Only today did I find your heart-breaking note. There are simply no words to answer such personal tragedy, which is surely more than anyone should have to endure. I can only hope that you will find comfort and peace from those who care about you, and that in the fullness of time, you will again find life meaningful and worthwhile. I would certainly urge you to seek professional counseling if you find that this is not the case. My best wishes for healing go out to you and your family, and thank you for writing.

Sincerely,

Ronald Pies MD

Thanks.

At the same time, when grief becomes so destructive of one’s emotional health that one can’t function (“pathological grief”); or when grief is accompanied by a bout of major depression, professional help is usually needed.

I heartily commend you and your husband for bringing something positive out of your own tragedy, by working to help others, and to change the law for the better–even with all the resistance you have encountered. –Best regards, Ron Pies MD

•In the Bonano study, the specific pre-loss measure of dependency on the spouse was developed by averaging four items: “The idea of losing my (husband/wife) is terrifying to me”; “No one could ever take the place of my (husband/wife)”; “If my (husband/wife) died, it would be the worst thing that could happen to me”; “I would feel completely lost if I didn’t have my (husband/wife)”. I don’t believe the degree of dependency of the deceased was specifically assessed; however, it was found that chronic grievers were most likely to have lost a healthy spouse. Nevertheless, I agree that when a deceased spouse or family member was extremely dependent upon the surviving spouse/family member, the latter may find that a sense of purpose and focus in life is missing. Of course, in a sense, this, too, could be called a kind of “dependency” on the part of the surviving person. So I suspect that the issue of dependency is more mutual than “one way” in many such instances.

•I think it’s a good point that unresolved grief can complicate depression, just as the reverse may be true. I think of it as a kind of “vicious circle” in which depression can impair working through grief; the intensified grief than “feeds” the depression, which may further impair grief resolution, etc., etc., until the “loop” is interrupted by some therapeutic intervention. Interestingly, there are data from Dr. Zisook showing that when major depression criteria are met after bereavement and the patient is treated with an antidepressant—which I do not advocate for uncomplicated grief!—both grief and depression decline together or “in parallel.”

•Tom Wootton raises a very good question re: “resiliency”. But first, a couple of comments on the issue of “reactions” to feelings in grief and depression. I certainly do believe that we have a fair amount of “choice” in terms of how we react both to our losses, and to the feelings that the losses engender. For example, if someone near and dear to us dies, we can reason, “Well, this is the end of my life”, or we can reason, “Well, this is terribly painful, but I will get through it.” I do think that one is more likely to become depressed reasoning in the first way than in the second. However, I also believe there are many factors that “feed” the likelihood of developing a major depression, after loss or otherwise; for example, one’s genetic predisposition (for example, a strong family history of major depression), biological factors (such as having suffered a stroke), degree of social support, etc. So, I would not want to endorse the idea that we can simply “choose how to react” to loss, or to our own feelings. But we certainly have some degree of self-determination in that regard, and this is really the underlying premise of Rational Emotive Behavioral Therapy (REBT, developed by Albert Ellis) and CBT (developed by Aaron Beck). I do think that Tom’s suggestion that resiliency has something to do with how we choose to react to stressors is largely correct; i.e., it is a mark of the resilient person to think, “Well, this is a very painful loss, but I am going to get through this, and life will go on.” Of course, why it is that some people have this ability and others do not is a complex and interesting question!

•Ms. O’Toole raises an interesting and poignant question about the incarcerated and grief. First of all, it is, in my view, a national tragedy that our prison system has become the largest de facto “mental health center” in the nation. In some states, it is probably true that more persons with mental health problems are being treated (or mis-treated) in prison settings than in real clinics. Needless to say, the “care” in a prison setting is usually not up to the standard we would like, despite many dedicated health care givers who work in such settings. Now, as to the grief of the incarcerated: I sympathize with Ms. O’Toole’s family member, particularly after the painful loss he has experienced. My hunch is that, in such instances, when the incarcerated person is not permitted to attend the funeral of the deceased, spend time with grieving family members, etc., this would likely intensify and prolong the person’s grief. The only published article I could find on this is by Sease, J Psychosoc Nurs Ment Health Serv. 1982 Jul;20(7):25-7.. The author states, “The newly admitted inmate, as demonstrated here, is in a state of crisis and is suffering grief and experiencing losses not unlike those traditionally ministered to by nurses. Providing the needed counseling and helping the client through his “grief work” might demonstrate to that inmate new ways of dealing with feelings and situations that perhaps contributed to his incarceration. For family members of incarcerated loved-ones, I would suggest checking out the ACLU’s National Prison Project, at http://www.aclu.org/prisoners-rights.

Best regards, Ron Pies MD

Secondly, when you mention Bonnano’s conclusion that “chronic grief was associated with pre-loss ‘dependency’ upon the deceased spouse,” I think it might be important to clarify (and I wonder if Bonnano does) that ‘dependency’ is not limited, as might be imagined, to the griever having been dependent on the departed. It can also powerfully impact the grief process if it was the departed who was inordinately dependent on the bereaved. I learned from personal experience that the void left for a caregiver (for example of a parent or spouse with Alzheimer’s) can be profound and extended precisely for the fact that the caregiver, wittingly or not, comes over time to invest their sense of ‘raison d’etre’ in the caring for the one who is now gone, seemingly taking one’s raison d’etre with them. And it can take a long long while to find back a solid sense of ‘raison d’etre’ when suddenly a multiplicity of daily roles (e.g., parent, child, nurse, cook, friend, detective, etc.) all vested in that one person may seem to hang in suspended disbelief. The death may not have been sudden at all, but the loss of all these roles the caregiver plays is. One very useful tool in the grief process, at least for me, came from a pie chart my bereavement group counselor, Paula Hinz, MSW, walked me through. Creating a pie chart of all the roles I’d held in my world and seeing just how many of them, what percentage of the total me, had been invested in caring for my mother with Alzheimer’s and cancer, was enormously helpful for my understanding of why I felt so bereft in ways that got confounded with depression. Awareness of that fuller picture of how much was lost — of my own daily roles I had become unwittingly “dependent” on –– gave a key piece of the clarity that I think Jamison well describes as being available in grief in ways that it is not in depression.

Secondly, when you mention Bonnano’s conclusion that “chronic grief was associated with pre-loss “dependency” upon the deceased spouse,” I think it might be important to clarify (and I wonder if Bonnano does) that ‘dependency’ is not limited, as might be imagined, to the griever having been dependent on the departed. It can also powerfully impact the grief process if it was the departed who was inordinately dependent on the bereaved. I learned from personal experience that the void left for a caregiver (for example of a parent or spouse with Alzheimer’s) can be profound and extended precisely for the fact that the caregiver, wittingly or not, comes over time to invest their sense of ‘raison d’etre’ in the caring for the one who is now gone, seemingly taking one’s raison d’etre with them. And it can take a long long while to find back a solid sense of ‘raison d’etre’ when suddenly a multiplicity of daily roles (e.g., parent, child, nurse, cook, friend, detective, etc.) all vested in that one person may seem to hang in suspended disbelief. The death may not have been sudden at all, but the loss of all these roles the caregiver plays is. One very useful tool in the grief process, at least for me, came from a pie chart my bereavement group counselor, Paula Hinz, MSW, walked me through. Creating a pie chart of all the roles I’d held in my world and seeing just how many of them, what percentage of the total me, had been invested in caring for my mother with Alzheimer’s and cancer, was enormously helpful for my understanding of why I felt so bereft in ways that got confounded with depression. Awareness of that fuller picture of how much was lost — of my own daily roles I had become unwittingly “dependent” on –– gave a key piece of the clarity that I think Jamison well describes as being available in grief in ways that it is not in depression.