分类目录归档:心理学

Getting Grief Right

By the time Mary came to see me, six months after losing her daughter to sudden infant death syndrome, she had hired and fired two other therapists. She was trying to get her grief right.

Mary was a successful accountant, a driven person who was unaccustomed to being weighed down by sorrow. She was also well versed in the so-called stages of grief: denial, anger, bargaining, depression and acceptance. To her and so many others in our culture, that meant grief would be temporary and somewhat predictable, even with the enormity of her loss. She expected to be able to put it behind her and get on with her life.

To look at her, she already had done so. The mask she wore for the world was carefully constructed and effective. She seemed to epitomize what many people would call “doing really well,” meaning someone who had experienced a loss but looked as if she was finished grieving. Within a few days of the death of her daughter she was back at work and seemed to function largely as before.

The truth of her life was something else. Six months after her baby’s death she remained in deep despair. She was exhausted from acting better than she felt around co-workers, friends and family. As is so often the case, she had diagnosed her condition as being “stuck” in grief, believing that a stubborn depression was preventing her from achieving acceptance and closure.

Was she in denial, she wondered. She also wondered if she was appropriately angry. The bottom line was that she knew she was depressed — a psychiatrist had prescribed an antidepressant — and that is what she wanted me to treat.

Earlier in my practice, I would have zeroed in on that depression. Was there a family history? Had she been depressed before? Was the medicine helping? What were her specific symptoms? Knowing the answers might suggest why she was stuck. Or I would have reviewed the stages of grief, as she had, looking for one in which the work remained incomplete.

But I had begun to operate differently by the time Mary showed up, which was 10 years after my own loss. My firstborn child had also died before he was a year old. It was why Mary had chosen me.

In our first session I put Mary’s depression aside. I asked her to tell me the story of her baby rather than describe the symptoms of her grief. Though she was resistant, she eventually started to talk.

Like most other things in Mary’s life, the baby, whom she named Stephanie, was planned. Mary was delighted with her pregnancy and had wonderful dreams for her daughter. After a routine delivery, Mary stayed home with Stephanie for the first three months. Returning to work had been difficult, but Mary was comfortable with the child-care arrangement, and managed to balance motherhood with her busy professional schedule.

Then Mary told me about the Saturday when she went to check on her napping daughter and found that Stephanie wasn’t breathing. She began C.P.R. as her husband called 911. There were moments of surreal focus as she and her husband tried to save their baby. Then this woman, so accustomed to being in control, had to surrender her daughter to an emergency crew. Her husband drove as they followed the ambulance to the hospital.

She described the waiting room in great detail, down to the color of the furniture. When the hospital chaplain walked in with the doctor she knew her baby was gone. She and her husband were taken into a room where they held the baby for the last time.

At this point in her story Mary finally began to weep, intensely so. She seemed surprised by the waves of emotion that washed over her. It was the first time since the death that the sadness had poured forth in that way. She said she had never told the story of her daughter from conception to death in one sitting.

“What is wrong with me?” she asked as she cried. “It has been almost seven months.”

Very gently, using simple, nonclinical words, I suggested to Mary that there was nothing wrong with her. She was not depressed or stuck or wrong. She was just very sad, consumed by sorrow, but not because she was grieving incorrectly. The depth of her sadness was simply a measure of the love she had for her daughter.

A transformation occurred when she heard this. She continued to weep but the muscles in her face relaxed. I watched as months of pent-up emotions were released. She had spent most of her energy trying to figure out why she was behind in her grieving. She had buried her feelings and vowed to be strong because that’s how a person was supposed to be.

Now, in my office, stages, self-diagnoses and societal expectations didn’t matter. She was free to surrender to her sorrow. As she did, the deep bond with her little girl was rekindled. Her loss was now part of her story, one to claim and cherish, not a painful event to try to put in the past.

I had gone through the same process after the loss of my son. I was in my second year of practice when he died, and I subsequently had many grieving patients referred to me. The problem in those early days was that my grief training was not helping either my patients or me. When I was trained, in the late 1970s, the stages of grief were the standard by which a grieving person’s progress was assessed.

THAT model is still deeply and rigidly embedded in our cultural consciousness and psychological language. It inspires much self-diagnosis and self-criticism among the aggrieved. This is compounded by the often subtle and well-meaning judgment of the surrounding community. A person is to grieve for only so long and with so much intensity.

To be sure, some people who come to see me exhibit serious, diagnosable symptoms that require treatment. Many, however, seek help only because they and the people around them believe that time is up on their grief. The truth is that grief is as unique as a fingerprint, conforms to no timetable or societal expectation.

Based on my own and my patients’ experiences, I now like to say that the story of loss has three “chapters.” Chapter 1 has to do with attachment: the strength of the bond with the person who has been lost. Understanding the relationship between degree of attachment and intensity of grief brings great relief for most patients. I often tell them that the size of their grief corresponds to the depth of their love.

Chapter 2 is the death event itself. This is often the moment when the person experiencing the loss begins to question his sanity, particularly when the death is premature and traumatic. Mary had prided herself on her ability to stay in control in difficult times. The profound emotional chaos of her baby’s death made her feel crazy. As soon as she was able, she resisted the craziness and shut down the natural pain and suffering.

Chapter 3 is the long road that begins after the last casserole dish is picked up — when the outside world stops grieving with you. Mary wanted to reassure her family, friends and herself that she was on the fast track to closure. This was exhausting. What she really needed was to let herself sink into her sadness, accept it.

When I suggested a support group, Mary rejected the idea. But I insisted. She later described the relief she felt in the presence of other bereaved parents, in a place where no acting was required. It was a place where people understood that they didn’t really want to achieve closure after all. To do so would be to lose a piece of a sacred bond.

“All sorrows can be borne if you put them in a story or tell a story about them,” said the writer Isak Dinesen. When loss is a story, there is no right or wrong way to grieve. There is no pressure to move on. There is no shame in intensity or duration. Sadness, regret, confusion, yearning and all the experiences of grief become part of the narrative of love for the one who died.

女儿被婴儿猝死症夺取生命的六个月后,玛丽(Mary)找到了我。那时,她已经聘请并解雇了两名心理医师,她努力想要从悲伤中恢复过来。玛丽是成功的会计师,充满斗志,很少被悲伤压垮。她也非常清楚所谓的悲伤的各个阶段:否认、愤怒、协商、沮丧和接受。对于她和我们文化中的许多其他人来说,那意味着悲伤是暂时的,在一定程度上也是可以预测的,即使是她的生命承受了如此巨大的损失。她期待着能放下痛苦,继续自己的生活。从表面上看,这些她都已经做到了。她戴着一张精心构造的面具来面对世界,掩饰的效果相当不错。她似乎就是许多人所说的“很坚强”的典范,意思是虽然经历了打击,但看起来已经不再悲伤。在女儿夭折的几天之后,她就回来继续工作,言行举止基本上和以前一样。她在生活中的真实情况并非如此。宝宝去世的六个月之后,她仍然处于深深的绝望之中。为了在同事、朋友和家人面前表现得更坚强,她已经疲惫不堪。就像多数情况一样,她已经察觉自己“陷入”了难以摆脱的悲伤,认为顽固的抑郁正在阻止自己实现接受和解脱。她想,自己是不是还处在否认的阶段。她还琢磨,自己是否合理地发泄了愤怒。但最重要的是,她知道自己抑郁了,一位精神科医生给她开了抗抑郁药。她想让我帮她治疗的,也是抑郁。倘若是在我行医的初期,我会把所有精力放在她的抑郁症上。她有家族病史吗?她以前抑郁过吗?那些药管用吗?她有哪些具体症状?了解这些问题的答案可能会解释她的状况。或者,我会评估她经历的悲伤的每一个阶段,就像她所做的那样,找出哪个阶段还没有完成。不过,当玛丽前来就诊时,我已经不那么做了。那时距离我自己遭受同样的打击,已经过去10年了。我的第一个孩子不到1岁就去世了。也是出于这个原因,玛丽找到了我。在我们的第一次治疗中,我把玛丽的抑郁放在了一边。让她对我讲讲她女儿的事,而不是描述自己悲伤的症状。尽管一开始她有些抗拒,最终还是讲了起来。就像玛丽人生中的其他许多事项一样,这个被取名斯蒂芬妮(Stephanie)的宝宝也是按计划降生的。玛丽怀上她非常开心,对这个女儿有很多美好的期盼。顺产后的头三个月,玛丽待在家里照顾斯蒂芬妮。重返工作很痛苦,玛丽把带孩子的事安排得很好,努力平衡着母亲的角色和繁忙的工作。然后,玛丽给我讲述了那个星期六,当她回到家想要看看正在睡觉的女儿时,却发现斯蒂芬妮没有任何气息。她开始做心肺复苏,丈夫拨打了911。她和丈夫试图挽救孩子的时候,做到了异乎寻常的专注。然后,这个习惯了把所有事情纳入掌控之中的女子,不得不把女儿交给了急救人员。丈夫开车带着她,跟随救护车驶向了医院。她详细地描述了等候室的样子,甚至包括桌椅颜色这样的细节。当医院牧师和医生一起走进来时,她意识到自己的孩子已经不在了。她和丈夫被带到了一个房间,最后一次把女儿抱在怀里。讲到这里,她终于哭了出来,而且一发不可收拾。她似乎对这种排山倒海的情绪感到不可思议。这是孩子去世以来,她第一次以这种方式宣泄悲伤。她说,她从来没有这样完整地讲述过女儿从孕育到去世的过程。“我这是怎么了?”她哭着问。“都已经过去将近七个月了。”我非常轻柔地,用简单的非医学词汇告诉玛丽,她没事。她既没有抑郁,也没有陷入悲伤无法自拔,更没有做错什么。她只是非常伤心,内心被悲伤填满,不是因为她承受悲伤的方式有什么不对。她的悲伤之深,只不过是因为她爱女儿之切。她听到这里时,转变发生了。她仍然在哭泣,但面部的肌肉松弛了。我看到她压抑了数月的情绪释放了出来。在这之前,她用大部分精力想要弄清楚自己为什么无法摆脱悲伤。她把自己的感受埋在心里,发誓要坚强起来,因为人理当如此。现在,在我的办公室里,悲伤的各个阶段、自我诊断,以及社会的期待都不重要了。她可以自由地屈服于悲伤。她和幼小的女儿之间那段深刻的联系被重新点燃。她所承受的打击成了她的一段故事,一个可以讲述和珍藏的故事,而不是一段努力想要遗忘的苦痛经历。在我的儿子夭折后,我经历了同样的过程。那是我当上医生的第二年,之后就有很多悲痛的患者被介绍到我这里。一开始的问题是,我的治疗方法对病人和我都没有帮助。在上世纪70年代,我接受培训的时候,悲伤的五个阶段是评估一位患者治疗进展的指标。这个模式仍然深刻而顽固地存在于我们的文化意识和心理话语中。它让痛苦的人们做出了许多自我诊断和自我批评。推波助澜的,则是周围的人常常含蓄和善意的看法。一个人的悲伤的时间和强度,都应当适度。当然,有些来找我寻求帮助的人显示出了严重的、可以诊断的症状,这些症状需要治疗。然而许多人寻求帮助只是因为他们和周围的人认为,他们悲伤的时间该结束了。实际上,悲伤就像指纹一样独一无二,它不会遵照任何时间安排或者社会期待。根据我自己和我的患者的经历,我现在想说,失去至亲的故事有三个“章节”。第一个章节与依恋程度有关:指的是你和去世者之间的关系。理解感情程度和悲伤程度的关系,会让多数患者感到极大的宽慰。我常常告诉他们,悲伤的强度和爱的深度是相称的。第二个章节是死亡本身。在这个阶段,失去至亲的人常常会开始质疑自己的精神状况,如果是过早死亡或创伤性的死亡,就尤其如此。玛丽对自己在艰难时期把控全局的能力感到自豪。她女儿的死亡导致的深度情绪混乱让她抓狂。她会尽可能地抵制这种抓狂的状态,抑制自然产生的痛苦和折磨。第三个章节是从外部世界不再陪你一同悲伤的时候开始的,这是一条漫长的道路。玛丽想要让家人、朋友和自己相信,她很快会从悲伤中走出来。这个过程让人精疲力尽。她真正需要的是让自己沉浸在悲伤里,然后接受它。

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