Complicated Grief; Frozen in Loss

This is the last in a series of articles over the past month exploring loss and grief.  It is our hope these posts have provided chaplains and caregivers better insight into issues concerning crisis and bereavement.

There is a degree of chaos which follows any loss, no matter how insignificant it might seem. We are pulled from our place of security all the way to the edge.  From losing credit cards to the death of a loved one, the question Why always comes around. 

Suddenly it becomes a matter of being judged, cosmic payback or karma. 

Why is it happening to me?

Why do I deserve my fate?

Why am I left behind to survive alone?

Why is God doing this?

Of course, asking questions surrounding the Whys is a normal part of grieving, but when it persists and becomes acutely internalized along with a lack of resilience, there exists a bereavement disorder called Complicated Grief.

Just what is Complicated Grief?

It is life turned outside in. It is chaos. Several years ago, the National Institute of Health began to recognize the phenomenon of persistent and all-consuming grief.  Studies show that 7% of those who suffer significant losses such as the death of a child are unable to make a transition to acceptance but rather, begin to present with symptoms of PTSD or clinical depression. CG (Complicated Grief) is particularly prevalent in older adults (about 9%) who have experienced many losses over the years (parents, siblings, friends, spouses) causing a cumulative reaction. It has also been reported that at least 20% of those with substance abuse disorders have unresolved grief or CG.

Complicated Grief Defined

Complicated Grief is a persistent form of intense grief in which maladaptive thoughts and dysfunctional behaviors are present along with continued yearning, longing and sadness and/or preoccupation with thoughts and memories of the person who died.  Grief continues to dominate life and the future seems bleak and empty.  Irrational thoughts that the deceased person might reappear are common and the bereaved person feels lost and alone." ~ Columbia University Center for Complicated Grief

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384440/

Katy's Story: A Grief So Deep It Won’t Die

The reason I refer to Complicated Grief (CG) as chaos is because it cycles endlessly leaving life in disarray with a seeming inability to adapt to loss.  This kind of grief was not uncommon in the patients I treated for substance abuse disorders.  But a good example of a life dominated by the chaos of CG is the story of my patient named Katy.  She suffered deeply after the death of her young son.  Her husband, a physician, and daughters were devastated by the loss as well, but only Katy found it impossible to heal.  Ultimately she became dependent upon the benzodiazepines prescribed to relieve her emotional turmoil and depression. 

For over three years, Katy refused to leave the house except to buy groceries.  When alone, she spent hours preoccupied with thoughts of Joey.  Her last words to him were cross as he went over to a friends house for an afternoon of video games and sleepover.  And she failed to tell him she loved him in response to his "Love you Mom" as he left.  Joey was accidentally shot while playing with a handgun that belonged to his friends' father less than an hour later.  Her self blame and inability to function increased until she was finally forced into treatment by her family. Luckily, Katy came to a center familiar with CG and was able to treat her dual diagnosis effectively.  She told me that "When Joey died, I died too. I stopped doing everything." Katy was finally able to engage in treatment and her condition improved dramatically.  Of course, she continues to grieve Joey's death. She regularly visits and decorates his grave. Katy created a  FindAGrave virtual memorial site and a Memorialized FaceBook page to preserve his memory, but has resumed her normal activities and is rediscovering pleasures in life.  She no longer uses mood-altering substances to cope.

https://youtu.be/aAEfYSOS8W8

"CG is a form of grief that takes hold of a person’s mind and won’t let go." ~

Dr. Katherine Shear, MD

All grief is permanent and it is experienced differently by everybody. 

For most people who face losses, the intensity begins to ebb and soften over the months.  However, this is not the case for those who suffer from CG. The negative feelings become chronic and the condition becomes diagnosable. Though CG was not included as a mental illness in its' 2018 Diagnostic and Statistical Manual (DSM-V), the American Psychiatric Association did refer to it as a persistent complex bereavement-related disorder and gave it a "v" code which identifies conditions "other than a disease or injury and are also used to report significant factors that may influence present or future care."  So, like most chronic disorders, professional assistance is necessary for dealing with Complicated Grief. There can be a purpose-filled, abundant life and happiness after CG is treated.

Effective CG Tool

I am including a Grief Questionnaire pdf that is very useful in determining the presence of Complicated Grief for the use of those professionals and others who are trying to help people who are overwhelmed by long term suffering. 

Grief QuestionnaireDownload

My intention in offering it for your use is that it might help identify the possibility of Complicated Grief and direct you to someone who is familiar with its specific treatment.  Remember...this is not a disorder that will go away over time and requires expert intervention.  The Center for Complicated Grief provides a list of therapists who can be of service by using the following link https://complicatedgrief.columbia.edu/for-the-public/find-a-therapist/

Download Grief Guides

The Center for Complicated Grief also offers these two pdf handouts for your perusal and use. 

Risk Factors for Complicated GriefDownload

Complicated Grief Signs and SymptomsDownload

Survivor Guilt: What Happens When We Are Left Behind

When tragedy strikes and we are untouched by its’ full force, the pangs of Survivor Guilt can plague us.  We are grateful on one hand, but filled with thoughts of “Why not me?” We ask ourselves what we might have done to prevent this from happening.  How could we have not seen this coming? There is a sense that we are responsible for remaining intact and living on. The self-condemnation can be crippling.

“The problem with surviving was that you ended up with the ghosts of everyone you’d ever left behind riding on your shoulders.” ~ Paolo Bacigalupi

How Can We Begin to Understand and Cope With Survivor Guilt?The awful weight of self-indictment is the main characteristic of Survivor Guilt.  People experience a seemingly endless loop of the gut-wrenching belief that they did something wrong or failed to do what they could have done.  It happens to war veterans, accident survivors, those who live through natural disasters, cancer survivors, police officers, and Holocaust survivors. It is also common among friends and family members who have suffered the loss of a loved one to suicide.I am no stranger to Survivor Guilt.  My sister died of neuroblastoma when she was four years and nine months old.  Mother was grief-stricken as one might imagine.  Her beautiful little child had been taken and she was left to cope with the terrible loss feared by almost every parent.  We should not have to survive our children.She slipped deeper and deeper into dark sadness and depression. Her continual demand was to know why God would take Mary Kathryn instead of her. She had begged to be the one to die in my sisters’ stead only to be forsaken. There was no comforting her.  Despite opening her own business and trying to carry on with family and friends, she could not.  Our family doctor told Dad that the only thing that might help would be for Mom to get pregnant again.She did, and I was the replacement kid. Sixteen months after my sisters’ death, I was born into a house replete with Survivor Guilt. I have learned that many kids who survive the death of their siblings also experience this phenomenon.  I will never forget an occasion while playing on the living room floor with my Aunt Lucille. She was a registered nurse and had spent many hours with my sister.  At one point she mistakenly called me Mary Kay.  I could hear my mother break down into sobs in the kitchen.  I wondered why I was alive when my sister was not.  A wave of shame swept over me. I wished we could trade places. I was only three years old.Symptoms, Indicators and Healing ToolsSurvivor Guilt has been linked with PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which recognizes the role of negative emotions such as guilt and shame.  The following are symptoms associated with those negative emotions;

• Avoidance
• Feeling on edge
• Hypervigilance
• Detachment
• Easily startled

Other associated indicators not included in DSM are;

• Feeling disoriented, confused and unworthy
• Obsessing over the tragedy
• Being ambivalent about living
• Overwhelmed by the sense that you’re never really safe

Measuring Survivor Guilt

A good instrument for measuring Survivor Guilt and PTSD is the Trauma and Loss Spectrum Self-Report instrument (TALS-SR).It explores the lifetime experience of a range of loss and traumatic events and lifetime symptoms, behaviors and personal characteristics that might represent manifestations or risk factors for the development of a stress response syndrome.This tool is of great value to those like Police Chaplains, who deal with survivors.  Police Week reported in www.officer.com that one of the most important things an LEO who is experiencing Survivor Guilt can do is to “share your story with someone you trust and who will actually hear you rather than judge you.” The Chaplain fulfills such a role for many officers. First responders witness some of the most unimaginable sights in unfiltered, graphic situations. Police officers, firefighters, and paramedics also need to be given action-oriented methods of healing to cope with all they experience.

Survivors Continue to Suffer

The Associated Press reported that Survivor Guilt and symptoms of PTSD continues to plague those New Yorkers who lived through the attack on The World Trade Center on September 11, 2001. Dr. Nomi Levy-Carrick, mental health director of World Trade Center Environmental Health Center program reported that; "There was tremendous Survivor Guilt, so people who survived didn't feel worthy of wanting to seek care.The fact that they had survived, they felt, should have been enough." She said people who tried moving on despite the lingering psychological effects of 9/11 realized they weren't getting better. 9/11 is perhaps the national tragedy that most of us remember in vivid detail.  We were devastated on a personal and community level beyond anything since the bombing of Pearl Harbor.Think what it must be like for those who continue to suffer as if it happened yesterday. It never seems to leave. In a real sense, this is the essence of understanding Survivor Guilt PTSD.  When it brings the darkness once again, unannounced, that unspeakable yesterday suddenly becomes today…here and now.

Not Limited to Tragedies Surrounding Death.

We have learned that Survivor Guilt is not limited to tragedies surrounding death.  I have provided counseling services for both adult men and adolescent boys who were victims of sexual abuse. The effects of the abuse are lasting. They have complicated feelings and vivid memories that haunt them relentlessly.  One of the most heartbreaking revelations is that so many feel that they were somehow responsible for what happened.“I was cute and kind of a sexy kid,” said Shane “He (the abuser) probably couldn’t help it.  I could have stopped it.  If I would have, other boys wouldn’t have been hurt.  It’s all my fault.”  He begins to sob uncontrollably. Shane is reduced to the little boy in a dark bedroom under the blanket of violence in the monstrous act at the hand of a trusted adult. My response is to try and carry light into their darknesses.I have found that the most valuable thing we can bring to those who experience Survivor Guilt PTSD is the listening ear and open heart of one willing to accompany them without judgment and with unconditional acceptance and love.  When the victim is no longer alone in the memory healing can begin.

Our Veterans and the Burden of their Experiences

Veterans of war carry the burden of their experiences in silence like so many victims of sexual abuse.  Their service is often marred by the loss of comrades and buddies in bloody scenes that none of us can imagine.  They come home to families who have longed for their return only to feel estranged.  A different person seems to be living in the body of their loved one.  Repeated inquiries about what happened ‘over there’ are met with silence and denial.  I remember men, including my Dad, who were soldiers and sailors in WWII.[embed]https://youtu.be/0HUf68gFGEE?t=2m24s[/embed]They rarely, if ever, talked about their combat experiences.  There was a wall of unknowing behind which nobody could come.  One of my friends fought in Vietnam and was known to have witnessed something horrific over there.  It was not until thirty years later when we read his suicide note that we found he had held the body of his wounded best friend for hours.  Merciful death or help from medics was not coming so Billy did what he had to do and ended the suffering with his service revolver.The note said he could no longer bear the decades of pain.  Billy was alone for all of those years. I was never able to bring him a torch for the darkness.Some Truths and Some Hope for Survivor Guilt PTSDWe know of so many things can cause Survivor Guilt and how to cope or heal.  The one who lives on after a loved one takes their own life, the one who survives after a sibling dies and the one who stays alive in an otherwise fatal auto accident are among the many who might shoulder the weight of Survivors Guilt.  There are two facts which are universal when it comes to this;

• It always comes when something happens which brings an extreme state of feeling previously unexperienced
• It must be dealt with or will persist for a lifetime

Here is some good news that comes to us from the most unlikely of situations. A most remarkable thing is happening for survivors of the Marjorie Stoneman Douglas High School mass shooting. Social media, protest marches and the honoring of fallen friends seem to have empowered the young people who survived, helping them in ways that were not available to earlier such tragedies.  They tweet to huge audiences of thousands about their pain and about actions they are taking to prevent further violence.Their #NEVERAGAIN page on FaceBook has more than 165,000 followers. These kids bravely stand up to criticism by adults and persist in their efforts day after day. They are courageous. Though probably unaware, they are doing almost all of the things that are offered by experts on Survivor Guilt PTSD to heal from their tragic losses.We can learn a lot from these young people. They seem to be carrying light to each other (and to us) in the darkness.  Not in the form of a torch but in hundreds of thousands of little beams coming from their cell phone flashlights.Robert Kenneth Jones is an innovator in the treatment of addiction and childhood abuse.In a career spanning over four decades, his work helping people recover from childhood abuse and addiction has earned him the respect of his peers.His blog, An Elephant for Breakfast, testifies to the power of the human spirit to overcome the worst of life’s difficulties. We encourage you to visit and share this rich source of healing, inspiration, and meditation.Contact Bob Jones on LinkedinBob Jones’ blog An Elephant for Breakfast

Suicide Prevention (1-800-273-8255): A Way to Prevent, Understand and React to Suicide Death

by Robert Kenneth Jones

This is the truth. We are experiencing a dramatic rise in suicide in The United States.

While other causes of death are on the decline, suicide is climbing…and it's doing so for every age group under 75. Suicide is the second-highest cause of death for 15 to 34 year-olds with the phenomenon of ‘suicide contagion’ or copycat suicide ever-increasing among teens.  The suicide rate in the United States has grown by 24 percent over the last 15 years. Don’t you wish this was fake news?  But it’s not.Music and Youth Culture Raise Suicide AwarenessLogic, the American rapper, singer, songwriter, and record producer has released a track on his most recent and third studio album called Everybody with the title, “1-800-273-8255” featuring Alessia Cara and Khalid in an effort to increase awareness and put a personal face on suicide.  The song offers up the 800 number to guide people, especially his young audience, to the National Suicide Prevention Lifeline. The hit song turned out to have an incredible impact in 2017. The National Suicide Prevention Lifeline (NSPL) says they received a 50 percent surge in calls last year after the April release of his new track.  Logic performed the record at the 2018 Grammys.  The NSPL revealed that in the two hours following Logic's performance of the track counselors received three times the number of calls they usually receive in that time period.It Feels Like It's My FaultI am no stranger to suicide.  My work as a human services provider has all too often brought me to the broken hearts of those who are contemplating suicide as well as those that have loved a person who ended their own life. It’s hard to find anyone who is untouched by this.  My own family has suffered through several. Each one has left us in a state of confusion and self-blame. I can never forget the awful notifications.  I can never forget having to then break the news to loved ones. The memories are so vivid.  I can never forget.Along with the fact that suicide is devastating and painful, it is also highly stigmatized. Its illusion of shame elicits a code of silence creating an even deeper misery.  By ending this code of silence and destigmatizing suicide (and other mental health issues) the desolation they cause will be diminished. John Nieuwenburg is an award-winning business coach who addresses the way that we might move beyond silence and shame. His TEDx Talk is a must-see for those who suffer, family members, friends, human service providers, and Chaplains.New Trends in Suicide Prevention: Brain Science and ACESPrevention is possible.  It is important to understand the risk and to know the facts. We are beginning to better understand the suicidal brain through new scanning techniques.  Studying differences in the brains of suicide attempters and depressed individuals who never attempt suicide may help in developing better treatments. The incredible work being done with adverse childhood experiences (ACES) is leading us to believe that cumulative trauma in children increases suicide ideation in adults.  A whole new treatment protocol is being established in communities like Memphis where schools, parents, hospitals, physicians, and other human service providers are being trained to recognize, screen for, and deal with trauma with its long term consequences. We have learned that 50 percent of lifetime mental illnesses like depression, anxiety, personality disorders, suicide ideation, and PTSD begin by age 14. Do you want to be the one to help?  Here is a useful hashtag tool that might lead you in the right direction. #BeThe1ToThe Startling Truth of Blue SuicideThere is an alarming increase in police officer suicide that escapes national attention.  ‘Blue Lives Matter’ is more than a slogan. These men and women who bravely serve and protect us face trauma or the threat of trauma every day they go to work.  Like veterans of war, they are likely to think about suicide and act on those thoughts much more frequently than the average adult.  Dr. David J. Fair, President, and C.E.O. Homeland Crisis Institute Crisis Intervention, Training, Consulting, and Response wrote recently that; “Police officers must deal with  Traumatic Stress Disorder (PTSD) daily. With officers being killed on almost a daily basis PTSD is raging. Not just for the officers where the shooting happened but on a national basis with something called Secondary PTSD. You can't work in law enforcement and not be affected by a police officer being injured or killed.”  The Action Alliance for Suicide Prevention has created a study guide for Chaplains and other counselors.  We are told that more law enforcement officers in The United States die by their own hand than are killed by felons. We must help break the silence and elevate suicide prevention efforts for the sake of our dedicated public servants, their families, and communities.Creating Suicide Programs and Ending the SilenceThere is so much more to be said.  Worldwide, 350 million people (that’s 5 percent of the population) struggling with depression every day. They are suffering and sometimes dying in silence because we can’t seem to talk openly about it. We must push the conversation forward. Middle and high school health classes would be a perfect place to begin the dialogue. But precious few programs exist. Instead, remain silent or we continue to put most of our efforts into postvention.Let’s get out of our cycle of denial by admitting openly that these issues are real and lethal.  Perhaps then, a Power Greater Than Ourselves can restore us to sanity.