mourning

September 26, 2021

Prolonged Grief Disorder

The permanent absence of a loved one can seem endless. The mornings are full of mourning and emptiness no amount of OJ or coffee or alcohol can fill.

If the sadness appears to extend to infinity, therapists have a less poetic task. They must determine whether your extreme unhappiness fits the criteria for Prolonged Grief Disorder (PGD). This diagnostic category is new, but the ailment is as old as human history.

To start, here are some of the symptoms of PGD in the American Psychiatric Association’s September 23, 2021 press release describing the soon-to-be-published complete formulation. A prior draft indicated that at least three of the eight must be present for the diagnosis to apply:

  • Identity disruption (e.g., feeling as though part of oneself has died).
  • Marked sense of disbelief about the death.
  • Avoidance of reminders that the person is dead.
  • Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.
  • Difficulty moving on with life (e.g., problems engaging with friends, pursuing interests, planning for the future).
  • Emotional numbness.
  • Feeling that life is meaningless.
  • Intense loneliness (i.e., feeling alone or detached from others).

They also state the following:

The bereaved individual may experience intense longings for the deceased or preoccupation with thoughts of the deceased, or in children and adolescents, with the circumstances around the death.

These grief reactions occur most of the day, nearly every day for at least a month. The individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Moreover, the length of the condition goes beyond cultural norms.

Experienced therapists know people are not so easy to categorize as labels suggest. Many times counselors encounter individuals with more than one psychological concern. For example, depression might be coupled with substance abuse or PTSD.

In the case of forms of bereavement, many have questioned the appropriateness of putting an identifying sticker on an almost inevitable experience in life. Our time by itself has created nearly five million deaths from COVID-19 and a much larger number of their loving survivors.

However, the APA emphasizes that Prolonged Grief Disorder goes farther than the normal grieving observed within one’s community. To the good, the health care field will help you take on your heartache and impairment, whatever name is given to it.

The APA’s announcement and a publicly available 2020 draft do not mention causes of extended lamentation other than death. A few come to mind.

We might include those who become caretakers to their radically changed lifelong partners, parents, or children. Transforming accidents, dementia, or lasting vegetative afflictions often create a world of joylessness in those who take on a job for which they did not apply.

Calamity takes too many faces. Mortals needn’t die to cause dear ones the realization they are no longer interacting with the “same person.”

While discussions about lengthy sorrows have been ongoing, the APA’s decision to recognize and define PGD can be expected to produce more words and productive research.

Even now, if you find yourself among those suffering from unrelenting adversity of the kind suggested here, professional consultation is recommended to discover if you fall into the new category.

Finding the best treatment options for PGD — something distinct from conditions like Major Depressive Disorder or Dysthymia — is a first step in the direction of recovery.

Click here for an infographic on Prolonged Grief Disorder

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The first of two works by the Ecuadorian artist Oswaldo Guayasamin is called Spring. The second is Project for a Poster. Both of these date from 1956.

February 22, 2014

Lessons in Saying Goodbye: The Farewells of Carlo Maria Giulini

Giulini

Meaningful farewells are rarely easy. Some people hide their emotions, others are overwrought. Here are two examples from someone you will relate to: Carlo Maria Giulini (1914-2005), the famous Italian musician whose 100th birthday anniversary we are celebrating this year. His model of how to handle parting might nudge you to rethink your own.

The first farewell was both heart-rending and public, beginning with a rehearsal and then in performances by the Chicago Symphony Orchestra (CSO) in March, 1971 when Giulini was its Principal Guest conductor.

Fred Spector, a now retired CSO violinist, told the story in 2001:

We were doing the Verdi Requiem and we knew that his mother had just died (unexpectedly, while he was in Chicago). He walked out on stage (to rehearse with us), starts to conduct the Requiem and stops. He was crying and he said “They want me to come home. What good is that? My mother is dead. It is more important that I have this experience with you and the Verdi Requiem and think about my mother.” And now he’s got us all crying, the whole orchestra in tears. “That’s more important because then I can experience and think about my mother in this marvelous Requiem.”

That is kind of what this man was about and those were the greatest performances I’ve ever played of the Verdi Requiem, bar none…. We wanted to get that feeling that he wanted for his mother.

Giulini said goodbye in a different way when he accepted the Music Directorship of the Los Angeles Philharmonic, to begin in 1978. It would mark the end of his 23 year association with the Chicago Symphony, the orchestra with which he made his American debut in 1955. The announcement came about one year before his final CSO concerts.

The conductor handwrote a letter to the Orchestra itself shortly after the news became public, and he eventually would make the rounds of the various staffers at Orchestra Hall to say a personal farewell when he returned during the 1977/78 season, before taking on his Los Angeles duties. Here is a portion of his April 16, 1977 letter:

My Dear Friends,

Circumstances made it that during the week of your deserved rest I was regrettably unable to personally meet with you. In a sense, this may have been a blessing in disguise, since such a meeting would have produced in me so many emotions that I would have been overwhelmed. That is why I am writing this letter to each and every one of you.

How long has it been since we have been together and made music together? At times it seems it was so long ago and at others, as if it were yesterday. In all of these years, so much music and work was translated in a rare and precious manifestation of friendship and collaboration between us that transcends the level of dutiful professionalism and indeed represents the true spirit of our calling as musicians. In the course of our long association, a rare and precious relationship developed among us — much as the one that existed among my quartet companions of my younger days (when I was a violist). A relationship that springs from excellence, love and dedication to the noblest purpose of music — of which we are the custodians.

For the music and work we did together, for your trust and loyal support, for all the feelings of joy and fulfillment we shared, and for what we have been able to transmit to music lovers, I thank you most profoundly.

There is not much more for me to add — because I am sure that you will understand both what I feel and what I mean.

You will continue to occupy a special place in my heart as you always have,…

As for the future… it is in the Hands of God.

Until we meet again, I fraternally embrace each and every one of you and wish you all the very best and —

Godspeed.

Carlo Maria

Thomas Saler* wrote of the rehearsals that preceded the conductor’s last CSO performance on March 18, 1978:

“Chicago was the most beautiful moment in my musical life,” (Giulini) said. “It is in my blood, not just in my heart.” Ever the Italian poet, Giulini expressed that sentiment to his musician friends at the first rehearsal before those final concerts. “For me, Venice is more incredibly beautiful every time I return. And so, gentlemen, are you.”

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For more on Giulini see: A Man Who Refused to Judge.

*Thomas Saler, Serving Genius: Carlo Maria Giulini (Urbana and Chicago: University of Illinois Press, 2010), 86.

January 16, 2010

How to Grieve, How to Live

grieving-parents-side-view

You might think that grieving is not an uplifting topic. But there are ways in which that is precisely what it is.

We start with the pain of loss, specifically a loss of something of value. If you lose a penny, you won’t much care. But if the loss is of something of great importance to you, you will care greatly. The pain of loss points to the value of the thing that you have lost; and the value you place on a thing points, at least potentially, to the pain to which you are vulnerable.

What are the things we value? A job, a relationship, friends and family, a promotion; our physical-self, which can be defaced or damaged… many things: money, status, a good name, a pet, and power, too. Take your pick. You decide what is important and whatever is inside the basket in which you put your emotional pain or your vulnerability to such pain — that item has value.

Grieving involves opening yourself to the pain. Now, you might think, “It must be only a recent loss that causes the hurt.” But the heart has no clock attached to it, no timer reading off the digits of distance between you and the loss; so, if you had a difficult childhood, you might still be holding the pain inside even though it is decades old.

Not only must you open yourself to the pain, but you must do it with a witness, a listener, someone who cares and who is present, who is “there for you.” This is necessary to reattach you to human contact — to life, to intimacy — rather than closing off and pulling away from people. And in this sharing — this openness, this talk and tears and gnashing of teeth — the pain eventually subsides. It’s a little bit like kneading dough — you continue to work it until it changes. The story of your feelings will be repeated by you, if necessary, dozens of times in different ways, until the emotions are changed and the excruciating intensity of the loss passes.

How long does this process take? Six months to a year would not be unusual, although it can be longer. The first anniversary of the loss is often especially hard; so are birthdays and holidays in the first year and sometimes beyond. But if you do not do the grieving “work,” the process can be extended and a sense of melancholy or a lack of vitality can follow you relentlessly.

To grieve doesn’t mean you will forget what you have lost. And, indeed, if it is a loved one, certainly you will never forget and you will never be untouched by the memory. There is a dignity in this. We honor the loved ones who are lost in this way and perhaps they live, metaphorically speaking, inside of us. As the Danes say, “to live in the hearts that you leave behind is not to die.”

But “how” to do this grieving — that is the problem. If you have lived your life trying to be tough, you will find that the toughness might prevent you from doing the emotional work that will allow the grief to end. If you maintain that “toughness,” you might find yourself living as if you are numb, or displaying a sunny disposition totally at odds with what is felt deep inside, in the place where you have buried your hurt. And if you have deadened yourself enough, you will have a hard time “living,” since you will be closed-off to feelings. Joy, abandon, and spontaneity will be harder to achieve. Instead, the time ahead of you would be better called “existence” than “life.”

But perhaps you are afraid that if you allow all the pain to come out, you will be overwhelmed to the point of being unable to function. And, indeed, this can happen, at least temporarily. Or perhaps you are afraid of what others might think of you if they see you without your typical emotional control, and you are afraid of their negative judgments.

And so, grieving involves having the emotions without the emotions having you; accepting them and not struggling with them; metaphorically speaking, it is like driving a car with the radio on, but not so loudly that you are overcome by it. In other words, you will have the emotions but still be able to drive — still be able to lead your life.

To do this you must open the pain in a place that is safe and in a way that it is neither deadened or perpetually out-of-control. You must hold the hurt not too tightly and not too loosely, but gently, since it is precious; not walling the emotions off or letting them carry you away from active life for days at a time. Part of this is simply allowing yourself to be human, to honor the injury, not judging or trying to change what you feel (the change will happen by itself if you allow it), but permitting yourself to do what our mammal relatives do — to lick your wounds (metaphorically speaking) and accept the support of others, whether they are friends, lovers, relatives, or therapists.

And, in the end, if you have grieved and have the courage, good luck, and time to continue the human project that we all have been given, you are likely to heal enough to venture forth into the world, again putting yourself into the things and people you hold dear, risking injury once more, not hiding from the dangers that life brings, but also experiencing what is good in life — all the things you still value.

You will be alive again, and the grieving process will have led you there.

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The above image is The Grieving Parents, Kathe Kollwitz’s 1932 memorial to her son Peter, who died in World War I.