combination of medication and psychotherapy are considered the best practice,” says Colman, adding that appropriate bereavement support groups can contribute to the healing process as well.
During the evaluation process, the clinician should keep the circumstances surrounding the traumatic event in mind to determine the most beneficial therapy. For instance, for a miscarriage, Colman considers the psychological construct. She says, “Was the woman further along [in the pregnancy]? Was she ambivalent about the pregnancy? These factors impact the grief process.”
Clinical depression presents with more biological symptoms, notes Colman. “You have to make distinctions in the beginning of treatment. If I have been seeing someone a few weeks after a loss and there is no improvement, I might refer the person to a psychiatrist for medication evaluation,” she says.
Sharon Volansky-Gerard, MA, a psychologist in private practice in Stowe, Vermont, says, “Generally, people think in terms of 13 months as a typical grieving period. Usually, the first three months are very intense, but at 13 months, those people will be far better off than those who were stoic and did not grieve at first.”
“In time, the person can choose to take out memories and look at them more consciously, perhaps at an anniversary or other occasion to re-experience some of the sadness or sense of loss,” Volansky-Gerard says, adding that anyone going through the grief process should anticipate emotions to surface at the most unexpected times.
No set rule exists for when to seek counseling; some individuals may wait three or four months or longer before seeking counseling. “If you find yourself disconnected from the world, have lost interest in normal things in life, can’t get off the couch, the person usually contacts a counselor,” Volansky-Gerard says.
Not all grief issues are readily apparent. At times, a client may present with an unrelated diagnosis and in the course of treatment, unresolved grief may surface. In such cases, Volansky-Gerard indicates that it’s necessary to revisit the traumatic situation and proceed from there. “When old grief never gets expressed, it takes its toll in time,” she says. “I can’t back it up with research, but anecdotal evidence indicates that physical illness may be involved with grief.”
Clinicians should also bear in mind cultural beliefs when treating an individual who is grieving. “Some cultures require mourners to cover mirrors, wear black and remain isolated. We need to figure out if this is normal or disproportionate,” says Volansky-Gerard.
The topic of grieving has been under discussion as a study team charged with updating the “Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition” (DSM-V) examines the diagnoses in the current version. This team is considering removing the bereavement exclusion; this action would suggest diagnosing anyone manifesting normal grief symptoms two weeks after a loss with depression, rather than as a typical response to a traumatic life event. However, the group is suggesting a footnote be added that would advise clinicians that grief is normal and expected after a loss and that symptoms may resemble another diagnosis.
Sheila Gardner, Ph.D., private practitioner in Durham, N.H., president-elect and chair of the New Hampshire Psychological Association’s legislative committee, says, “I see the value of having categories, but I’m not looking to over-pathologize normal processes. What would be the point of putting a timeline of grief? How does that help the person? How does it change what I do with the person?”
She notes that when clients come to her they are already aware they are “stuck.” “To approach them with a predetermined notion would not be useful and would be overly rigid. I don’t want to do anything to enhance the shame they feel [because] they’re still grieving. I do not want people to think they have pathological grief.”
Volansky-Gerard says, “We’ve lost sadness as part of our language. The typical, normal grief reaction has an intense, wide range of emotions. I appreciate that if things are going on much longer than one or two years, it makes sense to get more formal intervention. Treatment can be helpful for some, depending on the type of death.”
She prefers an alternate diagnosis, Persistent Complex Bereavement-Related Disorder, which is still undergoing research. She believes this diagnosis would more specifically categorize grief, although she hesitates to apply a mental health diagnosis to a grieving individual in the first place. “It can be a real problem when someone gets a psychiatric diagnosis. It never leaves you,” she says, citing a case in which a person was denied a much-needed lung transplant because he had, at one time, been given a mental disorder diagnosis. “There is something important about normalizing grief. That experience is not a medical disorder,” Volansky-Gerard says.
Colman points out that not grieving is unhealthy. “Common wisdom says we all have a certain number of tears. They have to come out somehow,” she says.
By Phyllis Hanlon