Complicated Grief

— What It Is, How to Process It, and Why It’s Different Than Typical Grieving

Complicated grief is more difficult to cope with, experts say. Here’s why.

By Claire Gillespie

It’s fair to say that grief is a complicated state in all its forms. People deal with it in different ways, and there’s no “right” way to grieve. But one type of grief is actually called “complicated grief,” and it’s primarily seen in people who enjoyed a very rewarding and loving relationship with the deceased.

For these people, working through the sadness and loss may be even more difficult than grieving over someone they were not as close to, says Mayra Mendez, PhD, a licensed psychotherapist and program coordinator for intellectual and developmental disabilities and mental health services at Providence Saint John’s Child and Family Development Center in Santa Monica, California.

“Extended grieving that does not lessen in intensity and continues beyond six months in a manner that significantly impairs functioning, thinking, social engagement, and self-care is termed complicated grief,” Mendez tells Health.

Complicated grief vs. common grief: how to tell the difference

When someone experiences complicated grief, thoughts of the lost loved one are overwhelming, Mendez says.

“The natural process of grief allows for the loss to be understood and accepted,” she explains. “The grieving process grows less intense, the pain of the loss decreases (but may not extinguish), and the time spent grieving reduces such that it is not all-consuming.”

Mendez stresses that grief has no “normal” timeline. However, there is a natural process of working through the grief. As part of this process, the grieving person becomes less likely to react emotionally to reminders of their lost loved one, and sadness is gradually replaced by fond memories. “A healthy grief process results in mindful discovery of ways to use the memories of the relationship to promote continued psychological growth,” she says. “In grief, pain for the loss is accompanied by positive emotions about the loved one and includes experiences of humor, relief, warmth, pleasure in closeness to others, responsiveness to being consoled, and preservation of self-esteem.”

Complicated grief interferes with the positive coping processes that are part of normal grief, which can affect a person’s day-to-day functioning and their ability to care for themselves, Leela R. Magavi, MD, a psychiatrist and regional medical director for Community Psychiatry in California. “Normal or common grief can be illustrated by a working woman taking care of her children and finishing her work for the day, but simultaneously grieving under the ‘normal’ exterior and day-to-day activities,” Dr. Magavi says. “On the other hand, complicated grief may lead to withdrawal from social interactions and lack of interest in once loved activities, including exercise and wellness.”

Are some people more prone to complicated grief?

If you have a history of depression, you may be more likely to experience longer-term grief when you have to cope with loss, Mendez says. Grief is frequently a trigger for a bout of major depression, she adds.

People who struggle with trauma are also vulnerable to experiencing complicated grief. “When grief intensity doesn’t decrease, stress prevails, and the loss is experienced as a traumatic life event—one that ultimately triggers major depression that is more serious than you would typically experience with a normal grief response,” Mendez says.

Other people who may develop complicated grief are those who have lost loved ones to suicide, experience multiple losses, or had a problematic relationship with the person who died, Dr. Magavi adds.

Signs of complicated grief

Someone experiencing complicated grief may engage in avoidant behavior, use alcohol or substances to numb their pain, or show little interest in spending time with family members and friends.

Some people may experience psychotic symptoms (such as hearing voices) or experience suicidal thoughts due to the severity of their depressive or anxiety symptoms, Dr. Magavi says.

Other signs of complicated grief include anxiety about the meaning of the loss, fear that the pain will continue indefinitely, worry that happiness is lost and will never be realized, feeling cheated, blaming others for the loss, and feeling anger toward the person who died.

Survivor’s guilt—a common reaction to traumatic events and a symptom of post-traumatic stress disorder (PTSD)—may also be tied into complicated grief, Mendez says.

While it’s common for people with complicated grief to experience relentless longing, yearning, sorrow, and overwhelming deep sadness, sometimes there’s nothing but a sense of numbness.

Dealing with complicated grief

The best way to deal with complicated grief depends on each individual’s circumstances, and it may be best to work it out with the help of a therapist or psychiatrist. Mendez advises seeking treatment from a professional who specializes in issues of death, dying, and coping with depression that stems from unresolved grief issues.

“Therapy techniques that follow a cognitive behavioral approach can help someone struggling with complicated grief to change faulty cognitive processes that reinforce depression and negativity,” she says.

Dr. Magavi recommends scheduling your days in advance to keep yourself busy and divert your attention from your pain in a healthy way. “Composing a gratitude list could also prove beneficial,” she says. “If you have lost someone, you could celebrate their life by recounting memorable moments, looking through photographs, partaking in their favorite activity, or perhaps even writing a letter.”

While spending time with other loved ones can provide comfort and support, it’s also important to pinpoint your own emotions and thoughts in the midst of collective grief. Sometimes you need time alone to process your own emotional response, voice, and needs in order to reduce stress and gain clarity, Dr. Magavi says. If you’re an empath, you’ll naturally absorb other people’s emotions—which could lead to an emotional breakdown during a tumultuous time.

Small, daily efforts can make a big difference in your journey out of complicated grief. Dr. Magavi advises all her patients to simply name their feelings out loud, then describe what they are feeling, both emotionally and throughout their body. “They make a log of their emotions and identify any triggering factors (those that exacerbated their condition), as well as alleviating factors (those that helped them feel better),” she explains. “This activity helps us learn more about what we feel, why we feel, and what we can do to combat helplessness and take control during times of uncertainty.”

It’s also important to own your grief, Dr. Magavi advises. That means resisting the temptation to alter your grieving process to match other people’s (or society’s) expectations. “Embrace your feelings, which may shift on a day-to-day basis,” she says.

Whatever you do, remember the things that are always true about grief. First of all, it’s a normal response to loss. “It’s expected, and generally an adaptive response to loss from various perspectives,” Mendez says.” Also, grief is not a permanent state—even if it takes longer to process.

Complete Article HERE!

Grief Can Strike Even Before a Loved One Is Gone

Uzo Egonu: Woman in Grief, 1968

By Cara Murez

Feelings of grief are expected after the loss of a loved one, but having those feelings when your loved one has a terminal illness is also real and can fluctuate over time, experts say.

Individuals can adjust to their emotional pain, according to a new study focusing on what is known as “pre-loss grief” observed at two points in time for people whose family members had advanced cancer or dementia.

“There’s a lot of research on anticipatory grief, which involves worry about the future. But pre-loss grief in that moment is pretty ignored,” said study author Jonathan Singer, a clinical psychology intern in psychiatry and behavioral health at Ohio State University.

“With medical advances, people are going to be living longer with life-limiting illnesses, so there will be a bigger and bigger issue with grief before the person passes away,” he said in a university news release. “Symptoms of pre-loss grief can predict long-term negative outcomes after a loved one’s death, so this is a good intervention target that we should figure out now.”

Participants completed questionnaires assessing their symptoms of grief, depression, post-traumatic stress and caregiving burden. These included 28 people whose loved ones had dementia who responded to both the initial and follow-up questionnaire and 33 of those whose loved ones had cancer. The initial survey was answered by 138 people.

The first questionnaire uncovered substantial pre-loss grief among participants. One month later, symptoms of pre-loss grief decreased for 69% of participants, though women and those with heavy caregiving burden were more likely to feel more intense grief.

Family members of patients with dementia were more likely than family members of cancer patients to have severe pre-loss grief, though some people anticipating the loss of a loved one to cancer also had unexpectedly high levels of grief.

Symptoms were similar, no matter how long the individuals had known that their loved one had a life-limiting illness.

“People in this study had pre-loss grief at a very high rate after many years. That was shocking, because one might think over time it would get easier. But with Alzheimer’s disease, it can get harder, and with cancer there could be a similar trajectory, starting with hope at the beginning but feeling worse over time,” Singer said.

“What’s happening with these family members still struggling — is it the caregiver burden, is it that they’ve lost their identity, is it that they’re not engaging in pleasurable activities anymore? That’s what we want to hit on next,” he said.

Pre-loss grief is not a clinical diagnosis, but prolonged grief disorder in people mourning the death of a loved one was added to the Diagnostic and Statistical Manual of Mental Disorders released this year. Symptoms include preoccupation with thoughts or memories of the lost family member combined with symptoms such as intense emotional pain, a sense of disbelief and difficulty moving on with life.

The researchers also found that 10.5% of family members of dementia patients and 2% of family members of cancer patients met the criteria for a diagnosis of prolonged-grief disorder.

Singer led a recent study designed to help provide a better understanding of how preparing for the death of a family member may prevent mental health problems for their survivors. He is now involved in a study of a longer-term trajectory of pre-loss grief.

Complete Article HERE!

The Secret to Happiness?

Thinking About Death.

In an excerpt from his new book, journalist Michael Easter travels to Bhutan to learn about how confronting death head-on can lead to a more fulfilled life

By Michael Easter

In his new book, The Comfort Crisis, Michael Easter investigates the connection between modern comforts and conveniences and some of our most pressing problems, like heart disease, diabetes, depression, and a sense of purposelessness. Turns out, engaging with a handful of evolutionary discomforts can dramatically improve our mental, physical, and spiritual wellbeing. One of those fruitful discomforts? Thinking about dying.

Death has always been the most uncomfortable fact of life. And as modern medicine, comforts, and conveniences have given us more years, we’ve seemingly become less and less comfortable with life’s only guarantee. Roughly seven out of ten Westerners say they feel uncomfortable with death. Only half of people over 65 have considered how they want to die.

After someone dies we’re encouraged to stay busy to take our mind off it. A dead person’s body is immediately covered and sent to a mortician where it is prepared to look as youthful and alive as possible before one final, hour-long viewing, after which it is dropped into the ground of a perfectly manicured cemetery.

But new research is showing that death awareness is good for us. For example, scientists at the University of Kentucky had one group of people think about a painful visit to the dentist and the other contemplate their death. The death thinkers afterward said they were more happy and fulfilled in life. The scientists concluded, “death is a psychologically threatening fact, but when people contemplate it, apparently the automatic system begins to search for happy thoughts.”

The country of Bhutan has made it part of its national curriculum to think about death anywhere from one to three times daily. The understanding that we’re all going to die is hammered into Bhutan’s collective conscience, and death is part of everyday life. Ashes of the dead are mixed with clay and molded into small pyramids, called tsa tsas, and placed along heavily trafficked areas like roadsides, in window sills, and public squares and parks. Bhutanese arts often center around death; paintings of vultures picking the flesh from corpses, dances that reenact dying. Funerals are a 21-day event where the dead body “lives” in its house before being slowly cremated over fragrant juniper trees in front of hundreds of friends and relatives.

All of this death is doing anything but bumming out the Bhutanese. Despite being ranked the 134th most developed nation on earth, extensive studies conducted by Japanese researchers have found that Bhutan is among the world’s 20 happiest countries. But what you probably don’t know is how morbidity contributes to their feelings of happiness. And neither did I.

After four flights across 48 hours, 14 time zones, and 9,465 miles, I stepped off an aging 737 onto a runway 7,333 feet above sea level at Bhutan’s Paro International Airport. THE thin air filled my lungs as the sun illuminated the surrounding snow-capped Himalayan foothills. I was there to find out how Bhutan’s uncomfortable intimacy with death might improve my life—and maybe yours too.

I’d arranged to meet with a host of characters, including government leaders who study happiness in Bhutan. But the most compelling men I met with were both leaders in the Buddhist faith.

The first was Khenpo Phuntsho Tashi. He knows as much about death as a living human can. He’s one of Bhutan’s leading Buddhist thinkers, and he’s found a niche in the study of death and dying. The Khenpo is the author of a 250-page book called “The Fine Art of Living and Manifesting a Peaceful Death.” And unlike many of Bhutan’s monks, the Khenpo is intimately familiar with what ails people in the West. Before he dedicated himself to his spiritual practice he lived in Atlanta, with a girlfriend who was the Dalai Lama’s translator. He, I thought, would be able to get to the heart and consequences of the West’s fear of death.

My boots kicked up a low-hanging dust as the Khenpo’s cliff-side shack came into view. It was wooden, tin-roofed, and in the shadow of Dakarpo. Dakarpo is an ancient Buddhist monastery built on an outcropping that overlooks the Shaba valley. Fifteen or so people walked clockwise around the white, fortress-like monastery. They chanted as they carefully stepped around its rocky terrain. Bhutanese mythology says a person will be cleared of all of his or her sins by circumventing the Dakarpo 108 times. Each lap takes roughly 25 minutes. The full 108 takes most pilgrims about four full days, a relatively small fee for absolute absolution.

The scent of burning incense crawled into my nose as I peeled back the heavy orange embroidered silk drape leading into the Khenpo’s room. Light was entering the room through a hazy window, catching smoke. It obscured a small altar anchored by a three-foot statue of the Buddha. Around it were smaller Buddhist statues, photographs, and burning sticks of champa. Through the smoke I saw the profile of a face. It was the Khenpo.

“Welcome,” said the Khenpo, his voice a heavily accented butter. I bowed and sat. “You want to talk about death?”

I nodded. “Hmmmm,” he said. His chest slowly rose and fell in the silence.

“You Americans are usually ignorant,” he said, using a word often seen as an insult in the United States, but that by definition means “lacking awareness.” In Bhutan and other Buddhist countries, “ignorance” is the rough English translation of “Avidyā.” That’s a Sanskrit word that means having a misunderstanding of the true nature of your reality and the truth of your impermanence. “Most Americans are unaware of how good you have it, and so many of you are miserable and chasing the wrong things.

“You act like life is fulfilling a checklist. ‘I need to get a good wife or husband, then I get a good car, then I get a good house, then I get a promotion, then I get a better car and a better house and I make a name for myself and then …’” he rattled off more accomplishments that fulfill the American Dream. “But this plan will never materialize perfectly. And even if it does, then what? You don’t settle, you add more items to the checklist. It is the nature of desire to get one thing and immediately want the next thing, and this cycle of accomplishment and acquisitions won’t necessarily make you happy—if you have ten pairs of shoes you want 11 pairs.”

The Khenpo then pointed out that by pursuing this checklist, we’re often forced into acts that take us away from that higher reality and happiness. He was echoing a sentiment shared among many leaders in the tradition of Vajrayana Buddhism. Sogral Rinpoche in his 1992 work The Tibetan Book of Living and Dying called this checklist phenomenon “Western laziness.” It consists of “cramming our lives with compulsive activity, so that there is no time at all to confront the real issues … If we look into our lives, we will see clearly how many unimportant tasks, so-called ‘responsibilities’ accumulate to fill them up … Going on as we do, obsessively trying to improve our conditions, can become an end in itself and a pointless distraction.”

The average American works 47 hours a week. Our entrepreneurs and “productivity gurus” preach that a “grind” and “shut up and work harder” mentality is the secret to satisfaction. This upset in our work/life balance—or, perhaps, our problem integrating our work into our life and not the other way around—factors into why other research has shown that America is, in fact, less happy than it was decades ago.

“So this checklist plan does not make you truly happy. Then what?” said the Khenpo. He was silent. Left it open for me to ponder.

“I don’t know. I’m an ignorant American,” I said and smiled.

“Then you could be happier!” he responded with a chuckle. “Whereas if you understand this cycle and nature of mind and you prioritize mindfulness then everything will be ok. Even if you don’t become rich. Fine, you’re mindful. Even if you don’t get a perfect wife? Fine, you’re mindful.”

Ah, yes. “Mindfulness.” That squishy, what-the-fuck-does-that-even-mean word that’s so hot in America today but has, in fact, been a part of Eastern traditions since before Christ. It’s roughly defined as purposefully paying attention to what’s happening in the present moment without judgment, according to Jon Kabat Zinn, a profes-sor at the University of Massachusetts Medical School and pioneer of mindfulness in the Western world. In other words, it’s being aware of what’s going on upstairs.

The Khenpo made mindfulness sound akin to jamming a stick into the spokes of the checklist and developing a state of okayness. In other words, whether I’m rich or poor or famous or a nobody, I should avoid becoming caught up in the narratives my mind spits out and just accept the direction of things. This will help me go beyond the checklist and be just fine.

The woman who took me through the cleansing ritual entered the room. She placed a plate of sliced cucumbers and mandarin wedges on the floor between the Khenpo and me. “All organic!,” he said and grabbed a spear of cucumber. It crunched as he bit into it.

“Well, the Bhutanese, we also have ignorance, anger, and attachment. We have the same problems of the checklist. But I think less. This is because we apply what we call mindfulness of the body. We remember that everyone is dying right now,” said the Khenpo. “Everyone will die. You are not singled out. Do you know this? To not think of death and not prepare for it … this is the root of ignorance.”

Pretend you are walking along a trail, he explained, and there is a cliff in 500 yards. The catch: The cliff is death and we will all walk off it. “Buddha died. Jesus died. You will die. I will die. I would like to die on that bed,” said the Khenpo, pointing to a twin mattress on the floor.

“Don’t you want to know that there’s a cliff?” he asked. Because only then can we change our course. We could take a more scenic route, notice the beauty of the trail before it ends, say the things we truly want to say to the people we’re walking it with.

“When you start to understand that death is coming, that the cliff is coming, you see things differently. You change your mental course—you naturally become more compassionate and mindful,” said the Khenpo. “But Americans, they don’t want to hear about the cliff. They don’t think about death. After a funeral, they want to get their mind off the death and just eat cake. The Bhutanese, they want to know about the cliff and they will be happy to talk about death and ruin the cake eating.”

“So remember,” he continued. He was able to sustain the perfect upright lotus position while I was slumping and couldn’t feel my legs. “We are all dying right now. To develop this mindfulness of death you have to think of Mitakpa.”

“Mitakpa?” I asked.

“Yes,” he said. “Mitakpa.”

Before I could probe the Khenpo on Mitakpa—what it is and what it might be able to do—his time was up and I was back in Dorji’s hatchback. We were like bouncy balls in the seats as gravity aggressively pulled the car over all the rocks and ruts that once thwarted us. As we descended I asked, “Dorji, what is mitakpa?” He looked at me and shook his head. “Mi-tak-pa,” I said.

“Oh. Mitakpa,” he replied, pronouncing the word less like an ignorant American. “Takpa ‘permanent,’” he said. “Mi ‘no.’ Mitakpa ‘no permanent.’”

I began to ask him to explain further, but a Bhutanese traffic jam interrupted me. A herd of seven bulls and cows ambled up the one-lane road. Dorji pressed into the brake to slow the car to a crawl. The half-ton animals lazily parted around us. Their bells clanked as they slid down the length of the hatchback.

The next day, I headed into an apartment in the city of Thimpu to meet Lama Damcho Gyeltshen. He doesn’t ponder death in any abstract sense—he experiences it every day. He’s the head Lama at the Jigme Dorji Wangchuck National Referral Hospital, the main hospital in Bhutan. It’s there that he councils the dying. After the Khenpo elucidated the problem and hinted at some solution, the Lama, I figured, might be able to expand.

The Lama was sitting on a platform that was covered in silk meditation pads. He hopped off of it as we entered. He and I shook hands and did a lot of smiling and nodding. He was bald, short, and doughy, with wire-framed glasses. His bright white smile popped against his blaze orange robes. He sat back atop the platform, in the lotus, while Jigme and I sat on the floor. Jigme explained what I was there to talk about. Death, dying, and the Bhutanese death complex.

“Well first I’d like to thank you for coming and reminding me of death because it is important for the mind,” said the Lama. His words, naturally, set me up to ask why.

“When people come into my hospital there is a chance they leave,” he said. “But there is also a high chance they do not leave. My job is to help people prepare for death. I have found that the people who have not thought about death are the ones who have regrets on their deathbeds. Because they have not used a necessary tool that could have made them live a fuller life.” An American study conducted across various hospitals like the Yale Cancer Center, Dana -Farber Cancer Institute, and Massachusetts General Hospital supports this notion. It found that dying patients who had open conversations about their death experienced better quality of life in the weeks and months leading to their passing, as judged by their family members and nurse practitioners.

“The mind is afflicted with many delusions. But they come down to three,” continued the Lama. “And those are greed, anger, and ignorance. When your mind is not taken care of these three things have an advantage. The dying people I council … they suddenly do not care about getting famous, or their car or watch, or working more. They don’t care about the things that once angered them.” In other words: When a person realizes death is imminent, their checklist and everyday bullshit becomes irrelevant and their mind begins to center on that which makes it happy. Research from Australia found that the top regrets of the dying include not living in the moment, working too often, and living a life the person thinks they should rather than one they truly want to.

“Whereas those who have thought of their death and prepared for it,” said the Lama, “they do not have those regrets. Because they have often not fallen so much into those delusions. They have lived in the moment. Maybe they have accomplished a lot. Maybe they have not. But regardless it has not affected their happiness as much …” He expanded on this phenomenon, explaining that a sort of cosmic psychic shift often occurs in the dying. It brings them closer to the things that matter in the end. A living person who thinks of dying will, yes, initially face mental discomfort, but they’ll emerge on the other side having stolen a bit of this end-of-life magic.

“What is mitakpa?” I asked. “Someone told me it translates to ‘no permanent…’”

“Close. Mitakpa is impermanence,” said the Lama. He raised an arm and finger, like a professor making a point. “Impermanence, impermanence, impermanence.” This, he said, is the cornerstone of Buddhist teachings. Nothing lasts and, therefore, nothing can be held onto. By trying to hold on to that which is changing, like our life itself, we ultimately end up suffering. Buddha’s final words were on impermanence, a reminder that all things die. “All things change. Whatever is born is subject to decay…” he said. “All individual things pass away.”

“It’s important to preserve this precious understanding of mitakpa in your mind. It will significantly contribute to your happiness,” said the Lama. He echoed the Khenpo’s sentiment. He explained that not thinking of mitakpa often leads a person to believe that “things will be better when I do X.” Or with a false sense of permanence that causes a person to put off the things they truly want to do because “I can do that when I retire.”

“But when you understand that nothing is permanent you cannot help but follow a better, happier path,” he said. “It calms your mind. You tend not to get overly excited, angry, or critical. With this principle, people interact with others and it improves their relationships. They become more grateful and gratuitous. Because they realize all their material goods and status will not matter in the end.” And not just in Bhutan. A study in Psychological Science discovered that people who thought about their death were more likely to show concern for people around them. They did things like donating time, money, and even their blood to blood banks.

“How often should I be thinking about mitakpa?” I asked.

“You must think of mitakpa three times each day. Once in the morning, once in the afternoon, and once in the evening. You must be curious about your death. You must understand you don’t know how you will die or where you will die. Just that you will die. And that death can come at any time,” he said. “The ancient monks would remind themselves of this every time they left their meditation cave. I, too, remind myself of this every time I walk out my front door.”

We talked for a half-hour more about death and his work at the hospital. Then it was time for me to leave.

“Remember,” said the Lama as we were saying goodbye. “Death can come at any time. Any time.”

The next day I spent the morning hiking five steep miles to Paro Taksang, “The Tiger’s Nest,” a sacred 15th-century Buddhist monastery built in the traditional Bhutanese Dzong style. The monastery sits at 10,240 feet above sea level and clings to a cliff like a reptile on a vertical wall. It’s the location where in the eighth century Padmasambhava, a man considered the “Second Buddha,” meditated in a tiger-filled cave for three years, three months, three weeks, three days, and three hours.

I’d come to see the monastery’s famous artwork, much of which depicts death. It holds various images and statues of, for example, Mahakala, a protector god whose crown is ringed with skulls and whose sash is strung with severed heads. His Sanskrit name translates to “beyond time” or, more simply, “death.”

As I exited the monastery and put my shoes back on, Dorji, my driver (Bhutanese law requires all tourists to hire a guide and a driver … my guide had conked out due to the altitude), hurriedly approached me. “Someone sick,” he said in his broken English. He pointed up the trail, to a set of steep stairs cut from a cliff that lead up to a small meditation hut next to a waterfall. Towards the top of the steps, a group of people huddled. They were all wearing either traditional Bhutanese ghos or monk robes. Dorji jogged towards the group. I followed. As I quickly stepped up the thin stairs I could see feet hanging from the edge of the steps.

A monk—bald head, thin glasses, maroon robes—was down on the steps, unconscious. I recalled some basic emergency wilderness training I took and checked his spine for signs of fracture. Nothing. A general understanding arose within the group. The man needed to be moved to flat ground so he could be airlifted out.

The stairs were too steep and thin for a group carry. So we carefully propped the monk onto the back of the largest driver, who hoofed him down the steps. With the help of the group, he laid the monk onto a flat grass patch along the cliffside trail.

The monk’s eyes were rolled back as if he was scrutinizing the brain above them. “I’m going to do CPR,” I slowly told the group. They only partially understood me. As I knelt in front of him two tiny women, a mother and daughter who were both doctors in Hong Kong, were suddenly at my side. They were hiking to the monastery when they walked into this scene.

They pressed their fingers to the man’s neck to check vitals and agreed that CPR was needed. These two were surely better trained. But I was the only person with any training who was also large enough to optimally execute CPR on the 200-pound monk.

I tore open his robe, revealing a gold t-shirt. I dug my knees into the dirt, overlapped my hands, and placed the heel of my right hand on the monk’s sternum. Then I began hammering into his chest; 100 beats a minute as the daughter doctor began a timer.

I was unsure of the cultural implications of giving a monk mouth-to-mouth. So the younger Hong Kong doctor quickly instructed one of the other monks, a woman, on how to do it. She breathed into him, repeatedly pushing air into his lungs. Then I was back to compressing his chest.

“Time is 10:26,” said the daughter. A crowd had formed around us, and a driver who was on the phone stepped into the group. “Helicopter cannot come,” he told us. There was nowhere to land, and the cliffs were too close for an airlift.

The daughter checked the monk’s vitals. She shook her head. I continued pressing. Pressing, pressing, as hard as I could, thinking that if I could push hard enough it might kickstart his heart. We hit the fifteen-minute mark. His face was distant. “20 minutes 11 seconds,” said the doctor. “You can stop.” He was gone.

Here was a man who just minutes ago had hiked five steep miles. And he was joking and laughing and talking with friends along the way. Death can come at any time.

Complete Article HERE!

Understanding family members’ grief for a living loved one

Study looks at factors that influence pre-loss grief

By Emily Caldwell

The symptoms of grief people feel for a loved one facing a life-limiting illness fluctuate over time, a new study found – suggesting that individuals can adjust to their emotional pain, but also revealing factors that can make pre-loss grief more severe.

Researchers examined changes in the severity of pre-loss grief symptoms in people whose family members had either advanced cancer or dementia.

The study is the first to document pre-loss grief at two points in time, and found that about 70% of participants’ symptoms decreased over a month. However, compared to initial symptoms reported by participants, women and those with a heavy caregiving burden were more likely to be experiencing more intense symptoms a month later.

The results also showed that family members of patients with dementia, for which there is no long-term treatment or cure, were significantly more likely than family members of cancer patients to have severe pre-loss grief – but that some people anticipating losing a loved one to cancer also had unexpectedly high levels of pre-loss grief.

Participants reported similar symptoms no matter how long they had been living with the knowledge that their loved one had a life-limiting illness – another surprising finding for Jonathan Singer, lead author of the study and a clinical psychology intern in psychiatry and behavioral health at The Ohio State University.

“People in this study had pre-loss grief at a very high rate after many years. That was shocking, because one might think over time it would get easier. But with Alzheimer’s disease, it can get harder, and with cancer there could be a similar trajectory, starting with hope at the beginning but feeling worse over time,” Singer said.

“What’s happening with these family members still struggling – is it the caregiver burden, is it that they’ve lost their identity, is it that they’re not engaging in pleasurable activities anymore? That’s what we want to hit on next.”

The study was published recently in the Journal of Health Psychology.

Though pre-loss grief is not a clinical diagnosis, prolonged grief disorder in people mourning the death of a loved one has been added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released this year. Clinical criteria for a diagnosis include preoccupation with thoughts or memories of the lost family member combined with a number of symptoms such as intense emotional pain, a sense of disbelief and difficulty moving on with life.

Adding prolonged grief disorder to the DSM-5 represents progress, Singer said – but the relatively new area of research on pre-loss grief demonstrates a need to consider therapies that can ease symptoms of people who are grieving for an ill loved one who is still alive.

“There’s a lot of research on anticipatory grief, which involves worry about the future. But pre-loss grief in that moment is pretty ignored,” said Singer, who treats patients at Ohio State Wexner Medical Center.

“With medical advances, people are going to be living longer with life-limiting illnesses, so there will be a bigger and bigger issue with grief before the person passes away. Symptoms of pre-loss grief can predict long-term negative outcomes after a loved one’s death, so this is a good intervention target that we should figure out now.”

Though it’s too soon to tell what types of therapies might work best, Singer noted two approaches that hold promise: behavioral activation that encourages people to engage in pleasurable activities, and meaning-centered psychotherapy designed to enhance spiritual well-being and quality of life.

For this study, the researchers recruited family members of patients with advanced cancer (100) and dementia (38) who completed questionnaires assessing their symptoms of grief, depression, post-traumatic stress and caregiving burden. Of those, 33 family members of cancer patients and 28 family members of dementia patients completed a follow-up assessment one month later.

The initial assessment showed that participants were experiencing substantial pre-loss grief. Women and participants with a higher caregiver burden were the most likely to be experiencing more intense grief one month later.

Overall, 69% of participants reported decreases in symptoms a month after the first assessment – a phenomenon that Singer plans to explore in follow-up studies.

There were no differences in pre-loss grief at baseline or one month later based on the nature of the life-limiting illness. But in a secondary analysis of the severity of reported symptoms, the researchers found that 10.5% of family members of dementia patients and 2% of family members of cancer patients met the criteria for a diagnosis of prolonged-grief disorder.

“We expected to see this severity in family members of patients with dementia,” Singer said. “But there is a lot of hope in the cancer community, so it was a big surprise to see so much pre-loss grief in family members of cancer patients.”

Singer led a recent study designed to help pave the way to a better understanding of how preparing for the death of a family member may prevent mental health problems for their survivors. He is currently involved in a study of a longer-term trajectory of pre-loss grief and is interested in investigating its biological effects.

Complete Article HERE!

In Ghana, Funerals Are A Party.

But My Dad’s Couldn’t Hold My Grief.

Leonie Owiredu lost her father when she was young. His funeral was a loud celebration, full of family and friends, in keeping with Ghanaian custom. But in all that noise, she didn’t have the space she needed to grieve him.


When I was four years old, I turned up to school in uniform on a day I wasn’t supposed to. I went to the school’s front desk and asked to call my dad to have him bring me my favorite outfit, a can of 7UP, and some sausage rolls. It was a brazen request that came from an assurance that my dad would always be there for me. When I was a bit older, and he fell ill, I believed that he would survive. My dad wasn’t supposed to die. He was supposed to walk up to the front of the congregation at our church to give his testimony of his survival. Everyone would stand up and join in praising God for such a miracle. When my dad died, it didn’t feel real. At 14, I had no direct encounter with death, nor did I know the weight it held in my culture. As the 10-year anniversary arrives this year, I’m still trying to figure it out.

From custom caskets to pallbearers, Ghana is a nation that takes pride in honoring the dead.

I’d just come home from boarding school for half term, when word spread that my father had passed. I watched as people flooded my door, eager to relieve their grief. My living room became crowded with distant relatives spilling over into the kitchen, claiming offense when I said I didn’t recognize them. This being my first funeral, and as a 14-year-old, I learned as I went on that funerals are the events that bring Ghanaians together. From custom caskets to pallbearers, we’re a nation that takes pride in honoring the dead.

Our mourning involves wailing, dancing to highlife and drum beats that help shake off grief, eating pots of waakye and jollof,drinking and wearing red and black clothing from Friday to Saturday, and then white on Sunday, to celebrate the person who once was. I witnessed the bustle the adults created for the first time over the designated days of mourning. My siblings, cousins, and I were pushed out of the living room and instead spent this time trying to mirror a celebration of our own upstairs by watching Beyoncé’s Live at Roseland; hearing her sing “I Miss You” while wiping away her tears gave voice to the feelings I couldn’t quite place. That performance especially carried me through my grief.

A lot of my participation in the funeral was decided for me, removing my agency to navigate through grief in a way I could understand. Perhaps the way adults grieve required a certain physicality that I wasn’t able to possess as a child. But my father always involved my siblings and me, affirming our voices through holding family meetings and considering our suggestions. So to be excluded from his funeral was unfamiliar.

The way adults grieve required a certain physicality that I wasn’t able to possess as a child.

There was an unspoken understanding that I was to serve the adults around me and be silent as they mourned, as if their grief trumped my own. These rules arrived via orders of “Don’t cry, wear this, and be strong for your mother.” These customs were foreign to me—still are foreign. I recently spoke to my 50-year-old aunt who lost her father at 12. I asked her why the perspectives of children aren’t considered. She said, “There was so much going on, the plan was just to get you through the events. They tell you where to go, what to say, and then after, they may explain.” I also asked my eldest cousin why after-care for children of the bereaved isn’t considered. Her response was, “Obi nhwɛ obi ba”: Nobody should look after anybody’s child. It was incredibly isolating to be surrounded by so many people, searching for permission to express my grief but constantly being denied. When an adult’s grief is valued higher than the child’s, all the grief is repressed and becomes cyclical—the child’s right to grieve continually placed to the side. After the immediate shock of death passes, the funeral rites are complete, and the doorbell stops ringing, everyone has decided that mourning is over. These rituals demarcated it as so. But for me, it had barely begun.

It was isolating to be surrounded by so many people, searching for permission to express my grief.

Children are deeply emotional creatures and are capable of far more depth and clarity than those around me would give them credit for. The adults wanted to fill their grief with celebrations. Their denial of my emotions at that time made me feel that they were something to hide; I could experience it only in short, and it had to be in private so as to not be an inconvenience to others. A happier child is easier than one who is sad. In attempts to deal with that internally, in my first year of grief, I denied myself of food. I stopped attending meals and began exercising more under the guise of pursing modeling, when my actions were in actuality an attempt to control feelings within my body. It was when other students at my boarding school noticed and kept inviting me to meals that one day I accepted, prompting a different dynamic with food as I grappled with the waves of grief.

A happier child is easier than one who is sad.

I lost the ability to experience the still silence that grief requires; I had to fill it with doing. What good was my hurt if I couldn’t help everyone process theirs? My grief was best in service, and I became really good at performing. I turned into a guru of sorts as friends and family piled in for support and advice. I knew exactly what to say and how to say it, because I longed for those things to be said to me.

As the years passed, I made three attempts at seeking counsel. It was my fourth and most recent therapist who helped me realize that I could navigate grief if I looked at what the experience was like for me. Now as a 20-something, I feel safe enough to move through grief and recognize those emotions with no shame. The weight of grief can be numbing at times, and then light; by giving myself permission to feel, it enables me to choose who to grieve with and how.

I lost the ability to experience the still silence that grief requires

In her poem “Taking Care,” Callista Buchen writes, “I sit with my grief. I mother it. I hold its small, hot hand. I don’t say, shhh. I don’t say, it is okay. I wait until it is done having feelings. Then we stand and we go wash the dishes.” I now know my feelings toward grief are neither good nor bad; they simply need to pass. A decade after my father’s death, I finally feel ready to honor those feelings.

Complete Article HERE!

How the light gets in


When palliative care doctor Rachel Clarke looked back over her notes typed hastily pre-dawn in the midst of a global pandemic, she expected to find only darkness—an unrelenting stream of death and despair. To her surprise, her insomniac’s diary was “illuminated by pinpricks of light”. “People began to organise, street by street, village by village, to make sure that their most vulnerable neighbours…were safe and fed and kept from harm”, writes Clarke. Rainbows appeared in windows up and down the country in support of key workers, volunteers set to work sewing masks and manufacturing visors, and a retired British Army officer approaching his 100th birthday united a divided nation by walking laps of his garden to raise money for the National Health Service (NHS).

Clarke, who embarked on a career as a current affairs journalist before beginning medical training, has since punctuated her medical career with writing—from Your Life in My Hands, charting her experiences as a newly qualified doctor, to Dear Life, exploring death, grief, and the things that truly matter at the end of life. Her latest work, Breathtaking: Inside the NHS in a Time of Pandemic, spans the 4 months from New Year’s Day 2020 to the end of April that same year—a fleeting snapshot of a time during which life in the UK changed immeasurably.

“Pacing the kitchen and tapping a keyboard became a kind of nocturnal therapy”, she explains. These notes, typed “fast and furiously” while her family slept, open a window to life in the UK in its darkest hours. Turning the pages of Breathtaking, we relive the angst and uncertainty of those early months. The anguish about personal protective equipment (PPE) and testing, death tolls rising too high to take in, and the sudden, unexplained obsessions with baking bread and accumulating toilet paper that swept the nation. But, for those of us who know COVID-19 in only an abstract sense, following the news from the safety of our homes, Clarke gifts us a unique glimpse of life in the eye of the storm. As the crisis evolved, day by day, week by week, we learn, in real time, what life was truly like for those on the frontlines—those who risked everything, not knowing that they would see the other side. “To us”, she explains, beyond statistics and modelling, “the pandemic is a matter of flesh and blood. It unfolds one human being at a time”. In these darkest of times, Breathtaking shows us that the greatest sources of light came from within the NHS.

Beyond the inestimable challenges of treating a new disease, acquiring knowledge on the run as patients lurched from one physiological crisis to the next, health-care workers fought—through the physical barriers of masks, gowns, and distance—to restore the humanity to their practice that COVID-19 so cruelly stripped. Overnight, hospitals cleared of visitors, carparks emptied. For Clarke, whose work in palliative care has made her all too aware of the power of human connection, seeing patients isolated from their loved ones feels like a psychological assault. “Covid even steals the patients’ names. So great are the risks of communication in PPE that it is safer for the nursing team to use bed numbers to refer to the human beings for whom they care”, she writes. Humanity is restored by any means possible: medical students volunteer to liaise with patients’ families, many of whom are self-isolating and alone; hearts knitted by volunteers are used to symbolise the connection between patients and their families; health-care workers add laminated photos of their faces to their plastic gowns. “Our tools are uncertain and improvised”, she writes. “We use whatever we can to draw people back together and we refuse to settle for despair.”

Clarke’s style is intimate and generous, opening up to us her own home and family life. We join her pacing in her kitchen—glued to her phone—as she watches events unfold, first in Wuhan, then Lombardy, and finally on her doorstep. We watch her conceal her anxiety from her husband, guilty at even an insignificant deception. We feel her exasperation as PPE at the hospice runs perilously low. We feel her overwhelming desire to help, which drives her to volunteer on the frontlines. Misty-eyed, we’re there as she attempts to quell the fears of her 9-year-old daughter, terrified of losing her mother. “How can I possibly tell her I have volunteered, that I want to be the one helping these patients?”, she asks.

Although not yet over, the opportunity to reflect on these early pandemic months is at once cathartic and deeply humbling. Powerful personal stories allow us to grieve the loss we have suffered as a nation, far beyond the statistics, as well as to appreciate the sacrifices made by NHS workers and volunteers who put helping others above all else. Although Clarke cannot conceal her blistering anger at the failings of those in charge, at its core Breathtaking brims with pride and positivity. “Every single day, the grit and devotion of colleagues astounded me”, she writes. “In the 11 years I have practised as a doctor, I have never been prouder of nor more humbled by the NHS and its people.”

Complete Article HERE!

How rituals help the grieving process

Grief counsellor and author Lianna Champ explains why the rituals of death are crucial to our ability to grieve healthily.

Funerals allow us to show our love and respect to the person who has died, and can reduce the weight of our grief

When we entered the first lockdown of the pandemic, not only did we lose so many of our freedoms, we also lost routines and rituals that helped us to navigate life events.

Very often we don’t address grief until we actually lose someone and consequently, we are often unprepared, plunged into the unknown along with everyone around us, all experiencing our own unique reaction. If we withdraw into our own private pain, ritual has the power to pull us out. Rituals connect us with our community, however large or small, and provide us with the hope, love and support others have to offer.

Rituals connect us with our community and provide us with the hope, love and support others have to offer.

Rituals also help us to recognise that a death has taken place and carrying out these acts bring a feeling of closeness to the person who has died. They also provide an opportunity to show our love and respect and this helps to reduce some of the weight of our grief. Rituals also remind us that something fundamental has changed in our lives and changes need to be marked so we can process how feel.

Rituals connect us with the past, the present and the future.

The Past… in all its glory as we recall the life that has been lived.

The present… the hallowed acts we carry out which provide healing, allowing us to find comfort as we share this time with others. The death of someone significant in our lives temporarily disconnects us from the world around us.

The funeral preparations and ceremony provide a focus and a framework to hold on to. On the day of the funeral our physical relationship with that person ends but our emotional relationship with them lasts until we each die. We need time and space in which to make this transition from the physical to the emotional. Funeral rituals provide coping mechanisms, handles to grasp on to through the emotional confusion. The whole process of preparing for the funeral and experiencing the actual ceremony itself is essential, however much effort this may feel at the time.

If we withdraw into our own private pain, ritual has the power to pull us out. Funeral rituals help to blow away the clouds of uncertainty by engaging our minds, bodies and spirits at the time. We need to take these steps of preparation to allow the healing magic of ritual to begin. We also have a sense of doing something for the person who has died whilst we still physically have them.

The future… rituals force us to slow down, to connect with our inner self and find a doorway to lead us out of the isolation that so often follows loss. Through sharing the funeral rituals with family and friends we can emerge with a sense of hopefulness and the knowledge that life continues to unfold, even in the face of death. We learn that life is a changeable thing, and nothing is constant.

With the absence of rituals around death, we can overlook the importance of slowing down and really connecting with what is going on inside us. We can also store up unresolved grief if we don’t give it our time, focus and attention. This can eventually drag us down as we try to return to living normal lives. Repeated loss – and there are many losses we experience in our lives beyond bereavement – can impact grief upon grief. Repeated unresolved grief can sometimes make us search for an outlet which may not be good for us – alcohol, recreational drugs or a trail of relationships that we ruin in fear of loss and pain.

Today, many of us struggle to find any meaning in the face of sickness and death, particularly during this time of pandemic where we are seeing deaths taking place all over the world. While we may long for a great faith, few of us have that. All our usual practices around death, dying and funerals have been taken away from us so it is more important than ever that we find and create new ways of preparing for death that help us to confront the truth of loss and pain in order to begin the process of healing.

Complete Article HERE!