Is your grief lasting too long?

For more than a decade, mental health professionals have debated whether grief is a psychological disorder or a natural process. This spring, the American Psychiatric Association finally decided to add prolonged grief disorder to their Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the D.S.M.

The decision is not without controversy. Some have contended that it is pathologizing a normal part of life. They fear it will lead to overmedicating patients. Others question how long it should take to grieve. How long is too long? When will the pain end?

The answer the American Psychiatric Association came up with is that anything longer than one year is too long. The description of prolonged grief in the D.S.M. is: “intense and persistent grief that causes problems and interferes with life.”

Cape Cod Healthcare therapist/clinician Cheryl Powell, LMHC, MaCCS, said the new definition really isn’t anything to worry about. She has treated patients for grief for many years and expressed the belief that the new diagnosis should not change the way she does so.

“A diagnosis is a collection of words that guide and describe,” she said. “In order to treat a person and to charge an insurance company you must have an associated descriptive diagnosis. However, we treat human beings and the experience of grief is far more than words that impact on individuals differently."

“I agree that grief is unfortunately a normal part of life, but it is also an abnormal state from regular daily functioning due to increased stress and heightened overall reactions as a result of loss. What you do is look at the symptoms and try to figure out where an individual fits in. How can I tailor therapy to help this person?”

Prior to the new guidelines, grief was listed under acute stress disorder and that was a diagnosis that pertained to a disorder that typically lasts from one month to one year, Powell said. It was introduced in the DSM-IV to describe such reactions that occur in the initial month after exposure to a traumatic event, such as grief, and before the possibility of diagnosing post-traumatic stress disorder (PTSD), she said.

Coping Skills Differ

To Powell, it doesn’t matter if the grief lasts for one month or three years. What matters most is how to help that individual patient. Different patients have different reactions to grief and Powell has seen the full gamut.

“Everybody’s coping skills are different because everybody’s resilience is different,” she said. “It depends on a lot of things – genetics, upbringing, role models, culture, and the individual’s experience with resilience and processing difficulties in life. Some people handle it relatively well, while others do not.”

She points out that we all realize that death is unavoidable, but the circumstances have a huge bearing on how people cope. For example, the death of a beloved grandparent in their late 90s is sad because you love them and will miss them, but you can console yourself with the thought that they had a full and happy life, surrounded by love.

The death of a 5-year-old child in a car accident or of a 20-year-old with cancer can cause quite another sense of grief because it doesn’t fit into what we consider the natural order of things. Deaths by suicide or drug overdose can also be very hard to get over because there may also be a sense of guilt or outrage that it could have somehow been prevented.

“These are out of sync timings, out of what we perceive as a ‘normal’ order in life. They shouldn’t happen yet, sadly, and tragically, they do,” she said.

When a loved one who has had a prolonged and painful illness finally succumbs, a lot of family members feel relief that their loved one’s suffering is over, but they can also feel guilt that they feel that relief.

“Grief is a tough one because it’s very painful,” Powell said. “It’s not like a broken bone or an upset stomach or flu or something like that where there is a known treatment course. It’s usually an emotional upheaval and it can impact on a person’s entire life in various ways that are different for each person. Some people are just naturally more resilient, and they go through grief quicker. Others are shattered and/or feel trapped.”

Treatment is Individual

Powell looks at the individual patient and tries to assess their needs and strengths. Then she tries to tap into those strengths to help. Some people are helped by making it more tangible, such as putting their grief into an object like a pillow on their bed or a small and meaningful object they can carry in their pocket as a symbol of their love. Others are helped by planting a tree or shrub in memory of the person they lost.

Another idea she suggests after some time has passed and the loss is no longer so “raw," is to create a memory book with photos, certificates and other mementos of the person who passed, which can be a family project toward which they can direct their shared grief.

“Having a support system is very important,” Powell said. People with strong support systems tend to do better than those who really don’t have anyone to give them a hug or stop by for a visit. In cases like that, a support group is a huge help because it offers a shared experience with other people who will understand your pain and can share in the healing process.”

One of the common things she hears from patients who start therapy for grief is, “Can you make me forget?”

“The answer is no,” she said. “For one, I wouldn’t recommend it. You don’t want to learn to forget. You want to learn to heal and honor the time shared, which is far easier said than done. Neither is it linear. Words are easy; emotional pain is hard.”

Most people are familiar with the five stages of grief, based on the research and books by Elizabeth Kübler-Ross. Kübler-Ross proposed that grieving people usually go through the following five stages: denial, anger, bargaining, depression and acceptance.

“Not everybody goes through those five stages,” Powell said. “And not everybody goes through them in order, either. It’s rarely a linear thing.”

Powell doesn’t always agree that acceptance is a fixed stage. She refers back to the 5-year-old killed in a car accident. “How do you accept that? Sometimes you just can’t accept a loss no matter how much time has passed. The book, It’s Okay That You’re Not Okay, by Megan Devine, can help in those situations,” she said. “Reframing is also possible.”

“You can learn to live your life and to value and honor the person or people who have passed and to cherish the moments and the time you had,” she said. “You can learn to find meaning to carry on with a meaningful and joyful life and still find value in life.”

Powell said she occasionally references her own grandfather, when speaking of her own grief.

“When I was a teen, he tried to prepare me for his and my grandmother’s passing. I sometimes share his explanation that: ‘We never completely die because we, as sentient human beings, live on in the mind and hearts of those we loved and who loved us in return through our shared memories and emotional ties.’ That thought, and realization has comforted many which, for me, helps to prove my grandfather’s point."