I had been looking forward to and, at the same time, dreading this appointment. Her husband had been ill for many months, but that had not stopped the verbal abuse that superseded the physical blows he could no longer inflict. She had, over many previous visits, told me stories, chronicled the behaviors, and responded with an icy coldness that left me chilled of heart and spirit every time she walked out my door. She had long since stopped crying. She no longer wasted energy on displays of emotion, public or private. At our last visit, she told me he had been heading towards hospice. At this visit, she wasted no time in updating me.
“Well, he’s dead.”
“Oh, my, I’m so sorry,” I said, the generic response ringing quite hollow.
“Don’t be. The bastard took long enough to die.”
I waited.
“You expect me to be sad, don’t you?” Her eyes were bright hot coals.
I waited.
“Well, I hate to burst your bubble, Doc, with all that time you’ve spent educating me about grief.” She looked straight at me.
“I am free. I am happy. I am on my own, with nobody to hit me or hurt me or tell me what to do in so many years. I am happy, Doc. I am happy.”
She did not look happy, but of course, I took her at her word. And true to her word, over the next few weeks to months, she convinced me that she was indeed happy, that she was not depressed or angry, that she was not bargaining with any god to bring him back, and that she had joyfully accepted the fact that he was now out of her life, forever. She taught me a great lesson.
You will remember the 1969 book On Death and Dying by Elisabeth Kubler-Ross. Her model set out the classic stages of grief: denial, anger, bargaining, depression, and acceptance. I was taught that model in medical school, and many people are familiar with it. I recently read an article called “The Five Stages of Grief” that revisited this model of grief.
The stages of grief are a framework, but not everyone goes through them the same way, in the same order, or sometimes even at all. They are not linear. I have certainly seen that over and over in my thirty-six years of psychiatric practice. Denial is what initially helps us survive the crushing blow that grief can deal us. We go numb and enter what this article calls a “preferable reality.” Anger brings us back to actual reality as we ask questions like, “Where was God?” Bargaining brings in guilt and all the what-if thoughts that can plague us. Depression is that final emptiness and feeling of being overwhelmed by it all. Acceptance finally gets us OK, with good and bad days, hopefully, better as time goes on. We may experience crying, headaches, appetite and sleep changes, isolation, and guilt.
My patient? In a big shock to my system when she came to see me, she had almost immediate acceptance. Do not pass go. She was happy that her husband’s death had finally freed her from the burdens she had carried for decades. She was ready to move on and live the rest of her life, and that is exactly what she did.
Another patient I saw recently had the opposite experience. She was telling me about her depression, guilt, and inability to function, and I asked about losses and deaths in her life. Thinking that something might have happened acutely just before she saw me, she surprised me by saying that her mother’s death, five years before, was still stoking the flames of grief that burned hot and bright in her life even after that period of time. As I had also heard on a recent podcast about grief, these two patients clarified something very important for me. You must own grief: in your own way, at your own pace, and in your own time.
The loss of my father in 1995 from a sudden brain aneurysm when he was only sixty-two years old affected me in yet another specific way. I jumped straight into depression, going forward after we buried him for the next six months in a sort of functional fog. I very vividly remember the evening I opened the closet door, looked at my file cabinet there, and saw a large stack of bills and other paper correspondence (remember those days?) that had been cursorily processed at best and ignored at worst. It jolted me back to the actual reality of his death and my ongoing life, the latter of which was being consumed by the trauma of the former. Acceptance followed, albeit reluctantly. On the day I was exactly one day older than my father was on the day of his death, I was hit with a wave of profound sadness, unbelievable gratitude, and stark reality. I was ready, at last, to fully mourn the man he was and accept, cherish, and celebrate the man I was now meant to be.
Like many clinicians, I believe I am of two minds when it comes to the treatment of grief. The series of emotions, however you experience them, needs to be lived and dealt with, or else it festers for years. Counseling, grief support groups, and medication all have their place at various times and for different folks. You are not cured of grief in the classical sense. You gradually learn to accept the loss, cope with how it affects you, and move forward with your life. I would like to add to the Kubler-Ross classic model of grief with my own take on how this process affects us and how we can handle it. I will use the letters of the word itself to explain.
Growth: Our lives increase in amount/time, value, and importance as we grieve successfully.
Realignment: We begin to live our lives from a different position or state.
Introspection: We must examine our internal emotional processes.
Evaluation: We must judge the value and importance of our own lives moving forward.
Forward-thinking: How can this loss, no matter how severe and terrible, become an opportunity for us?
These are my own five stages of the response to grief, which should probably be negotiated in order but most certainly do not have to be. They are activities and tasks that help you to find a reason to go on after a major loss; to do a serious and thorough self-assessment of your own emotional, physical, and spiritual ability to heal, to reframe the loss into a more positive avenue of growth; and to look forward to the rest of your life and how you will best use it productively.
Greg Smith is a psychiatrist.
