Vamık D. Volkan, M.D., DLFAPA, FACPsa.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study of Normal Mourning Process Illuminates Grief Gone Awry
 
 
 
 
 
 
 
 
 
 
 
Daniel Goleman 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

MOURNING a loved one is always painful, but some people find the process more difficult than others, either becoming too distraught or holding too much emotion in. In studying these extreme reactions, researchers are coming to a sharper understanding of the normal course of mourning, and of the signs that it has gone awry.

The research is also spawning new psychological treatments for those who have trouble grieving. Most of the treatments focus on helping mourners follow the normal path, moving past a point where they might have become ''frozen.''

The death of a loved one ''is the prototypical psychological catastrophe, a blow to the unconscious sense of personal invulnerability that most of us carry,'' said Dr. Mardi Horowitz, a psychiatrist at the University of California Medical School at San Francisco. Dr. Horowitz, who has long been a leader in research on mourning, has just completed a new study on grief. More than any other research to date it details the specific ways in which mourning can go off course.

Dr. Horowitz said that the issue was a pressing one because about of a third of those who come in for psychiatric therapy have had difficulties mourning a loss, often one suffered long ago. In many cases, it is not the difficulties themselves that bring the person to therapy, he said. Instead, the issue arises as therapy progresses. The main signs of mourning, such as overwhelming sadness or anger, typically decrease noticeably after six to nine months, research suggests, and signals of the end of mourning come after a year or so. But researchers say that mourning for two or three years is not unusual, and in some people signs of grief can linger for years.

The question of when a mourner needs psychological treatment is best answered, according to Dr. Horowitz and others, by distinguishing between normal grief and extremes of intensity or duration. While a typical mourner may be deeply disturbed at various moments, that does not necessarily indicate the need for treatment. But some extremes indicate a freezing of the course of mourning, and therapists say that those who have not completed the mourning process may need help.

Some troubled mourning can approach the bizarre. One man kept his dead father's broken cameras hanging in his clothes closet for 14 years so he could glimpse them while he dressed in the morning. Another man had his wife disinterred and reburied under his bedroom window ''so she could be close to him.''

Other signs of unfinished mourning are more subtle: a flatness of feeling or the chronic inability to finish projects or start new relationships.

Studies of several hundred people by Dr. Horowitz and his colleagues at the University of California will be published later this spring in the book ''Introduction to Psychodynamics,'' from Basic Books.

The course of mourning runs through different stages, Dr. Horowitz said, typically beginning even before the death. Most deaths come slowly, through illness, allowing time for emotional preparation.

At this point, though, some of those close to the dying person may be unable to acknowledge that death is near. These people can feel confused or inexplicably angry. In extreme cases, such people avoid the dying person, which can lead to intense remorse after the death. But if the approach of death is acknowledged, it can present an opportunity to go over the events of life and reconcile any grievances.

Even with the best preparation, however, news of the death generally comes as a shock. A Wish to 'Do Something'

In the normal course of grieving, the research indicates, the emotional turmoil just after the death often revolves around a persistent wish to ''do something'' to protect or please the dead person, since the mourner has not yet begun to grasp the loss. This desire might be served, for example, by having ''the kind of funeral he would have wanted.''

When this stage goes awry, the reaction to the death might involve panic, with the bereaved person overwhelmed to the point of incoherence by fear and grief. At the other extreme, some mourners suffer a state of dissociation, in which they seem to protect themselves through a loss of recent memories.

Next, mourners commonly enter a phase in which they turn away from their feelings by avoiding reminders of the death. Yet, the dead person may seem alive in dreams.
 
This normal denial comes at an emotional cost: The mourners may feel numb to all emotions. But, Dr. Horowitz observed, it is a necessary prelude in which they regain a sense of equilibrium that will allow them to confront the loss.

At this phase, some people make extreme efforts to put the death out of mind: sometimes they abuse drugs or alcohol or throw themselves into a frenzy of work, athletics or sexual activity.

It is not until the next phase, when the mourners go through a mental review of their life with the deceased, that they actually begin to adjust to the loss. 'The Flow of Memories'

''At a wake or memorial service, those who were least battered by the death will have the most memories of the deceased,'' Dr. Horowitz said. ''For those most upset by the death, though, it is usually weeks or months later that the vivid memories start to flow.'' Normally, this phase is marked by intrusive thoughts of the deceased or intense sadness that make it hard for the mourner to concentrate on anything else.

A review of life with the deceased person, and all the feelings that arouses, alternates with putting the death out of mind, so that mourning proceeds in manageable doses, Dr. Horowitz has found.

Extreme reactions at this point include recurring nightmares or even night terrors - nightmares so real that dreamer may wake screaming. The person may also be flooded by overwhelming rage, despair, shame, guilt or fear. While ordinarily such feelings fade as time passes, in those who have trouble mourning, the feelings can go on for months or years, the researchers said. 'Gradual Acceptance'

Once this stage is completed, an intense yearning for the company of the dead person ordinarily develops, Dr. Horowitz said, and signifies a last-ditch effort to deny the death. This yearning gradually yields to an emotional acceptance of the death.

For those who do not reach this point, however, there may be a marked inability to work, to be caring or creative, or even to experience pleasant feelings. They may be plagued by anxiety, depression or rage, followed by shame or guilt.

''Many irrational thoughts come up during mourning, such as, 'If I'd been a better person they never would have died,' '' Dr. Horowitz said. ''Normally, people let go of these primitive ideas, but some get stuck in them, especially if they felt a strong ambivalence or anger toward the dead person.''

With the completion of mourning, the person once again feels a sense of mastery of life.

''Although some grief persists, the mourner has decided that life can continue without the dead person,'' Dr. Horowitz said. ''They're ready, for instance, to take on the risks of a new relationship - that they may be cherished, or abandoned and left.'' 'Some Special Circumstances'

Some kinds of deaths are more difficult to mourn adequately, researchers report. Although some of the reasons seem obvious, others are only recently discovered subtleties. Some recent research focuses on suicide, which experts say is one of the most difficult deaths to mourn.

''In addition to suicide being a loss the survivor suffers, he also experiences it as an accusation of sorts -that his love was not good enough to keep the loved one alive, or that their relationship was not important enough to stay alive for, for instance,'' said Henry Seiden, a psychologist in Queens, and co-author of the new book ''Silent Grief: Living in the Wake of Suicide.'' published by Charles Scribner's Sons, a division of the Macmillan Publishing Company.

''The typical response of the survivors of a suicide is, out of shame, to be silent about the fact the death was a suicide,'' Dr. Seiden said. ''That interferes with the normal course of mourning. The best thing is to talk about it. Because they don't do much of what is normal to handle grief, they can stay stuck in feelings of guilt, anger or shame for years.'' 'Each Feels He Is Alone'

By Dr. Seiden's estimate, the 50,000 suicides each year in the United States may leave a half million survivors to mourn. But because they tend to be quiet about the suicide,''each feels he is alone,'' he said.
 
A child's death is also difficult to mourn. Research by George Pollock, a psychiatrist and director of the Chicago Institute for Psychoanalysis, has found that for most parents whose child has died, ''mourning is never completed.''

''It's much easier to mourn the death of a parent than a child,'' Dr. Pollock said. ''To a child, the parent is the past, while to the parent the child is the future. The child's death is a presence that continues.''

Siblings also find difficult to mourn a child's death; often the problems associated with this difficulty to not emerge until adulthood.

Paradoxically, those who lose a spouse find it easier to finish mourning and start a new life when the relationship was happy, while those whose marriages are stormy find it harder to recover. This effect is sometimes seen in other relationships, too.

A sudden death can also make mourning difficult. In a Harvard Medical School study, those whose spouses died with little or no warning were more anxious or depressed two to four years after the death than those whose spouses died from long illnesses. 'Actuality of the Death'

Therapy for inadequate mourning usually involves an effort to get the normal process moving ahead.

Dr. Vamık Volkan, a psychiatrist at the University of Virginia medical school, said, ''The recognition of the actuality of the death is a crucial event in the course of mourning.'' Dr. Volkan's method of ''re-grief'' therapy is intended to help those who suffer pathological grief.

Dr. Volkan's approach makes use of a common phenomenon in those with problems in mourning: the possession of a special object that links him to the dead person, such as piece of jewelry. These links are more than just treasured keepsakes; they are jealously guarded and hold an eerie fascination for the mourner.

These objects, Dr. Volkan said, are symbolic tokens jointly ''owned'' by both the mourner and the deceased person; it is a way of keeping the dead person ''alive.''

Because the person with this kind of grief is in a chronic state of hope that the dead person will return, Dr. Volkan at some point asks the mourner to bring in the linking object and explore its symbolic meanings.

This typically allows the mourner to face the fact of the death. This, Dr. Pollock said, ''can activate the mourning they haven't completed.''

 

 
 
 

 
 
 
 
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Last modified on: Apr 20, 2016