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CLINICALLY SIGNIFICANT DIFFERENCES BETWEEN , PATHOLOGICAL GRIEF, AND DEPRESSION

JOHN M. SCHNEIDER, Ph.D. years before the exact sequence of the process is iden- tified.” As Parkes l1 has noted, the outcome of this Associate Professor of , end-result focus of medicine is that most individuals Michigata State University, who have experienced a recent loss and are seen by Colleges of Medicine, physicians, nurses, social workers, or East Lansing, h&cltigan professionals still may be labeled as reactive depres- sion and treated accordingly. ABSTRACT Grief and depression are different phenomena. Grief is a normal reaction to a significant loss and is char- Differentiating between grief, pathological grief, and acterized by , pangs, and exhaustion. depression is important for health professionals be- It is generally self-limiting. This capacity to mourn, cause significant differences exist in the treatment of which is not fully possible until at least age 10,12 can these conditions. This paper describes clinically ob- serve a major integrative function. According to servable differences between these diagnoses and sug- Smith ’ (IL **) “It is likely that every step in growth- gests intervention and counselling strategies appro- every ‘new integration-is preceded by some degree priate to each. In many instances grief can best be of being undone at a loss.” facilitated by a nonjudgmental, warm, and open com- Depression, on the other hand, is generally seen as panion or health professional who does not intrude a clinical syndrome characterized by negativism, help- unnecessarily into the bereaved’s need for but lessness, lowered , and reduced self-esteem. who can monitor physical health. Depression and While depression can be self-limiting and may occur pathological grief, on the other hand, frequently re- only once in an individual, the duration of incapacita- quire the skilled intervention of a mental health pro- tion (four to 13 months), the morbidity of its symp- fessional. toms, and the consequences (including ) have made it a significant focus of the clinician.13 Depres- INTRODUCTION sion has been characterized as the inability to grieve.’ A third distinction, that of pathological grief, was With the notabIe exception of Freud’s 1 classical work, made by Volkan,” (p. 334) who noted that a significant “Mourning and ,” the distinction between loss “may precipitate recognizably connected mental depression and grief has only recently become a focus disturbances, the form of which may range from neu- in mental health literature.‘-g Before 1968, according rosis to psychosomatic to .” Patho- to Averill, discussions of grief were conspicuously logical grief tends not to be self-limiting, and it sig- rare, mainly because the behavior of the bereaved nificantly disrupts the individual’s capacity for could not be explained in terms of most theories of , functioning. Volkan asserted that “established patho- . Even Freud’s work and his later revisions logical grief is an entity in its own right.” seemed not to find their way into larger analytic writ- Professionals in all helping roles are likely to find ings on the topic. Bowlby lo (W 26-*7) noted, “A read- such distinctions useful clinically. Mental health pro- ing of the psychoanalytic literature shows that, as fessionals, while more likely to encounter and treat a rule, separation , mourning, and defense have depression and pathological grief, are increasingly been considered a piecemeal. The reason . . . is . . . employed in medical settings where grief issues pre- in the history of medicine it is the end result of a dominate. Other health professionals, such as non- pathological sequence that is noted first, Only grad- psychiatric physicians, nurses, and physical therapists, ually are the earlier phases identified, and it may be are more likely to encounter grief as a reaction to the

FOURTHQUARTEW1980 162 multiple losses associated with illness and injury, being A number of clinical observers ‘*‘J point to sig a patient, and anticipating death. Depression and nificant differences between the grieving and the de pathological grief as a disruption of normal grief, how- pressed person, especially when observations are mad, ever, are not uncommon in such settings, even though over several hours or days. their comprehensive treatment may be beyond the scope of the primary care professionals and require Presence of a Loss specialized . Thus mental health professionals would be called on to diagnose and treat the more Peretz :I noted that in uncomplicated grieving then pathological conditions, while normal grief may best is a meaningful loss to the griever, while in depressiv, be facilitated by those involved in primary care set- reactions there may or may not be an immediate pre, tings. cipitating loss. When losses are noted and seen a: This paper will discuss both the clinically observ- related to his emotional state, the depressed individ. able distinctions between grief and depression or ual is likely to consider the loss “deserved” or a! pathological grief and the corresponding counselling punishment for some real or assumed transgression strategies that can be utilized by those in the, helping This phenomenon has been noted among Viet Nan professions. veterans, for example, who assumed their physical ill. ness was punishment for “what I did in ‘Nam.” Indi. viduals who are aware of the connection between 2 SIMILARITIES AND DIFFERENCES recent loss and what they are experiencing, who ma) JjETWEEN GRIEF AND DEPRESSION experience some but do not consider the loss ar punishment, are more likely to be grieving. Depressec The more clinically useful distinction would be be- individuals who have not made such connections ofter tween grief and reactive depression. The more endog- have difficulty seeing the relationship between loss and enous depressions are easily recognized by the chro- their , even when pointed out. As Freud ob. nicity of symptoms and the frequent absence of a served, “If depression involves an object loss, it is al known recent precipitating event. In most reactive an unconscious level.” depressions, as in grief, a definable change or loss is One general difference observers may note is that the precipitating factor. the reaction of one who is grieving seems appropriate Peretz 3 has discussed the range of responses to loss, to the loss experienced, whereas the reaction of a de- which includes grieving or the inability to grieve- pressed person seems too intense. A limitation of this one form of which is depression. They include: 1) distinction occurs when the bereaved or depressed in- normal grief, 2) anticipatory grief, 3) inhibited, de- dividual has experienced a loss that is greater than layed, and absent grief, 4) chronic grief (such as the any the health professional has personally experienced. inability to terminate mourning), 5) depression, 6) The professional may then view any reaction as appro- and exacerbation of preexisting symp- priate, for he cannot imagine himself being able ta toms and illness, 7) development of medical symptoms handle such a loss. and illness, 8) psychophysiological reactions (such as It is helpful to know the individual’s history, such sweating or palpitations), 9) acting out (sociopathic as what previous losses were experienced and how or promiscuous behaviors), and 10) specific neurotic they were handled, the culturally or sociologically ac- and psychotic states. These reactions often occur in ceptable ways of expressing grief that apply, and any combination. Although each reaction requires the at- previous treatment with psychoactive drugs for grief tention and often the intervention of a health profes- reactions. Along with the pretrauma personality of the sional, the distinction between normal grief and de- individual, these factors will what is observed. pression is probably the most difficult and important Table I summarizes some of the key differences be- to make. tween grief and depression. As with most differential Grief and depressive reaction have certain simi- diagnoses, the distinctions are not always clear in pm- larities Smith ‘(r. lR) observed that grieving and de- tice. When a mixed picture is presented, it is probably pressed individuals are alike in that “both are in best to assume that the ego functions necessary for despair, whether agitated or withdrawn. For the most uncomplicated grief have been disrupted. Thus treat- part, both are unable to be interested in anything other ment of any depressive symptoms becomes the first than that which further increases their . Either can priority. scarcely believe that pain and will ever cease; both can feel his or her life to be over or wish Mood States it to be. For both time stands still. For both, the usual cycle of life may be meaningless in which world events A person who is grieving usually shows a greater range’ pass unnoticed.” of feelings than one who is depressed.3 These can in-

PATIENT COUNSELLJNG AND HEALTH’EDUCA~OP’J 163

Table I. d Key differences between grieving and depression.

Grieving Depression Loss There is a recognizable loss by the There may not be a recognizable loss bereaved. by the depressed, or the loss is seen as punishment. Mood states Quickly shifts from sadness to more Sadness mixed with . normal state in same day. Variability in mood, psychomotor ac- Tension or absence of energy. tivity, level, verbal communication, appetite, and sexual within same Consistent of depletion, psycho- day/week. motor retardation, with weight loss; sexual interest is down, verbal communication is down; or agitation, compulsive eating, sexuality or verbal output. Expression of anger Open anger and . Absence of externally directed anger and hostility. Expression of sadness Weeping. DifficuIty in weeping or in controlling weeping. , fantasies, and Vivid, clear dreams, fantasy, and Relatively little access to dreams; low imagery capacity for imagery, particularly capacity for fantasy or imagery (except involving the loss. self-punitive). Sleep disturbance Disturbing dreams; episodic difficulties Severe , early morning in getting to sleep. awakening. Self-concept : Sees self as to for not providing Sees self as bad because of being adequately for lost object. depressed. Tendency to experience the world as Tendency to experience self as empty. worthless. Preoccupation with lost objects or Preoccupation with self. person. Suicidal ideas and feelings: Responsiveness Responds to warmth and reassurance. Responds to repeated promises, pres- sure, and urging or unresponsive to most stimuli. Variable restrictions of pleasure. Persistent restrictions of pleasure. Reaction of others to Tendency to feel for griever, Tendency to feel irritation toward affected person to want to touch or hold the person who depressed. Rarely feels like touching or is grieving, reaching out to depressed. elude , restlessness, anger, , sadness, responding physiological effects in the form of episodic hopelessness, and helplessness but also reflection, elevations of excretion.15* I6 savoring, animation, and a sense of humor when with While a person in grief may be immobilized, if others. While there is evidence of the interspersing of someone else initiates an activity, he or she is more periods of relative equilibrium and distress during both likely to respond than one who is depressed. Thus grief and reactive depression,lJ* l6 the periods of dis- moods can vaj as a function of interpersonal stimu- tress in grief usually occur when one is reminded of ’ lation, particularly by individuals already known to the loss. the bereaved. The bereaved person also exhibits more variability in mood and activity level, in willingness to communicate Dreams, Fantasies, and Imagery with others, and in appetite and sexual interest. As Parkes I1 noted, “The most characteristic feature of Individuals who aie actively grieving appear to differ grief is not prolonged depression but acute episodic from those who are depressed in their access to the ‘pangs.’ A pang of grief is an episode of severe anxi- levels of consciousness represented by fantasies and ety and .” These pangs have cor- dreams. There is evidence that depressed individuals

FOURTH QUARTER/ 1980 164 have a marked decrease in REM cycle sleep, which is differs. Persons in grief generally are preoccupied with usually associated with dreaming.]’ Depressed individ- the lost objects, persons, or illusions and their relation, uals also have difficulty using their fantasies or engag- ship to them; depressed individuals generally are nre- A~- ing in imagery in any positive manner. Any access o&pied with themselves, their inner feelings, and that exists is usually self-punitive, which in itself may what the loss says about them. be an ominous sign of physical vulnerability. In patients, for example, Achterberg and Lawlis lR found Responsiveness that’successful imagining of the white cells of the body defending against and defeating the cancer cells was There are, obviously, times when grieving_ persons__ are highly correlated with remission, stabilization, or ad- unresponsive to others. They want to be left alone, vancement of the illness (r=.71; n=58). This may and many will request this. Solitude is frequently seen be one aspect of the common observation that episodes as a necessary part of grieving, particularly in reflect- of depression frequently precede physical illness.17-20 ing on the loss and gaining perspective. Other times, Most actively grieving persons, even months or however, they are clearly responsive, able to experi- years after the loss, report vivid dreams representing ence and express what for them is a typical range of the deceased or lost object in a way that acknowledges involvement with others. The depressed individual is the loss.” In addition, bereaved individuals in their more likely to be either frightened of being left alone fantasies and daydreams are frequently able to focus or unresponsive to the presence of others. oc’who or what was lost or what they were doing and Pleasure that was exclusively associated with the at the time of the Ioss,?~ which often represents lost person, goal, or object (such as going to favorite a iignificant way of grieving. Morrison 2o reported that restaurants, participating in sports, school, sexual in- persons progressing through grief frequently have day- tercourse) may be absent until grieving has been com- dreams and are able to use imagery exercises to fa- pleted, but other types of enjoyment are often open cilitate awareness of what they have lost. to the bereaved. They may initially feel guilty or un- faithful or wish to share the experience with those they have lost, but they can frequently be persuaded to Self-concept do something and enjoy it. In contrast, depressed per- The self-concept of both someone in grief and some- sons generally restrict all pleasure and are usually un- one who is depressed is assaulted by a loss. Depressed able even to fantasize pleasurable acts without guilt individuals, however, often see the loss as confirming () .*I They usually seem immune to attempts to persuade them otherwise. In cases of agitated de- that they are bad, that they deserve what has hap- pened, that fate is against them, and that they are in- pressions or acting out, the ple,asure-seeking behavior deed worthless. They appear to use the loss to prove frequently takes on compulsive dimensions with little reported pleasure involved. a negative self-image, Thus someone with a poor self- concept before a loss is more vulnerable to depression as a reaction to loss. Effects on Others The person who is grieving, on the other hand, may There is a strong tendency to feel sympathy for the be- if the loss occurred because they are bad, reaved, to want to touch, hug, or otherwise provide worthless, etc., but this exploration is usually dis- him with some measure of protection and nurturance. cordant with their typical self-image, and they will There is often a softness, responsiveness, a vulner- have difficulty reconciling it with what else they know ability about someone in grief that is usually absent in about themselves. As Freud 1 noted, “In mourning, someone who is depressed. The health professional it is the world which has become poor, in depression initially may feel the same to nurture the de- it is ego itself.” pressed individual who has experienced a loss, but the The person in grief is more likely to search for a person’s incapacity to respond, pervasive despair, an- cause of the loss and may seek to blame himself hedonia, and passive rejection of nurturance often or others for what has happened. Individual8 who are provokes irritation, helplessness, and a sense of de- not prone to forming fixed, unquestioned beliefs can tachment in the helping individual. usually respond to warmth, reassurance, and logical questioning about issues of blame and guilt, while de- DIFFERENCES BETWEEN NORMAL pressed individuals are more likely to resist attempts AND PATHOLOGICAL BEREAVEMENT to either gain perspective or change their negative self- image. Although pathological grief reactions are not as com- Both bereaved and depressed individuals often ap- mon as depressive reactions, their distinction from pear preoccupied, but the focus of the preoccupation normal grief is also important. This section will dis- 165 cuss observations of both normal and pathological Ramsay ‘L3reported similar conclusions in his obser- grief. vations of and pathological grief reactions. Volkan 1’s 22 examined the characteristics of the The main similarity he saw was in the avoidance be- pathologically bereaved as part of his general studies havior, where the bereaved avoids situations that on death and grief. He noted, “Uncomplicated grief evoke the sense of loss. As with Lindemann’s obser- may be seen as nature’s exercises in loss and restitu- vations, the result is a phobiclike reaction from which tion. It involves pain, but it is worked through and there is no resolution, only continued restrictions of ultimately resolved, offering no drastic obstruction to behavior. the conduct of daily life after an average time of six Table II lists some of the distinctions Volkan and months . . . Established pathological grief . . . may others make between normal and pathological grief. be continuous, or it may appear periodically at the Six months seems to be a minimum time necessary anniversary of the death or when a symbolic loss re- to determine if the bereaved will be able to mourn minds the patient of the death. I consider this diag- and resolve the loss and begin to move on in life. Even nosis when, six months or more after death, I observe after that, those going through normal bereavement an attitude toward the loss indicative of an intellectual will still experience loneliness pangs, occasional peri- acknowledgment of its occurrence accompanied by ods of or preoccupation, or minor anniversary emotional denial, . . .” reactions (except for the first Christmas, for example, Hodge Z’ went further in stating, “If the grief work or the first anniversary of the loss) and may require is not actively pursued, the process may be fixated, a long time to understand the meaning of the loss. aborted or delayed, with the patient feeling that he Those in normal grief, however, will generally be able may have escaped it. However, almost certainly a dis- to carry on a preloss style of living with whatever torted form qf grief work will appear at some time adaptations are necessary to acknowledge the reality in the future.” Lindcmann,2L in observing those who of the loss within the first year.*” had pathological grief reactions, noted, “One of the big obstacles of this work seems to be the fact that Reality Testing many (people) try to avoid the expression of emotion necessary for it.” The result is pathological grief, Characteristic of pathological bereavement is an which Lindemann regards as an inability to terminate avoidance of reality testing. This is manifested in an the process. active seeking of reunion with the lost person or

Table II. Key differences between normal and pathological grief.

Grief Pathological grief Time since loss Most intense reactions are seen prior to Intense reactions last longer than six six months. months with little sign of resolution or relief. Reality testing of the Holding on strategies: wants to believe Continues to operate as if loss was still loss the loss can be restored but knows it there. Chronic, continuing for cannot. Reality-testing (after initial return of lost person or object. Refusal phase of shock) is intact. to actively reality test. Preoccupation Variable: can be intensely focused on Active: seeking reunion with lost object loss or able to function. Acute aware- or person or clear ongoing disruption ness of what happened at time of loss: and dysfunction in daily routine; acute emotionally, physically, and cognitively. awareness of what happened at the time of the loss is usually cognitive only. Dreams/imagery Manifest content of dreams is variable Manifest content focused on attempts but contains recognition of the absence to save or destroy what (who) was lost. of what has been lost. Approach/avoidance Ambivalent about dealing with.loss but Avoids situations which would remind behaviors willing to do so. bereaved of the loss. ~ntellectual/emotional Intellectual and emotional awareness of Intellectual awareness only or emotional integration loss. awareness without linking to intellectual awareness. 166 -- object long after the loss has occurred or the active Approach/Avoidance Behaviors avoiding of acknowledging the existence of the person Most grieving individuals are ambivalent about dis. who has been rejected or incorrectly assumed to be cussing their losses and the resulting feelings because deceased. One example of this failure at reality test- of the pain and helplessness they experience in bring ing is the typical use of the present tense when refer- ing their memories to awareness. In situations that ring to the lost person or object (“We always do it they perceive as facilitating and safe, however, they that way,” rather than, “We always did it that way.“). are often willing to share these feelings. The pathc. Another example is the total absence of mention of logically bereaved individual tends to avoid situations a rejected child by a parent, with hostility directed at that are reminders of the loss, including contact with anyone who risks mentioning such a person. people who might evoke feelings of grief. They \vill resist or avoid discussion of their loss, often stating Length of Preoccupation that it only brings up the pain, it does not do any good, Intense preoccupation with the loss is a clear sign of or they do not want to feel sorry for themselves. mourning. If this preoccupation maintains intensity for longer than six months, however, or increases to Intellectual/Emotional Integration the point where “the thread of daily life is lost,” l4 Normal grieving involves a reintegration process, the grief has reached pathological proportions. One which brings together the intellectual awareness of a example is a woman whose everyday life still focused loss, its implications and consequences, and the phys- oh her deceased husband. She maintained his clothes, ical and emotional experience of deprivation, mourn- prepared meals for him, and planned joint ventures. ing, and healing. In a general sense, Gendlin 2i viewed She had not adapted her behavior to account for the this integrative process as necessary for any growth reality of his absence. process. The integration is clearly absent in patho- .Part of this preoccupation in pathological grief is logical grief. There may be intellectual awareness in focused on searching through the events surrounding the absence of feeling, or there may be feelings (often the loss event repetitively and without a sense of relief. seen as chronic grieving) with little or no insight into Most people in grief experience a catharsis in telling their source, meaning, or implications and with little the story of their loss. The pathologically bereaved, more than temporary relief. however, often describe the events ‘without linking With such distinctions between grief and patho- feelings and actions that occurred at the time. Usually logical grief and depression, there are corresponding they report little or no relief from relating the details differences in the treatment of these conditions. of their loss. Those listening to the story may experi- ence feelings of distress and, as a result, assume that TREATMENT DIFFERENCES the pathologically bereaved must also be experiencing BETWEEN GRIEF, the same. Careful observation usually reveals that the PATHOLOGICAL GRIEF, pathologically bereaved are relatively unmoved and AND DEPRESSION seemingly detached in relating the story. As stresses on the adaptive function of the organism, grief, pathological grief, and depression all need mon- Dreams/Imagery itoring of the physical aspects by a health care pro- Many persons have disturbing dreams after a loss. fessional. Loss is a event in anyone’s life. Indi- In pathological grief, however, the manifest content viduals are vulnerable, physically and emotionally, repeatedly deals with attempts to save or destroy the after a loss. Engel’s 28 work on sudden death after a lost person or object. I-’ Often the same is re- loss is dramatic evidence of this. Parkes I9 and peated. Generally, in pathological grief, these dreams Weiner’s 23 summaries of studies on increases in post- have the associated feelings of anxiety or,guilt, and loss illnesses and increased visits to physicians in the there is little, if any, release experienced after awaken- six months after a loss also support this point of view. ing. In normal bereavement, the manifest content is Thus of illness after more likely to acknowledge the loss *O or to facilitate loss is important to prevent unnecessary complica- grieving the loss. For example, a young man described tions, regardless of whether the individual’s condition a dream in which he had dinner and a particularly is primarily grief or depression. meaningful conversation with his deceased father, Grief, however, does not require psychiatric inter- something he had not been able to have while the vention but rather a facilitation of what the person father was alive. The dream was experienced as re- already is experiencing.*’ As Frank1 3o pointed out, leasing and satisfying and a sign of progress in effective treatment requires of the crisis of grieving. meaning and attachment the bereaved is facing. 167

Defiression requires altering the person’s over- quilizers, barbiturates, amphetamines and )“G whelming feelings of helplessness, hopelessness, dejec- that might alter the person’s capacity to utilize dream- tion, and lack of meaning in his pain. Depression ing in grief and that might also create a further stress frequently requires intervention in the form of psycho- in the person’s life. therapy, hospitalization, medication, Many individuals who are grieving their unpre- resocializing, and, in the case of some psychotic de- dictable moods as signs of “craziness.” As a result, pressions, electroshock therapy.‘“+ “‘9 Ii1 Recent ap- they often avoid seeing mental health professionals. proaches have emphasized or Yet they are likely to be seen by other professionals vigorous treatment of the biological basis of depres- in the health care system.“i Thus recognizing signs of sion.1. 23,5’. 32 normal grief in a patient seeing a physican for physical The work of grief generally involves minimal inter- problems or in a medical hospital by a nurse or social vention, the presence of an ongoing supportive rela- worker may be a significant step in providing the nec- tionship, solitude, and time for healing.:“’ Counselling essary support and reassurance. Incorrect labeling and persons in grief generally involves helping the mourn- treating of grief as depression can inhibit, delay, or ers pay attention to whatever might be connected with interrupt the mourning process. their loss and providing comfort and companionship On the other hand, treating severe depressive reac- during periods of acute awareness.‘” Grief generally is tions as grief or providing simple support and avail- best aided by existing relationships rather than by ability to someone whose grief is of pathological pro- establishing new relationships. Referral to a mental portions ignores the morbidity of the process that must health profes$ional can be frightening to the bereaved. be interrupted. Depression results when the feelings The pain of grief is considered a useful experience associated with a major loss have broken through the in acknowledgment of the loss. In normal grief, this person’s defenses (as in grief). At the same time there experience need not be forced or brought out by con- is a continuing denial or inability on the part of the frontation. Often the mere presence and openness of person to acknowledge the loss or the need to grieve. a trusted professional or a friend can be sufficient to Because of the helplessness and hopelessness of de- facilitate progress. Touch, in the form of hand-holding, pression, these individuals frequently lack the neces- reassuring hugs, and , can also be therapeutic sary ego functions to permit grieving. Encouraging in grief.‘” depressed individuals to their feelings when they Counselling the pathological griever often involves are experiencing dejection, helplessness, hopelessness, actively helping him review the circumstances of the and self-depreciation can be frightening. Although en- loss and “emotional reliving.” 33 It is an active process couraging self-trust may be important in grief counsel- of supportive confrontation clearly described by Vol- ling, such an approach with the depressed person can kan,” which can include looking at old photos, visits also lead the helper to ignore important signs and to cemeteries or childhood homes, and inclusion of symptoms, such as temporary mood elevation, or get- other family members. It also may involve active coun- ting the house in order, which may be a sign that selling and advice to the bereaved to avoid precipitous has been resolved but in a way that and unwise decisions, such as moving away, alienating suicide risk is increased.38 Such facilitative techniques friends, or locking up the belongings of the deceased.24 usually do not lead the care provider to look for a By treating a grieving person as one who is de- possible biological basis for the depression 28 or to pressed or in pathological grief (such as by inter- actively treat this biological base vigorously 32 with vening), natural healing processes could be inhibited. monoamine inhibiting drugs and the tricyclic anti- Such interventions as medications that cloud con- drugs. sciousness, confrontations however supportive, hos- Treating pathological grief as normal grief rein- pitalizations, and electroconvulsive therapy could con- forces the avoidance behaviors and permits the main- vince the bereaved that their experience is pathological tenance of dysfunctional behaviors. For example, to and they could be persuaded roof to trust themselves. remain silent when a person discusses a deceased The suggestion or use of treatments appropriate for spouse in the present tense can be perceived by the depression or pathological grief could deprive the pathologically bereaved as support for the belief that grieving person of access to full awareness of his feel- the spouse is still alive. ings and the associated significance of the loss, since When dealing with the pathologically bereaved, the any of these treatments suggest to the bereaved that attitude of support and sympathy, which is effective the process he is experiencing is not natural. In addi- in helping those who are grieving normally, creates in tion, tricyclic are contraindicated in the supportive person stronger feelings of pain and grief,” as is the systematic use of any REM altering or helplessness than it does in the bereaved. Sympathetic suppressant drugs (such as most , major tran- grieving on the part of the helping professional can be

FOURTH QUARTEW 1980 168 exhausting, discouraging, and even a source of irrita- expected loss, either of a loved person or else of tion when it is realized that the pathologically be- familiar and loved places or of social roles. A reaved reports no relief or no feelings. sad person knows who (or what) he has lost and Because it frequently is not clear whether the be- yearns for his (or its) return. Furthermore, he is reaved is in a period of normal mourning or depressed likely to turn for help and comfort to some or in a state of pathological grief, it is important that trusted .companion and somewhere in his mind the helping professional attend to the potential ab- to believe that with time and assistance he will normality first. Grieving demands all the ego strength be able to re-establish himself, if only in some the individual can muster. When a person experiences small measure. Despite great sadness, hope may a significant loss, the goal of the helping professionals still be present. Should a sad person find no one is to help that person mobilize his strength to meet the helpful to whom he can turn, his hope will challenge. Bowlby x!’ summarizes well the needs of surely diminish; but it does not necessarily dis- normal grief: appear, To re-establish himself entirely by his Sadness is a normal and healthy response to own efforts will be far more diffkult; but it may any misfortune. Most, if not all, more intense not be impossible. His sense of competence and episodes of sadness are elicited by the loss, or personal worth remains intact.

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