<h1>David Earl Johnson, MSW, LICSW</h1>

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    Grief is how we honor our losses. During the holidays we are often reminded of the losses we've had, the family and friends we miss. Grief is the process by which our review your losses, honor our feelings about them. By reviewing our losses, we learn as much as we can about how to make up for our losses and prevent similar losses in the future. Grief is a process of reassessing priority and values, and assigning meaning and purpose. A meaningful loss requires time and effort and is perhaps the most miserable emotional process we face in life. The process as necessary and important. The intensity of the grief will subside with time, and you will find yourself a better person because of it, wiser, and more focused on what is most important to you.

    Grief, Loss and Change Class Audio with Handout

    Download handout to follow along.

    Surviving the Holiday Blues

    Category: Grief
    Created on Sunday, 21 September 2014 17:09
    Written by DaveMSW
    Hits: 416

    The holiday season is such a joyous time of year. Colored lights adorn houses and business. Thoughts of holidays past fill our minds and conversations. But not everyone can enjoy the holiday season. Some of us inevitably find as the holidays approach what is called the "holiday blues". The holiday blues are quite common. We expect to enjoy ourselves during the holidays. Those around us expect we will enjoy holiday celebrations and their company as well. We feel that pressure within ourselves and others. But sometimes what we really need is acceptance of ourselves and others.

    There are many things that may bother us during the holidays: a death in the family, financial set backs, separations from loved ones due to work, military deployment, or other reasons. There can be losses due to health, a loss of relationship. Even happy changes have elements of loss and disappointment including getting married, or having a new baby. Celebrated changes often include a major change in lifestyle, a loss of choices and freedom. And of course those of us who struggle with depression and/or anxiety can experience worsened symptoms triggered by the holiday season.

    Sometimes memories stir during this time of year. While most of us are drawn to family during the holidays, some of us have had bad experiences in the past that complicate spending time with family. Our mood and behavior may be affected, our ability to enjoy ourselves is complicated by who we see. We might feel like our feelings get in the way of our holiday. But in fact, our feelings are telling us what we need, unfortunately in a way that is confusing and contradictory. Its like our body is talking to us, telling us what it needs without words, without the sense our mind makes. Sometimes what we need doesn't make sense, it's not logical, it contradicts what we plan and work towards. We might find we get angry at someone we love for something that seems petty. Indeed, it may well be petty, but in the context of our memories and feelings, it will make sense.

    One very common scenario happens when a family of origin comes together for the holiday. People find themselves falling into the roles they played years ago when they lived together. Remember the sibling rivalry you had as a kid? How might it manifest in a family gathering today? Find yourself trying to show off in front of your sibling or even your parent? Find yourself caught in a petty argument with a parent that sounds a lot those of the past? Our emotional or implicit memory provides us with immediate information in familiar situations, or it can provide an instantaneous reaction in a situation that might be risky or even dangerous. Not surprisingly, we react as if there is risk more often than it actually is risky. The cost of a temporary distraction of an emotional reaction is low compared to many risks we face everyday. That's why we find ourselves reacting with excessive emotion at times. We're just trying to protect ourselves.

    When we’re really young and inexperienced, our emotional memory dominates. Our judgment and reactions operate with excessive emotion very often. If something bad happens when we’re that young, we will remember it on an emotional level, perhaps without a detailed thought and image record like we have when we are older. That is why we are quite capable of reacting in what might be seen as an immature way as an adult.

    As an adult, we have learned a lot about ourselves, and most of us can contain an excessive emotional reaction with emotion regulation skills. Some of us, at least some of the time, lack confidence in our ability to regulate an emotional reaction, especially in particularly challenging circumstance. We all have the capability to capture an emotional reaction and consciously redirect it to constructive action. It just takes some practice. One of the best way to develop the skill of redirecting emotion is mindfulness. One of the best courses available on CD is by Jon Kabat-Zinn. It’s a complete course on mindfulness meditation.

    Negative emotions are not the problem, they are a symptom of the real problem. These feelings are how our body and sub-conscious mind communicates with us. Something important hasn’t been dealt with, and our feelings are letting us know.

    Unfortunately, feelings are not so simple to interpret. But once you have figured out what the feelings are about, you can begin problem solving. You are not helpless, even though it may feel that way. If your holiday blues is about the extra demands of the holiday, do something different. Decrease your family time.

    Set a realistic budget for presents. Presents are intended to be symbols of our feelings for each other, they should not break the bank! If you don’t know what to give someone, a gift certificate will do just fine, even though it may not feel quite right. Your first priority is to feel better within yourself. You can’t make others happy no wonder what you do. If someone you are giving to is demanding, that’s their problem.

    If you are grieving, honor yourself and feelings during the holidays. Grief is the process by which you review your loss, honor your feelings about it and learn as much as you can about how to make up for your loss and prevent similar losses in the future. Grief is a process of assigning meaning and purpose to your life. A meaningful loss requires time, effort, and reviewing your priorities and values. Accept your process as necessary and important. The intensity of the grief will subside with time, and you will find yourself a better person because of it, more focused on what is most important to you.

    The Process of Grieving

    Category: Grief
    Created on Friday, 26 September 2014 19:47
    Written by David Earl Johnson, MSW, LICSW
    Hits: 66

    The Journal of the American Medical Association [February 21, 2007--Vol 297, No. 7] published an important article on grief, Maciejewski et al (2007). While it's hardly definitive research, it represents an exciting trend in research that I've seen in recent years. Researchers seem more willing to take some risks with the rigor of their research models to produce information that is immediately relevant to practice.

    While, we are a long way from having clear guidance towards an evidenced-based practice in psychotherapy, testing models in active use in the field provides immediately useful information. Grief is one of the most common issues that emerge in psychotherapy. Grief unfolds in a purposive and meaningful way from the first awareness of loss. The grief process guides us through the painful reassessment and renegotiation of our needs and goals. What that process entails appears to have not been researched empirically before Maciejewski et al (2007) made their ground breaking attempt. They did a great job of researching an abstract and difficult to define topic and made a meaningful attempt at measurement.

    They also managed to validate, for the most part, a widely held belief about grieving. A four stage theory of grief was first discussed by Bowlby [Bowlby J. Processes of mourning. Int J Psychoanal. 1961;42:317-339.]: shock-numbness, yearning-searching, disorganization-despair, and reorganization.

    Kubler-Ross E. in her widely read book, On Death and Dying, adapted Bowlby's model into a 5 stage theory. Jacobs Pathologic Grief: Maladaptation to Lossasserted that a normal grief process is completed within 6 months following the loss of a loved one. He also postulated a five stage theory: numbness-disbelief, separation distress (yearning, anger, anxiety), depression-mourning, and recovery.

    Maciejewski et al (2007) took an odd combination of Kubler-Ross's and Jacob's model as the hypothesis to be tested. The study interviewed only persons who experienced a death of a loved one that was from natural causes, not trauma. Here I think they made a good judgment that difference causes of death would complicate the experience of grief. The interview method was described as a "single item interview screening" which was not defined clearly. The researchers took a single item from the Inventory of Complicated Grief-Revised and used a five point rating scale and asked participants to rate their experience of grief on each stages: disbelief, yearning, anger, depression, and acceptance at some point between 1 and 6 months, 6 and 12 months, and 12 and 24 months post loss.

    "Ideally, all individuals would have been assessed immediately after the loss rather than beginning at month 1 post loss. Due to respect for the initial mourning period and institutional review board concerns about harm to participants, we did not interview individuals within a month of the death. In addition, it would have been better to analyze data that reassessed individuals each month from 0 to 24 months postloss. However, no such data exist nor does the stage theory specify in what month postloss each stage would predominate. And, although we acknowledge that other grief indicators might have been used, the various proxy measures (ege.g.stunned for disbelief, bitterness for anger, hopelessness for depression, quality of life scores for acceptance/recovery) all revealed remarkably similar patterns to those presented herein. We chose to present the items that fit most closely with the stage indicators illustrated in the literature." The authors reported that they partially confirmed the Kubler-Ross/Jacob model.

    Reflected in their data, the authors found a surprisingly similar stepwise process of recovery at least partly confirming the stages, even the order by each each stage was addressed. "The odds of each of these indicators peaking in this exact sequence by chance is miniscule." But they also found some inconsistencies. Acceptance and yearning were endorsed most frequently beginning from the first interview increasing through the 24 month period. Traditional grief stage theory postulates that people experience disbelief immediately following the death of a loved one and eventually arrive at acceptance. Given the researchers interview method of a single item, presumably presenting the measures without explanation by the interviewer, it seems likely there was little reason to think that what the participants were identifying as disbelief and acceptance were not consistent with the model.

    Elizabeth Kubler-Ross defined denial as a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. Acceptance was described as varying according to the person's situation, although broadly it is an indication that there is some emotional detachment and objectivity. It seems most likely, participants endorsed the scales in a socially acceptable way. "Of course I accept that he died." The disbelief or denial in my experience refers to an awareness of the duality of a cognitive awareness of the fact of death, but an emotional disbelief manifest in more subtle ways such as speaking of the deceased in present tense.

    It's curious that the authors put so much into the order of the grief process, even though their two models don't agree on any one order. It even seems counter-intuitive that a human emotional process could be assumed to take on even an appearance of linearity. As in the example above, even the extreme ends of the process, acceptance and disbelief, overlap.

    The other inconsistency is about one of the clinical recommendations. The authors state that the study supports the theory that a six month duration of the grief process would be expected. Anything beyond six months may warrant a clinical assessment to determine if there was a complicated grief process in need of treatment. Their own data (see the figure above) suggests participants continued their grief process for nearly 18 months. As a practicing clinician, it's hard to imagine either author intended to describe the stage theory as a linear step by step model. Also neither author suggested an appropriate length of time for grief. It has been often stated in my training that grief takes no particular length of time but is unique for each person and situation.
    The final comment I have is about the use of the word "depression" in all the grief models. It appears to me that the general use of the word "depression" has been confused by the concept of clinical depression. A normal feeling has been confused with pathology. I'd like to see the word "sad" used in this context. Sadness is a normal part of grief. Normal grief may have some things in common with depression, but it is harmful to pathologize grief. Our culture has too much trouble with accepting intense negative feelings as "normal" and go to great self-destructive lengths to escape them. Sadness provides us with an intuitive guide to recovery if we listen closely and feel it fully. Regardless of these comments, it's the kind of research I love to see. Anxiety Insights had a recent post on another great sounding article about grief.

    "There are two guarantees in every person's life: happiness and sadness. Although lost opportunities and mistaken expectations are often unpleasant to think and talk about, these experiences may impact personality development and overall happiness. A seven-year study conducted by Laura King, a University of Missouri researcher, indicates that individuals who take time to stop and think about their losses are more likely to mature and achieve a potentially more durable sense of happiness. "People are generally in a hurry to be happy again, but they need to understand that it's okay to feel bad and to feel bad for a while," said King, who teaches psychology in the College of Arts and Science. "It's natural to want to feel happy right after a loss or regrettable experience, but those who can examine 'what might have been' and be mindfully present to their negative feelings, are more likely to mature through that loss and might also obtain a different kind of happiness.""

    It sure sounds like the authors made another attempted to unfold the process of grief. As with all emotions, there is a duality of process between the cognitive and emotional. The more we know about the emotional aspect, the more we can make sense of the emotion and apply it meaningfully our lives. Here is a quote I've used before from a former psychiatrist blogger shrinketteon the process of grief. I think it illustrates well the emotional challenge of grieving and how difficult it is to put it into words.

    "You go on. You go on. You bring the person you love inside you. That is how you cope. You make him or her live within you. The whole experience I had with my children is in me. It is nowhere else I can see. I can see a photograph, I can feel sad, I can read a poem, but the experience of having them within myself is what matters."

    Sometimes there is just nothing more to say.

    Reference: Maciejewski, P.K., Zhang, B., Susan, B.D., Holly, P.G. (2007). An Empirical Examination of the Stage Theory of Grief The Journal of the American Medical Association, 297(7), 716-723.