The headline on the New York Times article is unfortunate: “How long should it take to grieve? Psychiatry has come up with an answer.”
Um—no it hasn’t. Because there is no definitive answer, no “should,” no end to grief, no “closure.” Rather, we learn to manage our grief, to incorporate it into our lives and live around it and with it.
The Times article is about the addition to the DSM-5, the diagnostic guide for psychiatry, of “prolonged grief disorder.” As with so much in our health care system, this diagnosis is mainly about health insurance, providing a diagnostic code that allows patients to file for reimbursement.
Here’s how the American Psychiatric Association describes this diagnosis, which can be applied within at least six months after the death of a loved one for children and at least 12 months after for adults:
“…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.”
As those of us who have lost a loved one know, a year is a nanosecond in grief time, so, crucially, note that this diagnosis does not suggest that after a year you should be “over it.” Rather it applies to people who have not progressed from the crippling distress of the earliest days, who are so preoccupied with the loss that they are not functioning in their lives. It is beyond the grief I feel, for example, nearly two years after my husband died. I think about him constantly and still cry, but I am living my life around the pain and longing and moving (reluctantly) forward.
Who needs therapy?
But now let’s talk about your “average” griever (if there is such a thing) and therapy.
A lot of people wonder—as I did—how therapy can help with grief when therapists can’t do the only thing that will make us truly OK: bring our loved ones back. What’s the point of talking about how sad you are when the sadness is unavoidable and nonnegotiable?
I’ve been in and out of therapy since I was a teenager, wrestling with depression and complicated family dynamics. It has been life-saving and transformative for me, so I already had a relationship with a therapist when Tom died suddenly, and I turned to her to process this cataclysmic event. And because therapy is my port in any storm, I believed that everyone in grief needed therapy—until I talked to a couple of experts.
“Most people don’t need to go into therapy,” says Robert Neimeyer, a grief therapist, professor emeritus of the University of Memphis and director of the Portland Institute for Loss and Transition, where he trains professionals in grief counseling and bereavement support. “Human beings have evolved to deal with many life challenges. We are resilient. We have good evidence that the majority of people do not need a grief therapist when they’ve experienced the loss of a loved one.”
For many people, friends and family are enough to get them through the worst stretches. “Social support is something that benefits people in grief…[but] when we offer grief therapy universally, open the doors to anyone who is bereaved, we see vanishingly small effect," Neimeyer says. "The universal application of grief therapy is not an evidence-based practice.”
Elizabeth Cleary, senior staff psychologist, clinical supervisor, and former director of clinical training at the Simms/Mann UCLA Center for Integrative Oncology says, “Coping strategies also matter: writing, reading, mindfulness, exercise, a strong instinct to connect with others, share their emotional experience, not avoid or numb hard feelings.” But, she adds, “Those are really advanced skills that many of us take most of our lives to cultivate.”
Suffering in grief
People whose loss is particularly traumatic or stigmatized in some way—violence, suicide, drug overdose—are more likely to benefit from professional help. Other people might need help coming to terms with aspects of their relationship with the deceased. “We are often left with a good deal of what is called unfinished business,” says Neimeyer, “…all of the unresolved relational issues that continue to live on [such as] unresolved conflicts, relationships marked by tension, disputes, anger, avoidance, betrayal, abandonment.”
Some unresolved issues are less fraught: You didn’t tell your mother one last time that you loved her, or you were not present when your father died. And, Neimeyer says, one issue that does not receive the attention it deserves is “the assault of one’s self and our own identity. If I lose my only child, am I still a mother?”
So grief counseling is not to make you less sad, but less tortured. “In psychology we talk about the distinction between pain and suffering,” says Cleary. “With death, there is pain in the form of grief and we are not going to be able to change that, nor is it our goal to change that. But for many people, around the pain of grief there are also many different forms of suffering: regret, self-blame, guilt, shoulds about how we should be doing, how we should be feeling, what we should or shouldn’t be doing.”
Even therapists can be grief illiterate
Cleary believes that many people can benefit from some sort of grief counseling, in part for the education it can provide. “There are a lot of unrealistic expectations around grief,” she says. “Grief can be intensely physical, it can be accompanied by a lot of fatigue. It’s also very cognitively demanding for us to try to make sense of and adjust to a world without a loved one. That takes a lot of our processing energy. It’s hard to concentrate, hard to focus. [For example] lifelong readers all of a sudden find it’s hard to make it through a full page of text.”
For people who don’t know these things—which is probably everyone who has not experienced intense grief—these experiences can be confusing and worrying.
However, Neimeyer points out, grief education is lacking not only among the general population, but also among therapists. “There are few, if any, programs in which the word grief is spoken in the graduate classroom,” he says. “In the presence of that existential reality, many therapists may feel helpless.”
This is one reason some people give up on grief counseling. One woman I know who lost her husband tried three therapists but felt that all she did with them was ruminate, which was making her feel worse rather than better. Ultimately she found the spiritual teachings of Eckart Tolle more helpful, which doesn’t surprise Neimeyer. “One may say that various wisdom traditions do a better job of this than psychologists do.”
“Good therapy isn’t merely talking through experiences or narrating experiences,” says Cleary. “Effective therapy is building insight, making connections, having the experience of expressing and experiencing emotions in a way that is helpful. It’s different sounding from someone ruminating. A good therapist can hear where there’s ruminating and gets in there and says, ‘I hear there’s a stuck point there, a theme that we keep coming to.’”
Choose your therapist wisely
While grief may include depression and anxiety, it is not the same and cannot be treated exactly the same way. And just as not everyone in grief needs grief therapy, so too not every therapist has the knowledge to provide it. In seeking out grief support, Neimeyer says, start with word of mouth from others who have suffered loss. You can also look for therapists with some kind of certification in grief therapy. “That means they take it seriously enough to look at what is uniquely difficult about grief,” he says. Request a consultation session without the implicit obligation to continue with the therapist. “I think within one hour of working with the person you can know for sure whether it will work,” Neimeyer says. At the very least, if you are not feeling connected after three sessions, you might want to cut your losses and move on.
The take-home message here is that not everyone needs professional grief counseling. However, consider this as well: Women who lose partners are 10 times as likely (as those who haven’t) to die by suicide. Men are 66 times as likely. So if, even early on, you find yourself going into dark places; if you are using alcohol, drugs, or anything else to excess to numb your feelings; if you are tormented by regrets or guilt or flashbacks, “That’s the time to reach out for help,” Neimeyer says. “Probably beyond family and friends.”
