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Grief
   
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Grief

Gina Filkins
2006

Part I: The Myths of Grief

Introduction 

            Grief is an experience and a process that “encompasses a sense of loss” and, in fact, bereavement is an old English verb meaning “to be robbed” (Filkins, 2000, p.2). There may be similarities in the dynamics of grief; however, each individual is unique as well as whatever or whoever was involved in the loss.  Loss may involve death, disease, trauma, divorce or major unpredictable life changes or events. 

Since the beginning of time, humankind has struggled for perceptual control and a desire to be “all-knowing”…like the story of original temptation described in Genesis, the first book of the Bible.  According to these ancient texts, Adam and Eve were tempted to have the power to be as God, eating from the tree of knowledge of both good and evil.  The theory of adaptation indicates that cognitive processes have an adjustment period of the internal dissonance that occurs between “disarticulation of the way the world is and the way one’s assumptive world maintains” (HFA, 1997, p. 47).  Myths are frail human efforts to control what is uncontrollable.  They are often misnomers graciously administered in ignorance as an attempt to cure and ease the pain of those who appear to be suffering from grief.

Principles of adaptation and mercy, such as the twelve step process of admitting powerlessness, accepting things we cannot change, and having courage to change the things we can, are all strategies that can successfully assist in rearranging myths into truth, thus truly equipping individuals to face the many losses that will be challenging throughout a lifetime.

 There is an array of myths and it is significant that clinicians become aware of these as well as how to address them in a legitimate response.  Some of these, according to James & Friedman (1998) are 1) Don’t cry; 2) don’t feel bad; 3) replace the loss; 4) grieve alone; 5) just give it time; 6) be strong for others; and 7) keep busy.

Myth 1: Don’t cry

            This myth is most likely a result of the societal teaching that crying represents weakness and crying extensively may cause “a nervous breakdown” (HP, 2006, p.1).  Others may believe that “our tears are preventing us from getting on with our life” (Mitsch & Brookside, 1993, p. 66). However, there is evidence that “crying discharges tension; the accumulation of feelings associated with whatever problem is causing the crying” (HP, 2006, p.3).  Tears are known to help detoxify our bodies and they “actually carry away chemicals that build up in our bodies during times of stress” (Mitsch & Brookside, 1993, p. 67).  According to Wright (1993), “tears are the vehicle that God has equipped us with to express the deepest feelings that words cannot express.”  He goes on to say that once a person has fully entered into the deepest of sorrows, “you will be able to experience the wonder of being alive” (p.45).

            With knowledge that tears are physically, emotionally and spiritually healthy, a clinician needs to help others to dispel this myth.  This can be done through first addressing their personal beliefs regarding crying.  Second, educating a person about the benefits of tears, while third, being supportive of any signs of tearfulness or crying.

Myth 2: Don’t feel bad

            This myth is both learned from early childhood as well as intermittently reinforced in adulthood.  According to Filkins (2000), “Parents are frequently dishonest or fabricate ideas of death and …are intimidated to be honest with children regarding losses due to their own fears and uncertainties” (p. 7).   People, in general, do not embrace negative emotions because they are unpredictable and it is uncomfortable to see someone hurting, especially someone we love.  The myth of avoiding painful and bad feelings is due to beliefs that “it is better to put painful things out of your mind…and it is better to move on with your life” (JH, 2006).   Once again, it is obvious that individuals have difficult with the uncontrollable, and attempt desperately to control the uncertainty of emotions, especially negative emotions.

            As a clinician or helping person, we must first recognize that as uncomfortable as it is for people to “feel bad,” it is necessary for the process of grieving to embrace a full gamut of emotions, of which many appear negative.  According to Wright (1993), a person must come to the reality of the deepest agony of any sort of loss in order to recover in a healthy manner.  Avoiding negative emotions may result in displacement of emotions such as people becoming somatic and workaholics, or viewing the loss through the eyes of defenses, such as reaction formation or idealization (pp. 40-56).  Related to the myth of “ignoring the grief,” it is recognized that “One must experience the pain of grief in order to heal. Ignoring grief prolongs grief” (SIDS Mid –Atlanta (2006).   Secondly, be a willing listener, without trying to negate, minimize or transform the meaning of their pain into something more comfortable for us.  Often we listen, with the intent on fixing rather than pure listening.

Myth 3: Replace the Loss

            When a loss is experienced, well meaning individuals may offer a solution by inferring we can merely “replace the loss.”   For instance, “you can buy you another pet; you can always remarry; or you can have other children, etc.”  One needs to take into consideration the attachments and roles that individuals and situations have in the lives of those experiencing loss because “the grief reaction to the loss of such an attachment can also be expected to be multidimensional and complex” (HCA, 1997, p.137).   Losses cannot be replaced because of the meaning of the relatedness which may include the direct or indirect affect on a how a person interacts in their world around them.  The schedules they keep, the mutual relationships and social activities they may have been involved in, and the views and thoughts that may have been influential, are all examples of how a loss may impact the person grieving.  The fact is, it is not possible to replace someone you love because “human beings are not goldfish.  Each relationship is unique, and it takes a very long time…to say good-bye, and until good-bye is really said, it is impossible to move on to new relationships that will be complete and satisfying” (HP, 2006).

            A clinician can dispel this myth by helping to identify and address the various meanings that are connected with the loss.  Often the loss of someone is the turning point of an individual to regroup and gain an altered identity, with a deeper and different interpretation of life subsequent to the loss (Wright, 1993).  Assisting the person to gain insight towards how their identity may or may not have been changed helps to address the loss and not merely replace it through activities or newly sought out or imposed upon relationships.

Myth 4: Grieve Alone

            “Just grieve alone” is an easy recommendation for others to give since it would deflect personal responsibility to be supportive and interactive during the grieving period.  Others may be uncomfortable with tears and limited explanations regarding loss; therefore, the old adage, “laugh and the whole world laughs with you, cry and you cry alone” (James & Friedman, 1998, p. 29).  Other reasons people may believe it is better to grieve alone is because when someone has had a loss, then it is easier to distance from other loved one’s for fear that something else dreadful may happen.  This is somewhat normal; however, it is not beneficial to reinforce a defensive mental filter such as emotional distancing (JH, 2006).  Although an individual may in fact need some alone time, it is also significant to have a social support network and the ability to talk to others about their loss.  “Grief shared is grief diminished.  Each time a griever talks about the loss, a layer of pain is shed”(HP, 2006, p. 1).  In fact, grieving rituals may include “public responses, rituals, community acknowledgement, time frames, and religious responses” (Filkins, 2000, p. 6).  Other countries often promote and enhance the bereavement period to include hired mourners.

Myth 5: Just Give it Time

            This myth comes from the idea that time heals all things. It is a simplistic belief that because time goes by the pain will go away.   If that were the case then grief would just happen and there would be no need for actively grieving or working the grief process.  According to Filkins, “Western Culture expects individuals to grieve quickly and efficiently.  Two days, two weeks and then someone should just get over it in time” (2000, p. 7).

             It is not the time that does the healing, it is during the process of time, a person learns and applies healthy and healing principles of grieving.  According to Wright, “In a sense you will never recover completely because you will never be exactly the way you were before. Your loss changes you” (1993, p. 112).  It is through the process of time that those with losses redefine themselves, adjust, adapt and transform from the experience of loss.

Myth 6: Be strong for others

            It is very uncomfortable to allow oneself to feel the full gamut of emotions related to grieving so many people believe they should, “be strong for others.”  This also is a result of erroneous spiritual beliefs that imply that if one struggles with the painful emotions of anger, blame, guilt, unbelief, depression, etc. which are a normal array of emotions, then one must not be trusting God (Wright, 1993).  Often the avoidance of the pain gives the appearance of being strong. 

            Some believe that it is dishonoring to the loved one to keep thinking about them and “once a loved one has died it is best to put him or her in the past and to move on with your life” (JH, 2006, p. 2).  While working with the Kickapoo tribe, I found that they were not allowed to ever speak the person’s name again or it was believed to disturb their spirit and create torment.  Thus, the tribe would have an adoption ritual and adopt another family member to take his or her place.  I saw many tribal members come to counseling in secret just to be able to mention that person behind closed doors.

Myth 7: Keep Busy

            Some myths have partial truths, such as the need to keep busy.  It is important for a person “to maintain their social, civic and religious ties and not withdraw completely and isolate themselves from others;” however, when and how this transition back to typical daily activities evolves differs for each person (HP, 2006, p. 2).  Busyness does have the effects of distraction, but this will most likely postpone the inevitable demands that grief requires, investing thought and emotions.  Most individuals who keep busy will then be faced abruptly and without warning deep and painful emotions and not know where they are coming from or how to deal with them.  Those grieving may experience an ebb and flow in activities, which can be confusing to others.  One day they want to get out and the next day isolate.  This is both normal and healthy to find new patterns of activities.  After all, the situation of loss often has direct effects on whom, when and why a person was involved in specific activities.  Each person needs time to readdress and redefine their identity within their world around them.

Part 2: The Essential Elements of Grief Therapy

Introduction

            Clinicians have a wonderful opportunity to become familiar with essential elements of grief therapy so whenever the bereaved seek out services, they may find treatment that is conducive to greater understanding and appreciation for their loss.

Oftentimes, individuals face unresolved grief and may find themselves stuck or moving forward too fast to authentically work through the many processes involved with effective grieving (Wright, 1993).  “Grief is a long process of adjustment,” and to stifle, inhibit, dilute or prohibit its course, is to do a disservice to those involved (SIDS Mid-Atlanta, 2006, p. 2).  Some of these essential elements of grief therapy include the person:

            1) Making choices for recover; 2) making choices for commitment; 3) recognizing the myths; 4) identifying energy relievers; 5) dealing with emotional pain; and 6) doing the clean-up work (James & Friedman, 1998).

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Making choices for recovery

            Making choices for recovery includes taking responsibility for oneself and moving beyond the victim role, as well as determining if one would like to partner through the process of grief (James & Friedman, 1998, pp 60-68).  Taking responsibility is often confusing since blame and guilt are emotions that have been noted to evolve through the process of grieving (Filkins, 1997; Wright, 1993).  Depending on the type of loss, such as a sudden death, often the “what if’s” or “if only’s” may last a long time and result in unrealistic responsibility, or inordinate guilt (Wright, 1993, p. 70).  Once an individual recognizes these emotions, they can become a stepping stone and the person can work beyond the disempowerment of feeling victimized and the tormenting feeling that embody our limitations as mortal human beings. 

            Understanding that one cannot change, modify or undue the events and situations surrounding the loss; however, can own their responsibility for the process of grieving, including the choice of whether or not to find others to collaborate in the process.  Finding a partner in grieving can happen in the early process of grieving, and in fact, be with another family member experiencing the same loss.  It is important to not “seek out advice givers but those who are empathetic and can handle your feelings” (Wright, 1993, p. 77).  It may be that a person wants to grieve individually, feeling as if no one truly understands his or her pain.  Either way, or even if someone chooses to change from “alone grieving” to “partnering”, the point is having the power and right of choice.

Making Choices for commitment

            When a person begins to take ownership of the grieving process, then comes the choice of commitment.  This commitment is to honesty, and belief in the right to uniqueness and individuality is important.  Honesty becomes complex since oftentimes honesty is very painful.  Honesty requires that the person realistically recount the events surrounding the loss, rather than minimize or idealize the circumstances or person to make it easier ( Filkins, 2000; Wright, 1993).  “A helping interaction might continue by: providing accurate information about the illness or mode of death and its related circumstances; dispelling misinformation…” assisting in the rigorous and honest journey of grief (HFA, 1997, p. 140).

             Although Kubler-Ross held that there were specific stages of grief, much of the latest views of grief therapy, tends towards individuality within and throughout the grief process, insisting that although these stages may occur, they may not all occur for everyone, and the duration and sequences varies significantly due to the wide variety of losses (HFA, 1997; Wright, 1993).  Grief may be similar, with conflicting Stages that differ in “time and may fluctuate in order depending on certain variables: Types of loss, age, community response, support system, types of loss, and categories of death” (Filkins, 2000, p. 10).  Despite many who insist on understanding and knowing exactly what another is feeling and experiencing, it is best to allow each individual the distinctiveness of his or her own loss.

Recognizing the myths

As mentioned earlier, there are numerous myths that typically are offered in sincerity to those who innocently awake consolation from family and friends.  Myths, although often presented genuinely and in true condolence, they can be harmful if unsuspecting grievers take them as the gospel.    Some of these, according to James & Friedman (1998) are 1) Don’t cry; 2) don’t feel bad; 3) replace the loss; 4) grieve alone; 5) just give it time; 6) be strong for others; and 7) keep busy.  Helping clients to recognize and dismiss these when they occur can enhance their sense of self determination in the grieving process.

Identifying Short-term Energy Relievers

There are numerous behaviors that are often engaged in when grief becomes emotionally and even physically painful.  People resort to sort term relief that may offer a quick fix type of analgesia. “As the pressure builds up inside our personal steam kettle, we automatically seek relief” (James & Friedman, 1998, p. 80).  If a substance is taken or used and decreases negative effects or stimuli, it creates a memory of relief and a likelihood of short-term energy relieving behavior.  Also, if a substance generates a pleasurable stimulation, it increases “dopamine in the nucleus accumbens” which plays a major role in reinforcing repeated behavior that has an increased risk of addiction (Carlson, 2000, p.576-77).  According to Goldstein and Volkow (2002), it is the frontal cortex that is responsible for the reinforcement of addiction.  Through the activation of memory circuits (hippocampus and the amygdala) in relationship to drug related behavior the orbitofrontal cortex and anterior cingulated creates expectation of the reinforcement and then activates dopamine (p. 1647).

Some of these behaviors may include carbohydrate or junk food binging/overindulging; drinking; using tranquilizers; legal and/or illicit drugs; over working; over exercising, etc.  According to Filkins (2000) “addiction is used to numb pain & emotions unresolved (including alcohol abuse, prescription, shopping, food, illicit drugs).”  Many people “put emotional attachment to food…using food as their drug of choice, as a sedative, tranquilizer or an analgesic”…“ actually using food to emotionally beat themselves up” as a result of self destructive and shame-based issue developed as a product of feeling helpless from a significant loss (MCH, 2006).  Although, the emotional brain, may be triggered by anger, frustration and other negative emotions, resulting in eating, it is actually the primitive brain (amygdale, hippocampus, hypothalamus, etc.) that connects with meaning, beliefs and needs of food.

Dealing with Emotional Pain

            Emotional pain is experienced at intervals throughout the grieving process and can be facilitated in and through a variety of modalities.  According to HFA (1997), there are masculine style and feminine style grievers.  The masculine tend to want to methodically and predictably experience grief, while the feminine style desires an emotively expressive release.  Critical Incident Debriefing is a method of early grieving that gives a systematic, logical and sequential method of grieving that can be particularly used in a traumatic and unexpected loss (Mitchell & Everly, 2003).  Utilizing time lines, history lines, letter writing and family trees are logical and effective therapeutic tools to facilitate thoughts, feelings and emotions in a manner that makes logical and emotional sense (Filkins, 2000; James & Friedman, 1998; Wright, 1993).

Frequently there are feelings of blame, guilt and unresolved hurt during a loss.  It may be aimed towards or from the person causing an accident, injury, divorce or death; doctor or nurse; hospital; relative or even the person who died.  Forgiveness is a virtue that requires deliberation, fortitude and consistency.  Many hold to ideas of vengeance and retaliation, because they seem justifiable.  However, the benefits and practice of forgiveness can be learned even in angry and bitter people when they understand the mechanisms of thinking strategies and the power of cognitive restructuring.  Christianity holds firmly to the principles of forgiveness, teaching that Jesus died to forgive humanity of its sins, as well as exhorting its followers to “love your enemies and do good, lend, hoping for nothing again (Luke 6: 35-36).” 

According to Seligman (2002), unforgiveness has been a major contributor to learned helplessness and pessimism, which both result in negative long-term outcomes.  The strategy of forgiveness, as described through the R-recall the hurt; E-empathize; A- altruistic gift of forgiveness; C- Commit; and H- hold onto forgiveness (REACH), though it requires dedication, is portrayed in a unique and easily understood format (Seligman, 2002, PP. 79-81).  

The strategy of forgiveness first, begins with the person who has been offended, recalling the offense in an objective manner.  Second, the person then empathetically, attempts to put themselves in the other person’s shoes and consider the other’s perspective, not excusing or justifying, merely empathizing.  Third, the person chooses to giving an altruistic gift of forgiveness, not one that is earned.  This is done by remembering a time of unmerited forgiveness someone generously gave to them.  Fourth, is a person making the commitment to forgiveness because there are situations that trigger memories of an offense.  In fact, according to Loyd and Johnson (2004), negative memories especially those filled with destructive thoughts, such as unforgiveness, “broadcast a signal in the body that causes us to interpret current circumstances as threatening events even when they aren’t (p. 37).”  Fifth, the person holding on to forgiveness, understanding it is often difficult to sustain.  The act of forgiveness is allowing one to not be entangled with painful memories that could otherwise encumber the grieving process.

Doing the Clean up Work

This is one of the most difficult and yet rewarding aspects of grieving.  This is the process of disposing of and dealing with tangibles and belongings.  For many, this creates extreme anxiety and may necessitate others coming alongside to help, or may demand complete solitude.  Cleaning up has to do with properties, clothing, estates, banking, etc.  It can be simpler whenever the deceased has left an estate will that details what may or may not be taken, exchanged, bought, sold, auctioned, etc.  (James & Friedman, 1998).

Unfortunately, for many, this is not the case and therefore other family members are often involved and many disputes arise as a result.  It is a time where each family member may identify with the loss in a different way and therefore, to lay claim on certain items generates an enormous sense of meaning and relevance, thus potential conflict (Filkins, 1997).  On the same note, these tangible items hold a powerful key to feeling connected with the individual or situation that has been taken away.  For example, when a necklace, watch, ring or other item is worn by the bereaved, it brings a warm sense of comfort and closeness to the departed individual.

Conclusion

As a clinician, there are many methods and strategies to facilitate healthy grieving.  A few of these that have been mention can generally be utilized effectively and empathetically.  Unresolved grieving can leave individuals emotionally debilitated; therefore, it is pertinent to be knowledgeable on recognized strategies of grief therapy.

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 <>References  <>

Carlson, N. R. (2000). Physiology of Behavior (7th edition). Boston, MA: Allyn & Bacon.

Filkins, G. (1997). Seasons with You: A Journey through Grief, Copywritten:  Washington, D.C.

Filkins, G.(2000) Grief : When the hurting just won’t stop, Power Point Presentation.

Goldstein, R. Z.  & Volkow, N.D.  (2002). Drug addiction and its underlying     neurobiological basis: Neuroimaging evidence for the involvement of the frontal    cortex, The American Journal of Psychiatry,159, 1642-1652.

Healthplace.com (HP)(2006). People are not goldfish: Nine common myths and realities about grief, Retrieved on August 26, 2006 from
http://www.healthyplace.com/Communities/Depression/related/loss_grief_5.asp

Hospice Foundation of America (HFA) (1997).  Living With Grief When Illness is Prolonged, Bristol, PA: Taylor & Francis.

James, J. W. and Friedman, R. The Grief Recovery Handbook : The Action Program for Moving Beyond Death Divorce, and Other Losses. Harper Collins; Revised edition (June 1998). ISBN: 0060952733

Journey of Hearts (JH) (2006). Myths about grief, Retrieved on August 26, 2006 from  http://www.journeyofhearts.org/jofh/kirstimd/myths.htm

Lehrer, Paul M. & Woolfolk, Robert L. (1993). Principles and Practice of Stress Management,  (2nd ed.). New York: The Guilford Press. ISBN 0-89862-162-3.

Levin, J. (2001). God, faith and health: Exploring the spirituality-healing connection. New York, NY: John Wiley & Sons, Inc.

Medicine consumer Health (MCH) (2006). Obesity causes, retrieved on August 17, 2006 from http://www.emedicinehealth.com/obesity/page2_em.htmDepression

<>Mitchell, J, & Everly, G. (2003). Critical incident stress management: Basic group crisis intervention. International critical incident stress foundation, Ellicott City, MD.  <>

Mitsch, R. and
Brookside, L. (1993). Grieving the Loss of Someone You Love. Wheaton, Il: Tyndale House Publishers. <>SIDS Mid –Atlanta (2006). Bereaved families-Myths about grief, Retrieved on August 26, 2006 from  http://www.sidsma.org/bereaved_families/bereavement_packet/myths_of_grief.html

Seligman, M.E.P. (1990). Learned Optimism. NY: Knopf. ISBN: 0671019112.

<>Seligman, M.E.P. (2002). Authentic Happiness. NY: Free Press. ISBN: 0743222970.

Wright, N. (1993). Recovery From The Losses of Life. Grand Rapids, MI: Fleming,  H.Revell.