Diagnosing Grief

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Last week Jessa wrote about psychiatric diagnoses moving from the quantum to the continuum, from neat little packages to subtleties that include shades of gray and something called “a quantifiable baseline of life functioning.”  The same week, Ginny published a story about the same diagnostic changes but applied specifically to pathological grief – the problem being that normal grief already looks crazy.

I remember being at a meeting of a support group for bereaved parents maybe a year after my son died and listening to a sweet pretty lady tell how her golfing partner had asked her when she was going to get over her child’s death, and how the sweet lady had run the partner over with the golfcart.  The group thought her reaction was reasonable and appropriate.  I thought, with the amount of anger floating around in this group, we should form a roving SWAT team.

Anger, plus depression, numbness, apathy, isolation, bitterness, yearning, confusion, loss of meaning, you name it, newly bereaved people are a mess.  So what grief is normal? What’s pathological?  In the olden days of Freud, “pathological” was someone unable to detach themselves from the dead person and reinvest emotional energy in a living one, or maybe in a cat.  The detach-and-reinvest model isn’t talked about any more but I suspect it still underlies the idea of pathological grief.  Prigerson et al. — the world-class, experienced psychologists and psychiatrists who wrote the article Ginny cited — used not “pathological” but “prolonged” grief, and said that the field has had no explicit and standardized criteria for it

Prigerson et al. made an intelligent, thorough, and valiant attempt to create some criteria, and even though they’re trying to do science with the uncontrollable variables of the human mind, I don’t doubt them.  Some bereaved people seem just too angry, depressed, bitter, yearning, isolated, etc. for too long; they’re in too much pain, they’re functioning too badly.  When I met such people in the bereavement support group or while interviewing for a book I wrote, I felt they were unreachable, I couldn’t see where they were, they were in a dark little enclosed place — in a coffin, I thought, in their children’s company in death.

I did have a brief doubt about how long a person has to look crazy before being diagnosed as “prolonged.”  The first years after my son died, I felt like a cubist-period Picasso; life looked like death, a flat back lake melting into a flat black infinite sky.  By about year 4, I had cleaned up the house, was returning phone calls, meeting deadlines, and generally taking an interest again.  That seems the usual time frame:  after about 4 years, you’re indistinguishable from normal.  Prigerson et al. interviewed people up to 2 years, well inside the 4-year window. But they weren’t finding 100 percent of their interviewees bug-nuts diagnosable, so I assume they took the worst cases and declared them “prolonged.”   So, ok.  After all, they’re looking for the “quantifiable baseline of life functioning” that Jessa mentioned, for a gray scale of dysfunction.  So to put it all together, psych research says that after a couple years, some people just haven’t detached and reinvested enough that they can function normally; and now not-normal is quantified.

Here’s my only caveat:  refine that word, “detach.”  One day after I’d begun working on my book,  I stepped wrong off a curb and fell, cut my knee badly, and went to my family doctor.  He began stitching up the cut, and because he’s a gregarious fellow and knows I’m a writer, he asked me what I was working on.  I told him.  “That’s a subject no one wants to talk about,” he said.  “People suppress that.”

I thought he meant people who had not lost children don’t want to talk about children’s deaths, agreed with him, and let the subject drop.  He made a stitch.

“I lost a child, you know,” he said.

“I didn’t know that,” I said.  “I’m so sorry.”

“Well, it was a long time ago.  It was just a few months old, bad congenital heart problems,” he said in the off-handed, seen-it-all way that old doctors have.  “I never think about it.”

“How long ago?” I asked.

“Thirty years,” he said.  “It doesn’t affect me.  The reason I think it doesn’t is, you don’t have a chance to get close in just a few months.”

I don’t remember him referring to this baby as “he” or “she,” only as “it,” an age, and a fatal condition.  I thought, Ok, maybe he didn’t get close and thirty years is a long time, and I dropped the subject again.

“Are you going to put me in your book?” he said.

“I’d love to,” I said.  “I’ve had trouble finding fathers who will talk about it.  The interview would take several hours.”

He said, “I’d have to be anonymous,” made a tricky knot, then reconsidered.

“No, I don’t want you to interview me,” he said.  “I don’t want to talk about it.  I don’t want to dredge it all up.  It would hurt too much.”

I thought I’d let that pass but couldn’t.  “If it didn’t bother you too much,” I said, “maybe it wouldn’t hurt to talk about it.”

He started laughing.  “You really know how to hurt a guy, don’t you,” he said.  “Now I have to go see a psychiatrist.”

So before I left, I made a bargain with him.  I would ask him again in a month, and if he still said no, then no.  A month later, he still said no.  “It was so long ago,” he said.  “Time is the great healer and I don’t want to open up those old wounds.”

“Thank you for considering it,” I said, and thought, thirty years and a baby he didn’t get close to, and wounds that can still be opened.

“Detach.”  For a long time, I had regular dreams in which my son was pale and weak, so sick he was going to die; or he was shut up and dying in a room I couldn’t get into; or he was alive right then but he’d have to go back to being dead.  These dreams were unspeakable.  But now, 24 years later, I don’t have them any more.  In my dreams now he’s alive and going about his business as usual.  Sometimes I dream questions, can he go back to school? is he not dead?  And even in the dream, I know the answers: of course he can, of course he isn’t.  Here he is, he’s right here.

_____

Parts of this post have come from a Mar 4, 1997 op-ed I wrote for USA Today (behind a paywall), and from my book, linked to above.

Photo credits:  top – Kevin Dooley; bottom – Eric Vondy

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15 thoughts on “Diagnosing Grief

  1. Yes, quite. There’s no such thing as detaching from part of oneself. It’s such a silly notion that this depth of bond would have as its object something physical and would somehow dissolve — of course not.

  2. Powerful article. I see grief as soap bubbles. Always floating around somewhere, sometimes invisible, sometimes shimmering with colour, easily burst, beautiful moments, moments of sharp, terrible loss. Impossible to ignore but joy at having seen them in the first place.

  3. I’m not dead sure about any psych definition of “detach.” But I’m pretty sure they don’t pay much attention to it.

  4. That’s interesting that you say they may not have paid much attention to the definition of “detach,” because it seems crucial to me. Then again, maybe it’s just a red herring. What I mean is, I think that remaining attached to a child who has died doesn’t necessarily prevent people from “reinvesting” (man, I kind of hate that economic language) in other parts of their life, specifically in other children they may have already or who come along later. So what does “detach” mean, anyway? The kind of continuing attachment that you describe seems like the way it should be, honestly.

    What a beautiful post.

  5. I’m now firmly in over my head. Where would I look to find a psych definition of “detach” that’s based on research? I’d start with attachment theory, which doesn’t apply specifically to grief. I’d look for psych studies that covered more than the first 2 years of bereavement. I’d like to know whether, as Sarah suggests, detaching and re-investing are necessarily coupled, or whether you can have one without the other. Maybe the only definition of “detach” could be negative, that is, what it does not mean. As I said, in over my head. Anybody?

  6. Beautiful post Ann.

    I have a knee-jerk reaction against turning grief into a diagnosis, and the idea that that grief should have some kind of correct duration seems dismissive to me.

    The word detach feels very wrong too, unless it refers to the death itself, not the person. In my own experience, detaching from the experience of the death can free you to remember and connect to the person as they were in life. At first, you can’t stop thinking about the death itself, especially if it was shocking or unexpected, but at some point you have to let go of that moment so that you can regain the memory of the living person.

    I’ve never seen a better description of grief than Kathleen Sheeder Bonanno’s poem, Death Barged In.

    http://www.poets.org/viewmedia.php/prmMID/20585

  7. Bonanno sure nailed it with those last lines. Yup.

    The psych profession has to help these confused, frightened, frightening people and given the odds against, does a good job of it. So they focus on whatever helps them do that, which isn’t necessarily what I myself want to know. You’re certainly right, that you learn to distinguish between death itself, pain, and the person who died.

  8. Wonderful article Ann. Personally, I don’t think one ever becomes completely “detached” from the loss of a loved one (hearing this from my sister who lost her husband about 39 years ago). Each day may go perfectly and without a care in the world and then you hear a sound, a sight or a smell and all of a sudden you’re back in your own little nightmare. It’s been 2 1/2 years since I’ve lost my husband of 20 years, I agree, time has a way of healing wounds, but I’m still consistantly putting Neosporin on a would that repeatedly keeps getting infected. The dreams are also very interesting. Every now and then he pops up in my night visions and I am always angry at him – he’s cheating on me with another women, he’s drinking too much, etc. Maybe pathological is the correct word – for me anyway, but I’ll never give up. I know that this too shall pass.

  9. My wife and I lost our 25 year old daughter thirteen days ago, on June 1, 2011. My state of mind changes from minute to minute, hour to hour. Sometimes I cry. A lot of the time I feel very annoyed. Once or twice a day I feel like everything is fine: she wasn’t living with us, and it is as though we are in between visits. Usually she would spend the evening her once every week to ten days, and would sometimes sleep here. Sometimes I get quite angry.

    I will never detach from her — I can’t see any way that would be either possible or something I would wish for, unless I happen to develop amnesia for the past (and best) 25 years of my life. Now that would be pathological!

  10. I should also say, what a beautiful, insightful post. Thank you so much.

    My heart hurts for your doctor. Yes, I still have room left for someone else’s hurt. The manner, place and time of my beloved daughter’s death was kind both to her and to us, and we are fortunate to have time to think back to her life and gain a little more understanding of what just happened.

    For now, my daughter is peripatetic. She is definitely right here, and always will be, I hope, but at the same time I am looking for her everywhere, anywhere. Miriam, I love you.

  11. Thank you, Ann. I’ve been thinking a lot about this after reading The Year of Magical Thinking.

  12. I haven’t read that book, Naomi. It had great reviews. But I just didn’t want to go through it with her.

  13. In my search to understand perceived reality and human feelings among other things… this post and it’s comments have given me some perspective.. Thank you.

  14. It’s so tough to even write about this stuff, isn’t it. I have no words for my sympathy for you and your wife. I wish I could help you.

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