11 May 2018

Grief cannot, and should not, be rushed

Clinical Mental Health

We may be getting better at talking about death, but are we falling short when it comes to managing the longer-term grief?

Strange how you tend to get runs of certain presentations isn’t it? 

Von was about my fourth patient in as many months who was struggling to come to terms with the loss of a loved one. 

She was in her late 60s and her husband, who had been considerably older than her, had been ill for many months with severe heart failure, so his death hadn’t been a shock. Nonetheless, six months down the track, poor Von could not understand why she still felt so lost and unable to discuss him without dissolving into tears.

Compounding her distress was the fact she felt she should be “getting over it” by now and “moving on”. She was making people feel uncomfortable when she got emotional, so she simply avoided those triggering conversations, even with her children.

It was a familiar story among my recent run of older patients – two who’d lost husbands, one a sister and another a brother. There was a consistent theme of searching for guidance on how to manage mourning – after the death, after the funeral, after all the friends and relatives have resumed their often busy, and often unchanged, lives. 

They’d all presented thinking there must be something wrong with them for continuing to feel this grief past what they felt was “normal”, which in their minds was maybe a couple of months.

It’s been almost 50 years since Kubler-Ross gave us the classic phases of grieving. There is now a wealth of resources available that people can access when confronting mortality – either their own or that of someone close to them. And between advanced care directives, palliative care and the euthanasia debate I believe, as a society, we are getting a lot better about talking about death and dying.

But maybe we fall a little short when it comes to managing the longer-term grief. 

Maybe it’s our tendency, in this digital age, to focus on the immediate and our consequently short attention span that expects everyone to always be looking to the future rather than “wasting time” on the past. 

Maybe it’s our modern Australian culture that has left us without any rituals beyond that of the funeral. Historically, rituals tended to give stage gates for grief or, at the very least, a public acknowledgement of a realistic time-frame that it might take until that grief might lessen.

I have patients from other cultures who expect to wear black for a year or more after losing their husband, or who have a religious ceremony marking the monthly anniversary of their partner’s death for 12 months, or only unveil the tombstone at the one-year anniversary. 

I’m not suggesting we restore the notion of widow’s weeds, but perhaps there needs to be greater recognition that the grieving individual will be vulnerable for a period that is far more likely to measured in months rather than weeks.

I distinctly remember sharing cappuccino and Kleenex with a friend who had lost her husband unexpectantly, 10 weeks prior. We were joined by another friend who looked at the two of us and asked, more in genuine surprise than unkindness, “are you still crying?”

When the latest update of the classification of mental illness, the DSM-5, was published a few years there was considerable controversy about the guidelines in relation to grief. 

The new DSM-5 actually took away the need to exclude recent bereavement when diagnosing someone with a depressive or adjustment disorder. So theoretically, you could present within a few months of losing your much-loved partner and actually be diagnosed as having an affective disorder and be given medication.

To be fair, I don’t know of any doctors who do this, but this tendency to blur the distinction between significant grief and perhaps a mental illness is, I feel, reflective of modern-day thinking.

Even their classification of a complicated grief disorder which can’t be diagnosed until the person has been grieving for at least six months, gives the impression that by six months one should be over it. (Of course, complicated grief disorder is more than just persistent grief, but the broad-brush definition gives that impression).

No one wants to be persistently unhappy. No one wants their friend or relative to be persistently unhappy. 

The idea that someone should be allowed to have, and maybe needs to have, sad, painful conversations about their husband, mother, child many months after their death isn’t always a comfortable reality. 

But expectations that the grief process should be complete in a couple of months doesn’t help anyone, least of all the person going through it. And it is often the grieving person themselves who has these expectations, which explains why they appear in our consulting rooms.

I often explain to patients the concept of the year of firsts, which many grief counsellors talk about. The first wedding anniversary without their partner, the first Christmas, the first Mother’s Day et cetera. All are sad milestones that should be expected to be painful and acknowledged in some way, culminating in the first anniversary of the death. 

I’m hardly a psychological guru, but I have found just the 12-month time frame of this discussion often helps patients reconsider their concept of a “normal” grieving period.

In Von’s case, she made a point of acknowledging some of these “firsts” by organising get-togethers with particular family and friends on those dates. In a way she created her own rituals, which she found comforting. 

She was still sad, but less anxious about feeling sad. Perhaps just the recognition she didn’t have to concertina all that grieving for a lifetime of memories into just a short couple of months helped as well. Grief cannot, and should not, be rushed.

Something to say?

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5 Comments on "Grief cannot, and should not, be rushed"

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Chris Hazzard
4 years 3 months ago
I do not believe in putting a time limit on grieving. Although there are some common manifestations each one of us will experience loss in our own, sometimes inexplicable way. I discovered this with the death of my mother. She had concealed her breast cancer for years and late one night asked me to come around at which time she showed it to me. I have enormous feelings of guilt that I referred her to someone who badly mismanaged her. Never the less I had the fortune to be at her bedside when she died and we buried her in… Read more »
Genevieve Yates
4 years 3 months ago

Wonderful article, thank you. I feel quite passionately about the need to educate (patients and doctors) on grief being a perfectly normal life process and to help them resist the urge to either downplay or to over-medicalise it. I agree that culturally we are not good at talking about or understanding the grieving process. Having had some recent-ish significant losses, I am no stranger to grief, and have written about it here: https://genevieveyates.com/2015/05/07/the-importance-of-rituals-in-the-grieving-process/

I’m so sorry to hear about your loss and your consultant’s response, Alex. I have had similar experiences. 🙁

Alex Douglas
4 years 3 months ago
I’m fine Genevieve. I am fortunate to be very mentally strong. Tragically,my wife was not very well for a long time. My son would have turned 30 years of age,three days ago. To give you an idea how sick this senior consultant under whom I worked and his two sidekick consultants were,he complained bitterly to me ,at the time,that my personal issues were ruining their combined future holiday plans. When I stood up to them,they forced me to resign my job.At present I read widely as many of the trainees across Australia complain about similar behaviour now. Too many within… Read more »
Alex Douglas
4 years 3 months ago

This is timely. 30 years ago when I was a mere humble registrar in a major public hospital in a training program,four days after my son died unexpectedly,suddenly,my senior consultant told me that the best thing that I could do,was get back to work immediately and focus on little else. His idea of empathy was “don’t let your own personal issues get in the way of orderlieness at his hospital unit”. I wonder,really,whether many doctors have moved to a saner approach in recent years.

Karen Price
Karen Price
4 years 2 months ago

So sorry to hear that the “system” dehumanised your tragedy Alex. How especially awful. No one gets over loss of a loved one. Especially not a child. Somehow you get used to it and inexplicably the sun rises on another day. I don’t think grief runs out but then neither do you run out of love for someone once they are gone.

Lovely reflections Linda and an important conversation.