Differentiation between the Healthy Process of Grief and Depression

This information is lifted off the Diagnostic and Statistical Manual of Mental Disorders ( DSM 5).  Interestingly, this passage, which I consider to hold very important information, is written as a footnote on page 134 of the Manual.

What is the difference between grief and major depression, anyway?

For one thing, grief is a natural, healthy reaction to loss. It is an emotional response to something that has happened in our lives. We cannot escape encountering losses, and we cannot escape feelings of grief when it happens. Just because one feels terrible in a state of grief, does not mean that one has a mental / psychological disorder.

My reason for highlighting this, is with the hope that in grief, one one learns to find the right kind of self-support: find someone to talk to, try to not be alone, cry, find creative outlet and let time heal the wound (although it may leave the scar).

A potentially detrimental method of avoiding grief is to turn to drugs or narcotics, blame the self/self judgement for feeling bad, or any kind of harming the self or others.

grief and depression psychotherapy
Grief vs. Depression

Here’s what is written in the DSM-5 footnote:

“In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “’joining” the deceased, whereas in a MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.”

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Sabrina Benaim Poetry: Explaining My Depression to My Mother

Explaining My Depression to My Mother: A Conversation

Mom, my depression is a shape shifter.
One day it is as small as a firefly in the palm of a bear,
The next, it’s the bear.
On those days I play dead until the bear leaves me alone.
I call the bad days: “the Dark Days.”
Mom says, “Try lighting candles.”
When I see a candle, I see the flesh of a church, the flicker of a flame,
Sparks of a memory younger than noon.
I am standing beside her open casket.
It is the moment I learn every person I ever come to know will someday die.
Besides Mom, I’m not afraid of the dark.
Perhaps, that’s part of the problem.
Mom says, “I thought the problem was that you can’t get out of bed.”
I can’t.
Anxiety holds me a hostage inside of my house, inside of my head.
Mom says, “Where did anxiety come from?”
Anxiety is the cousin visiting from out-of-town depression felt obligated to bring to the party.
Mom, I am the party.
Only I am a party I don’t want to be at.
Mom says, “Why don’t you try going to actual parties, see your friends?”
Sure, I make plans. I make plans but I don’t want to go.
I make plans because I know I should want to go. I know sometimes I would have wanted to go.
It’s just not that fun having fun when you don’t want to have fun, Mom.
You see, Mom, each night insomnia sweeps me up in his arms dips me in the kitchen in the small glow of the stove-light.
Insomnia has this romantic way of making the moon feel like perfect company.
Mom says, “Try counting sheep.”
But my mind can only count reasons to stay awake;
So I go for walks; but my stuttering kneecaps clank like silver spoons held in strong arms with loose wrists.
They ring in my ears like clumsy church bells reminding me I am sleepwalking on an ocean of happiness I cannot baptize myself in.
Mom says, “Happy is a decision.”
But my happy is as hollow as a pin pricked egg.
My happy is a high fever that will break.
Mom says I am so good at making something out of nothing and then flat-out asks me if I am afraid of dying.
No.
I am afraid of living.
Mom, I am lonely.
I think I learned that when Dad left how to turn the anger into lonely —
The lonely into busy;
So when I tell you, “I’ve been super busy lately,” I mean I’ve been falling asleep watching Sports Center on the couch
To avoid confronting the empty side of my bed.
But my depression always drags me back to my bed
Until my bones are the forgotten fossils of a skeleton sunken city,
My mouth a bone yard of teeth broken from biting down on themselves.
The hollow auditorium of my chest swoons with echoes of a heartbeat,
But I am a careless tourist here.
I will never truly know everywhere I have been.
Mom still doesn’t understand.
Mom! Can’t you see that neither can I?

Psychotherapy for Cardiac Patients?

This article explores the mutual, interactive influence between cardiovascular disease and mental health. The psychological issues present among patients of cardiac health issues are mainly that of anxiety and mood disorders. Often termed “psychocardiology”, this field integrates both medical aspects of cardiology and psychotherapy.

The interactions between the mind and body are pronounced and evident. When we feel anxious, our heart pumps faster and we feel breathless. The interaction between psycho and soma is also complex and multifaceted.

Cardiological and psychiatric disorders are closely interrelated and have a bi-directional relationship. This is what we understand as a psycho-somatic interaction.

Mind and Body Connection in Cardiology

Cardiovascular disease is among the leading cause of morbidity and mortality in the industrialized world.  While psychiatric disorders have a prevalence rate close to 20% of the population, depressive illness  is one of the leading cause of disability worldwide (Murray & Lopez, 1997). 

Put together,  depression and anxiety related to depressoin is identified as a significant risk factor for mortality in patients with coronary heart disease (Barth et. al. 2004).

cardiovascular disease and depression

The article cites a meta-analysis of research papers and have found that depression and anxiety contributes to the mortality of patients of coronary heart disease. Cardiac patients who suffer depression are 2x more likely to die than cardiac patients who do not suffer depression in the 2 years of initial assessment of the disease.

Halaris (2013) highlights links underlying recognized cardiovascular disease and mood disorders. Genetic and epigenetic factors affect how an individual reacts to mental and biological stress. Psychosocial and environmental stressors together with lifestyle choices also determines susceptibility to level of disease states.

Among patients with Congenital Heart Disease, for example, it is found that illness perception of the patient is a significant predictor of  patients’ quality of life, cardiac anxiety and depression one year after the heart intervention (O’Donovan et.al. 2016). It indicates that how the patient see his/her illness and the self in this situation affects his/her health development and quality of life.

Psychological effect of Diagnosis of Heart Defects on Patients

Being diagnosed with heart complications, whether it is congenital heart disorder or coronary heart disease leads to years of continuous physical, psychological and/or social burdens for the patient and family.

Patients with early-recognized congenital heart defect live with the condition throughout life. This is especially so in the case of babies / children diagnosed with congenital heart defect.  The psychological state of these patients is deep rooted becomes embedded in identity.

Encased in the anxiety of other types of patients whose heart disease emerge later in life is the shock/abruptness of the heart failure due to a previously unknown / undetected defect. This further stir associations regarding health in general (loss of former self-identity, increase of insecurities etc.).

Psychotherapy needs of Cardiac Patients in Cardiology

Medical professionals in countries like Austria realize the need for an integrated-method of treatment of cardiac patients. Medical treatment is more focused upon when the symptoms are acute, and with chronic ailments the psychological work take precedence. Many fields of mental sciences work together with the doctors for after-care of the patients.

Psychotherapists, as per the studies cited in this article have un-covered the major psychological issues patients face: Clinical anxiety coupled with depression. These have also been shown to have adverse affect on the health development of the patients.

Anxiety is an increase in the awareness of psychic or physical sensations to a degree that makes it impossible for the real or imagined danger to be avoided; there is a constant danger signal together with the incapacity for active coping (Waelder, 1960). Relaxation in the tensions of anxiety seeks the experience not of satisfaction but of security (Sullivan, 1953). 

Patients come to psychotherapy with existential anxiety because of their life-death situation.  Illness perception is linked to these feelings. Along with it comes the perception of oneself in relation to a defect. Patients talk about the feeling of being vulnerable, ‘damaged’, ‘weak’.  For adult patients (especially those who are independent in life), these experiences are often concealed from relevant others.  

In therapy, these themes are worked through in the confidentiality and security of the session. The psychotherapist for such patients has to possess the resources to contain the very strong emotions of the clients, approaching the sessions with empathy and patience. Patience is normally understated, but important. Many patients take time to trust the therapeutic process, and may discourage the therapists from helping them. Feelings of hopelessness /helplessness do become projective identification.

“.. the therapist should function as a container of the patients’ anxieties. The fundamental therapeutic task at this stage is the analyst’s containment and interpretation of the patient’s anxiety. To the extent that this process is carried out, if the patient deposits—or rather evacuates — his anxiety and the analyst is able to bear it, a type of relationship is established in which the patient feels the analyst is an object who’s function is to contain him … As this process repeats itself, the patient develops a growing confidence in the relationship and gradually introjects ‘it’. It can be said theoretically, that from the moment there has been sufficient introjection, the patient has (achieves) within him an object where he (from now on) can deposit his anxieties … “

(Etchegoyen, 2005, p. 620).

The therapists who is able to see through the difficulties of the therapeutic sessions eventually builds the sound alliance. He/she is then able to support the client through the worst of feelings (especially that of loss), thus alleviating existential loneliness and isolation that is part of the depression.

Psychotherapy for Parents and Siblings of Children with Congenital Heart Defect

Psychotherapy cannot ignore that alongside a patient is his/her social system. Parents and siblings of child patients bear a big burden. Work with the family on a long term basis helps alleviate chronic stress faced by parents and supports the family. We can take heart from the research mentioned by Re et.al. (2013).

 

 

 

Bibliography

Barth, J., Schumacher, M., & Herrmann-Lingen, C. (2004). Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosomatic medicine66(6), 802-813.

Etchegoyen, R. H. (2005). The fundamentals of psychoanalytic technique. Karnac Books.

Halaris, A. (2013). Inflammation, heart disease, and depression. Current psychiatry reports15(10), 400.

Murray, C. J., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. The lancet349(9063), 1436-1442.

O’Donovan, C. E., Painter, L., Lowe, B., Robinson, H., & Broadbent, E. (2016). The impact of illness perceptions and disease severity on quality of life in congenital heart disease. Cardiology in the Young26(1), 100-109.

Re, J., Dean, S., & Menahem, S. (2013). Infant cardiac surgery: mothers tell their story: a therapeutic experience. World Journal for Pediatric and Congenital Heart Surgery4(3), 278-285.

Psychotherapy is about Uncovering Truths of the Self

It is said that the truth will set you free. In psychotherapy patients liberate from the psychological stressors in their lives through uncovering the truths about themselves.

This might sound counterintuitive if we believe that we know everything about ourselves or that we are in total control of the decisions we make. The field of psychology has proven empirically that this is not the case, and psychoanalysis has provided theories about how this is so.

Put briefly, the human person is an integral part of his/her society and culture through which our  psychological processes are influenced.

Knowing the truth is coming to terms with this realization. That we become depressed, anxious, angry… etc because we have lost the sense of our of needs. In so doing we turn them into symptoms, so that we do not have to face these needs.

An example would be that of a woman who is depressed and no longer able to enjoy simple things in life. Through therapy she uncovers the truth that her going into depression is a means for her to not face up to an inner rage, for it was safer to lock oneself into a state of depression than to attack another person, especially an abusive childhood caregiver.  Realizing the truth of her rage, she is able to talk about it and understand it. In Gestalt therapy, the client is encouraged to express this rage through art, speaking, acting out, writing… etc. When the underlying issue is set free, the depressive symptoms lose their foundation as well.

Therapy in this way is done with the patient being in control of his/her progress. Therapists in general do not advice, coerce or make analysis to tell the clients what the truth is. Clients find this out through dialogue with the therapist. The client has the agency to his/her own truths and healing.

When patients are asked retrospectively what they gained from a period of psychotherapy, their answers frequently feature an increase in their sense of agency: “I learned to trust my feelings and live my life with less guilt,” or “I got better at setting limits on people who were taking advantage of my tendency to comply,” or “I learned to say what I feel and let others know what I want,” or “I resolved the ambivalence that had been paralyzing me,” or “I overcame my addiction” are typical comments (McWilliams 1990 p. 16).

Bibliography

McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.