Even after all the funerals in Newtown are over, the mourning will long go on. If experience is any guide, the heartbreak there will slowly heal with time. But for some who lost loved ones, the pain of bereavement may remain intense and constant, even years afterward.
Psychiatry calls this ‘complicated grief.’ ‘Complicated’ meaning not complex but that the healing process that normally occurs, after even a sudden and terrible loss, goes somehow awry. It develops a complication, like an infection in a wound. Complicated grief is under consideration to become a new official diagnosis, and psychiatrists have developed specific therapy to help patients who become “stuck” for years in their grief. Carey Goldberg, of WBUR’s CommonHealth blog, explains:
One beautiful July evening, as 62 year-old Gerrit Schuurman was cooking dinner, he told his wife, Cynthia, that he was having some trouble swallowing. Two days later he was dead, killed by an aneurysm his surgeons said was like a ticking time bomb in his brain.
Numb, disbelieving and alone after 37 years of marriage, Cynthia soldiered on. She left Germany, where she and Gerrit had been living, and returned to her native Boston. She found work as a teacher trainer for a non-profit, spent time with her new granddaughter.
On the outside, Cynthia was doing all right. But not inside. Every pleasure was soured by sadness; she obsessed about Gerrit’s death — "Why did this happen? Could I have done something?" — and the parallels with her father’s sudden death when she was just 13. The grief just wasn’t letting up, and it threatened to break her.
"I thought, well, I’m going to feel better in a year. People always say the first year is very difficult,” she recalled. “Other people told me the second year is even worse in the grief process," she said. "And the second year came and it was worse. So I thought okay, maybe by the third year I'm going to feel better. But I was going through the motions. I was functioning but inside I was a mess. I was very, very upset and crying when nobody was around...About the third year, I was in a class, I was teaching my students and I broke down in the middle of a sentence.”
“The day I had that 'mini-meltdown,' I sent up a silent prayer to God and the universe saying, 'I need help, please help me.' So on the way home on the train there was a big sign, a big poster, an advertisement poster for 'complicated grief.' It said, ‘Are you crying all the time? Are you depressed? Are you stuck in grief?' And I said, 'Well, that’s me, it has my name on it.'”
Dr. Naomi Simon, head of the complicated grief program at Massachusetts General Hospital — the program Cynthia noticed in the subway ad — says people can 'get stuck' in grief for a wide variety of reasons.
“It could be a sudden or traumatic loss that is the main reason that one person gets stuck.," she said. "It could be a prior history of mood or anxiety, or a trauma, or early life loss is another example of what could get someone stuck. It could be how somebody is able to deal with emotions, so someone who's very, very avoidant of allowing themselves to feel those emotions can get stuck.
"So there are many reasons and we’re still really understanding it as to who would be at risk, to really need some kind of help in order to move to some more integrated form of grief. We really do think about it as that we are targeting where they got stuck with our interventions."
Researchers estimate that about 7 percent of bereaved people develop complicated grief. And it is being considered as a formal diagnosis in next year’s DSM-5, the so-called bible of psychiatric diagnoses, though some details — including its official name — remain to be worked out.
But should there be a diagnosis? Is there really a “normal” way to recover from a terrible loss? And isn’t there a danger of pathologizing the very personal process of grieving?
"We expect acute grief after someone dies, absolutely, we expect that," responded Dr. M. Katherine Shear, the director of the Center for Complicated Grief at Columbia University. "But we also expect a healing process, and that healing process can get derailed. So we’re not talking about normal grief. 93% of the population has normal grief. We’re not trying to diagnose the normal process."
Dr. Shear led the development of a targeted therapeutic treatment for complicated grief. While the factors behind it may vary, she says, complicated grief looks remarkably similar across people. The complications "are virtually always one of a small number of typical thoughts — counter-factual thoughts of 'if only' something different had happened the person would not have died; excessive avoidance behaviors; or extreme difficulty regulating emotions."
The treatment, she says, focuses on two main goals: Resolving the complications, and reactivating the normal healing process. As part of the treatment, she said, “We ask them to go back and revisit the time of the death."
For Cynthia, that meant that soon after she enrolled in grief therapy at Mass. General with Dr. Naomi Simon's team, she recorded her memories of her husband’s final hours and replayed them repeatedly.
"I had to keep playing it and playing it until what I call the emotional ambush stopped and I could really listen to what I was going through," she said. "At one point, I thought, 'Oh you poor thing, what you’ve had to go through!' I felt really sorry for myself. So I think I was turning a corner."
Cynthia’s treatment encouraged her to take better care of herself, do more pleasurable things and try to think of her husband’s death in the context of their long life together.
She also took an antidepressant, and the medicine combined with the talk therapy helped her feel better with surprising speed.
"I started to feel lighter," she said. "I explained to Dr. Simon that I'd been feeling like I'd been carrying an overcoat of sadness and depression on my shoulders, just weighing me down, and within two weeks it felt like the coat had come off somehow. I knew I was still in the beginning stages, but I was starting to feel the way I normally felt in the past."
The research into medication for complicated grief is ongoing, Dr. Simon says.
“We think medication is probably not necessary for everyone," she said, "but it can help in the way it helps in Post-Traumatic Stress Disorder, to help regulate emotions and to decrease the intensity of the depression so that people can re-engage with their life and the loss can be processed.”
As her treatment progressed, Cynthia tapered off the antidepressant. Toward the end of her treatment, her therapist, Dr. Cindy Moore, asked her to have an imaginary conversation with her late husband.
"So I was able to say to him the things I needed to say to him, to tell him that I loved him, I missed him and how am I ever going to get through without you?"
It did help, she said. "I do believe there’s a thin veil between us and them, wherever they are, and I think he heard that. I felt a relief."
Columbia University’s Dr. M. Katherine Shear says that this sort of “imaginal conversation” helps reassure patients with complicated grief that they can remain connected with their loved one even as they heal.
Also, "it gives them another opportunity, if there’s something that’s been really troubling them about the death, another opportunity to work through that...and that can also be very reassuring."
Early research suggests that this type of therapy may be roughly twice as effective as conventional psychotherapy for complicated grief patients.
"We did a prospective randomized controlled trial of this treatment using a very stringent test," Dr. Shear reports. "Of all the people who started treatment, 51% of the ones who got Complicated Grief Treatment (CGT) got much better compared to 28% of the ones who got a more usual psychotherapy. Among the ones that finished all 16 sessions, 66% of the CGT group and 32% of the other psychotherapy were much improved."
More research is under way, including at Columbia, the University of California at San Diego, the University of Pittsburgh and Mass. General, where Cynthia was part of an ongoing study comparing different treatments.
Cynthia says her complicated grief therapy unquestionably helped her heal and go on with her life. So is she cured?
(Admittedly, an unfair question: Dr. Shear says that unlike depression or anxiety, "We do not try to cure grief. We try to resolve or cure the complications but the natural healing process — grief itself — is a lifelong process.")
"I would say that this is going to be a lifelong journey at different stages," Cynthia said. "Now we have the holidays and I’m busy with my family...I think it’s better than it was last year, and I hope next year will be even better, and I think we just have to keep going on, and it’s a journey of mourning and grief. But the intensity is less. As far as being cured, I don’t know if any of us in this lifetime get cured of anything - but we learn how to manage it. It's my new normal. And though this program, I do believe I've learned how to manage this grief."
A poem about Complicated Grief and the process of "revisiting" — visualizing yourself at the time you learned of a loved one's death — with the aim of making peace with the finality of the death.
By Mary Kelly
The train stop
>>>>>> Where clouds of despair
>>>>>> suffering sorrow
>>>>>> No longer hover
>>>>>> Once off the train.
>>>>>> In the space between
>>>>>> The closed and opened steel doors
>>>>>> Hope kindled-
>>>>>> In the space between letters
>>>>>> That make a word
>>>>>> Meaning discovered-
>>>>>> In the space between the words shared and sacred silence
>>>>>> Spirit found-
>>>>>> Entrusted only in the truth of trust
>>>>>> Emptiness died ~ Creating anew
>>>>>> Separating to join~Enfolding to know
>>>>>> The bridge unites
>>>>>> Parallel train tracks
>>>>>> New destinations
>>>>>> The bridge offers
>>>>>> Life renewed
>>>>>> All directions
>>>>>> On the train
>>>>>> Tender times to cherish.