Since I heard of all the excitement in the therapy literature about forgiveness therapy, I've been a skeptic. I've worked with a lot of people who have experienced unforgivable abuse. Often they are tortured by their feelings of anger, resentment, helplessness, violation, and shame for allowing themselves to be a victim. They also feel guilt about their anger with the perpetrator so much so they feel morally obligated to forgive the perpetrator. When they do, they seem to feel no personal relief from forgiveness except for less anger and guilt and a better relationship with the perpetrator. But they seem no closer to recovery than before.

I work with persons with depression and anxiety, as well as long standing serious problems with relationships (personality disorder) due to growing up in a chaotic environment. So it is conceivable that forgiveness therapy may have been designed for a healthier population. Seeking to try to better understand this dilemma, I attended a great conference recently taught by Mary Hayes Grieco and colleagues on forgiveness therapy. From the conference flyer:

This day-long course is intended to introduce the counseling professional to a model of wholistic psychological health and an effective method for accomplishing forgiveness that is one of the most useful tools for therapy available today.

You will:

• review current research linking forgiveness with stress reduction


• learn the Psychosynthesis Model of psychological health and wholeness


• learn The Eight Steps of forgiving another and the steps of self forgiveness


• understand how forgiveness brings healing into a family system


• learn how forgiveness brings integration and closure to trauma survivors


• develop strategies for applying the eight steps of forgiveness in a clinical practice

The course material reflects the connection between spirituality and emotional healing but the content is inclusive and non-denominational. We will discuss how to incorporate these concepts appropriately in a secular setting.

It was a small class of 17. Mary and her three assistants seemed to thrive in a small group setting. The atmosphere was most comfortable for listening and it allowed Mary to shine with her skill of personal connection. I got a sense of her therapeutic leadership skills, her gentle and humorous style, and her amazing ability to instill hope with her gentle encouragement. Her eyes positively sparkle with warmth, confidence and belief in her method. She succeeds as well as anyone I've seen providing a secular foundation for spirituality even though her foundations are clearly religious.

She defines forgiveness functionally, rather than semantically. To forgive is to release an expectation that is causing one to suffer, to cancel a debt of demands and expectations that one is holding on to, and to dissolve an attachment that blocks one's flow of love and energy. This is not the moralistic obligatory forgiveness that seems to have locked many of my clients in place.

The core of her method follows:

The Eight Steps of Forgiveness of Another

1. State your will to make a change in attitude
2. Express your emotions about what happened
3. Cancel the expectation(s) you are holding in your mind
   • Shift expectation to positive preference
   • Acknowledge reality
   • Re-state your will to move on; open up to getting your needs met in a different way
   • Release the expectation with words and inner letting go
4. Open up to the Universe to receive exactly what you need
5. Sort out the boundaries: give them responsibility for their actions and take yours; visualize your personal space like a sphere of light around you
6. Send unconditional love to the person
7. See the good in them or in the situation
8. See the good

Notice the physical change and take time to gently integrate it.

Other authors have a bit more elaborate definition of forgiveness. Enright and Fitzgibbons (2000, p. 29), in their book Helping Clients Forgive, defines forgiveness as, after validating the person had been unfairly treated, a person chooses to forgive by willfully abandoning resentment (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principal of beneficence (providing aid without thought of reciprocity or restitution), which may include compassion, unconditional worth (because he is human), generosity (in receiving more than what he deserves), and moral love (concern and respect to which the wrongdoer, by nature of the hurtful act or acts, has no right).

They also define what forgiveness is not: pardon, legal mercy, leniency, condoning, excusing, reconciliation, conciliation, justification, forgetting, restitution, forgiveness for self only. It is not the same as incomplete synonyms of letting time heal, abandoning resentment, possessing positive feelings, saying "i forgive you", making a decision to forgive. They also note confusing similar concepts. Forgiveness is not a quick fix for most. Acceptance and moving on doesn't involve how one feels about the offender. Nor is it in any way cloaked revenge.

Clearly, the forgiveness I had in mind is not what is described here. I had in mind the moralistic obligation to "turn the other cheek", something I've never understood. Mary confidently asserts in her brochure:

Recent research on the relationship of forgiveness to health and happiness demonstrates empirically what religions and philosophers have suggested throughout history: that forgiveness is necessary in order to find peace from life's hurts, losses and disappointments. The ability to move on is critical to completing the emotional healing process.

I think at this point I agree with everything but the use of the word "necessary". The literature review in the presentation gives a compelling argument for the value of forgiveness. But I don't believe I've seen a proof that it is necessary. What the method does contain seems to be a bit broader concept of change. Franz Alexander et al. (1946) defined "the corrective emotional experience:

In all forms of etiological psychotherapy, the basic therapeutic principle is the same: to re-expose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.

In my clinical experience, there are two major obstacles to the effectiveness of forgiveness. Reed and Enright (2006) describes them well:

Women who have experienced spousal emotional abuse present at least two unique challenges for recovery. First, learned helplessness (Sackett & Saunders, 1999) develops as a pattern of self-blame in response to the criticism and ridicule by the abusive spouse and often remains well beyond the end of the abusive relationship (Dutton & Painter, 1993). "If only I had done this to please him" quickly deteriorates in the ongoing, unpredictable stress of the abusive relationship to "I am trying to prevent this, but nothing is working" and remains in a residual "Maybe I am worthless and none of my decisions are valid." Therefore, any treatment for these women should demonstrate outcomes in practical decision making and moral decision making....

Second, Seagull and Seagull (1991) described an obstacle to recovery for emotionally abused women labeled accusatory suffering, which entails maintaining resentment and victim status. The assumption in accusatory suffering is that healing the wounds of the abuse will somehow let the perpetrator off the hook. At a deeper level, accusatory suffering may be seen as a defense against the fear that the woman is somehow responsible for her own victimization, a fear that is often inculcated by the victimizer (Sackett & Saunders, 1999). Seagull and Seagull (1991) argued that although accusatory suffering (resentment and victim status) may function as a temporary strategy to help the woman adapt to the extreme experience of spousal emotional abuse, it seriously hinders substantial post-relationship, post-crisis recovery. Therefore, any treatment for these women should demonstrate a change in victim status.

Each of these two obstacles represent major challenges to clients from highly traumatic and abusive environments. The risk of attempting forgiveness prematurely potentially could lock in place both a sense of helplessness and personal responsibility. In that case, forgiveness removes the resentment and improves the broken relationship, it leaves in place the client's vulnerability to recurrence. Reed and Enright (2006) continues:

The FT client is encouraged to tell her own unique story of the abuse experience, with the purpose of working through this story to a healthy resolution that includes forgiveness. During the forgiveness process, the client does the hard work of uncovering anger and shame, grieving the undeserved pain from the abuse, and reframing the former partner (personal history, fallibility, and culpability, yet inherent human worth), with the purpose of relinquishing debilitating resentment.

Key here is the clients' ability to uncover and own their anger and, in particular, the underlying shame. The anger and resentment serves to both motivate the client to face her fears and change their circumstances, while protecting her sense of self from her underlying feeling of responsibility for having allowed the abuse and her own aggressive impulses to avenge their mistreatment. If the resentment is released prematurely, before the shame has been recognized and resolved, the client may be left will little emotional energy to move beyond self-loathing. From Greenberg and Pascual-Leone (2006):

maladaptive shame can be transformed into self-acceptance by accessing anger at violation, self-soothing, compassion, and pride. Thus, the action tendency to shrink into the ground in shame or to flee in fear is transformed by the tendency to thrust forward as part of newly accessed anger at violation or pride at accomplishment. This sequentially ordered pattern is what actually creates confidence.

Thus the negative emotion actually combines with natural positive emotions to trigger a transformation.

Consider this clinical description of a woman with possible borderline personality from Bridges (2006) who failed to respond with an emotional transformation.

Her general tone is one of blame, complaint, and resentment toward her husband for being away and enjoying himself while she is left to deal with the dog's illness. Yet, at no point does she mention that she is angry or even irritated. Her inability to put her anger into words and its relationship to her later waking with a "pain in the neck" almost cries out for interpretation. When she does mention her feelings, it is in regard to the puzzling, perhaps existential statement of feeling "nervous about living a lie." When the therapist makes an explicit attempt to inquire about her feelings related to the recent incident when she had started crying, she responds not by referring to her emotions but by instead focusing on legal details. The overall impression is one of the patient's skipping over the surface of her emotional life via her pressured, externally focused speech as a stone skips over the surface of water.

To summarize, this patient with a "venting" style displayed a pattern characterized by (1) high initial heart rate (HR) with little variability that gradually decreased from beginning to end of session; (2) rapid, incessant speech involving low-intensity expression of negative emotions, primarily complaint, resentment, and externalized blame of others; (3) very low levels of emotional processing (e.g., EXP < 2) characterized by an external focus on frustrating others and events with few references to their personal relevance or meaning or her immediate in-session experience; and (4) self-reports of experiencing intense negative emotions during sessions that were incongruent with her observable emotional behavior. One of the most surprising and interesting findings was that, on a purely physiological level, venting works! This patient showed an average decrease in heart rate from the beginning to end of each session of at least 18 beats per minute (bpm) for 9 of 12 sessions. If one were using progressive relaxation or desensitization and focusing only on decreased arousal as a measure, treatment would appear to be going very well indeed. Although this is obviously not the case, at least for this patient the opportunity to go to a session each week and "get out feelings" while experiencing a very real sense of physiological relief appeared to be very reinforcing in the short term but resulted in little if any long-term change.

So it's not as simple as venting one's anger about mistreatment, but venting reinforces the self-righteous anger by providing temporary emotional relief. To make a long lasting change, it is necessary to ferret out all underlying feelings as well. Resentment often defensively covers shame. The positive aspects of anger can be a strong motivator to transform shame into behavior change. Until this emotional transformation is complete, forgiveness is premature. It's most important to note, that adaptive negative emotions are at the core of movement in transformational therapy. Here anger serves as the energy to transform the shame into pride and confidence. The "debilitating resentment" Reed and Enright (2006) speaks of is not the core of being stuck. It's the shame of an often irrational sense of personal responsibility for ones own trauma and about aggressive impulses for revenge that is covered by the resentment and prevents recovery. Thus forgiveness of the other is not the primary ingredient, but forgiveness of one's self comes first.

Is forgiveness of the offender necessary? That I think depends more on the value system of the client. I believe an emotional transformation from maladaptive anger and shame to angry determination to make changes through self-encouragement and self-nurturance is the primary driver of recovery from trauma. Many of my clients seem to readily make the transformation from resentment to angry determination. Forgiveness, if it comes at all, comes as a consequence of the primary change, effortlessly, later on, as if part of a unforced natural process. Others feel an obligation to forgive and do so as a part of recovery. Unfortunately, too many go through a forgiveness process before they have made an emotional transformation. I find myself trying to encourage them to back track to their anger, which they thought they got over, so they can finally forgive themselves.

To be sure I'm pleased to have another important tool in the therapeutic tool box. However, given the acutity of the population I work with in a short term intensive program, there is probably little utility for full blown group forgiveness therapy. But at the very least I will be much more comfortable with a clients request that they wish to learn to forgive their victimizer.

References

Alexander, F. et al. (1946). Psychoanalytic Therapy: Principles and Application. New York: Ronald Press. Retrieved April 19, 2009, from http://www.psychomedia.it/pm/modther/probpsiter/alexan-2.htm.

Bridges, M. (2006). Activating the corrective emotional experience Journal of Clinical Psychology, 62 (5), 551-568 DOI: 10.1002/jclp.20248

Enright, Robert D. and Fitzgibbons, Richard P. (2000). Helping Clients Forgive - An Empirical Guide for Resolving Anger and Restoring Hope Washington DC: American Psychological Association IBSN: 1-55798-689-4

Greenberg, L., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly research review Journal of Clinical Psychology, 62 (5), 611-630 DOI: 10.1002/jclp.20252

Reed, G., & Enright, R. (2006). The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74 (5), 920-929 DOI: 10.1037/0022-006X.74.5.920

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According to The Virginian-Pilot in Norfolk, Va, calls to crisis lines in Virginia have jumped 20 percent in the past two months.

People say the economy is pushing them to the edge -- and some are contemplating going over. Widespread financial stress has long been linked to an increase in suicides. Job loss is at the heart of it, kick-starting a "chain of adversity" that feels too heavy for some to bear. [..] Most people, he said, won't crumble in times like these. "This may well get them down, but they'll weather it." For the chronically depressed, however, or those prone to suicidal thoughts: "This could be the tipping point."

Christy Letsom runs a crisis hot line in downtown Norfolk that collects calls from across the region. Volume there holds steady at around 55 calls a day, but when compared with the same time last year, logs show a 113 percent increase in the number of people who say they're anxious about money or employment. Most of those callers are between 30 and 50 years old. Men and women are dialing equally. Many are worried not so much for themselves, but for someone else they fear is at risk. Few have called a hot line before. "These folks are hard-working people who have never experienced the kind of crisis they're in right now," Letsom said. "They're simply overwhelmed."
[..]
At the National Suicide Prevention Lifeline, calls spiked by more than a third last year -- to 568,437, up from 412,768 in 2007.
[..]
More than 12 million Americans already are out of work, and according to the Mortgage Bankers Association, 4 million homeowners are at least one month behind on their house payments. A record 1.5 million homes are in foreclosure.
[..]
It's critical, experts say, to keep perspective. Hard times have come and gone before. "We'll get through this," Nunnally said, "and come out better for it." In the meantime, Letsom said, people should stop blaming themselves. "We really all kind of overextended ourselves," she said. "Jobs were great, we all thought the economy was great, and that just hasn't turned out to be the reality." Other people can be the best medicine, Nunnally said: "Talk to each other. It reminds you that you're not alone."

This is sage advice. It's important to remember that money and jobs are a means to an end, we use money to make a better place to live for ourselves and our family. Even without income, we have each other. It becomes critically important to stay connected, even strengthen our connections in these trying times. And its timely for those of us still fortunate to be employed to build new and stronger ties with others. After loss, it's not the time to be making new connections when our judgment is impaired by desperation.

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Horwitz and Wakefield (2007) have released what may prove to be a highly influencial book titled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. The title implies that psychiatry transformed sadness into depression. It's an unfortunate catchy title that misleads the uninformed reader. Instead, the book explores in a scholarly way a fundamental principle upon which The Diagnostic and Statistical Manual (DSM) was developed.

A review of Horwitz and Wakefield (2007) by Andreea L. Seritan appeared in Am J Psychiatry 164 (11): 1764.

The central thesis of this book is a persuasive argument that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship between symptoms and the context from which they emerge. Although he remains cautious about the possibility of incorporating situational context into diagnostic criteria, Dr. Spitzer encourages psychiatrists to place this issue on the agenda for the upcoming formulation of DSM-V.

The book's title is a reminder of the central role of loss as a potentially severe life stressor leading to depression, as well as of how modern psychiatry is being blindsided into extrapolating most states of sadness into depression. In the first chapter, "The Concept of Depression," Drs. Horwitz and Wakefield address the move toward using descriptive criteria in diagnosing mental illness. In response to criticisms during the 1960s and 1970s about the lack of reliability of psychiatric diagnoses, DSM-III started using lists of symptoms to establish clear definitions for each disorder. The authors argue that this approach, while greatly increasing diagnostic reliability, has created new validity problems (p. 8). In the definition of major depressive disorder, DSM-III "fails to take into account the context of the symptoms and thus fails to exclude from the disorder category intense sadness, other than in reaction to death of a loved one, that arises from the way human beings naturally respond to major losses" (p. 14).

Chapter 2, "The Anatomy of Normal Sadness," discusses biologically based nonverbal expressions of grief, with emphasis on their universality across cultures and their presence in nonhuman primates and human infants prior to socialization into cultural emotional scripts (p. 39). Besides grief at the loss of a loved one, loss of meaningful relationships, loss of job or status, chronic stress, and disasters are listed as additional factors to be taken into account. Chapters 3 and 4, "Sadness With and Without Cause" and "Depression in the Twentieth Century" are a historical review of descriptions of depressive states from ancient times to the present. Disordered sadness is considered "without cause" (or "endogenous" in later terminology), as opposed to sadness "with cause" (or "reactive" sadness), which arises in people who suffer losses. Robert Burton's classic work The Anatomy of Melancholy, published in 1621, was the first to describe the three major components of depression--mood, cognition, and physical symptoms--that are still viewed as its distinguishing features. In his seminal paper Mourning and Melancholia (1917), Freud made the same distinction between mourning due to conscious losses and melancholia due to the experience of unconscious losses. DSM-III eliminated psychodynamic etiologies, instead focusing on symptoms. In large epidemiological studies, such as the Epidemiologic Catchment Area study in the early 1980s, diagnosis was based on structured tools administered by trained nonpsychiatric interviewers. The authors argue that prevalence data was skewed and advocate for a more specific screening process, as well as careful use of subthreshold diagnoses, such as minor depression.

Thoroughly documented, the first chapters caution readers about the limitations of psychiatric diagnosis. However, momentum is lost in the second half of the book. Chapter 7, "The Surveillance of Sadness," makes assumptions about psychiatric treatment that are not supported by the literature. For example, it is suggested that in primary care, "diagnosis of a depressive disorder tends to quickly foreclose...discussions in the direction of medication" (p. 156). The recent avalanche of data from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study suggests not only that depressed primary care patients prefer psychotherapy to medication when offered (1) but that therapy is successfully delivered in this setting, along with pharmacologic management (2). In Chapter 8, "The DSM and Biological Research About Depression," the authors again overreach, selectively analyzing individual cardinal papers and doubting their "range of applicability" without turning to the multiple evidence- based studies available in the literature (p. 176).

Although a poignant reflection on how the misapplication of psychiatric knowledge can decontextualize the lives of its patients, this book seems to miss the point that psychiatric care is a great deal more than diagnostic labeling. In practice, mental health professionals who do not rely exclusively on DSM-IV-TR use biopsychosocial formulations, viewing the individual in his or her context. Thus for many psychiatrists, treatment planning is informed by this comprehensive understanding of the person, and not solely by the description and duration of their symptoms.

Seritan has a point that many clinicians do not rely exclusively on the DSM for diagnosis. However, the classification model considered the gold standard for diagnosis DOES decontextualize diagnosis. That is a concern for training and continuing education. Given all the incentives in practice to base treatment on measurable criteria from malpractice claims, insurance payors and accreditation agencies, its very easy to slip into a comfortable criteria based practice that requires little emotional investment.

Mulder wrote an article on an even more important point about diagnosis, titled An epidemic of depression or the medicalization of distress in Perspect Biol Med. 2008 Spring;51(2):238-50.

The syndrome of major depression is widely regarded as a specific mental illness that has increased to the point where it will be second in the International Burden of Disease ranking by 2020. This article examines the assumption that major depression is a specific illness, that it is rapidly increasing, and that a medical response is justified. I argue that major depression is not a natural entity and does not identify a homogenous group of patients. The apparent increase in major depression results from: confusing those who are ill with those who share their symptoms; the surveying of symptoms out of context; the benefits that accrue from such a diagnosis to drug companies, researchers, and clinicians; and changing social constructions around sadness and distress. Standardized medical treatment of all these individuals is neither possible nor desirable. The major depression category should be replaced by a clinical staging strategy that acknowledges the continuous distribution of depressive symptoms. Trials that test social and lifestyle treatments as well as drugs and cognitive behavioral therapy across different levels of severity, chronicity, and symptom patterns might lead to the development of a coherent evidence-based stepped treatment model.

Mulder's point is that diagnosis is a academic exercise designed to communicate a cluster of symptoms among professional colleagues. It's a model of communication. The syndromes described have acquired meaning well beyond communication. Diagnostic labels have been elevated from theoretical constructs into real phenomena. Major depression includes a cluster of symptoms that is shared by many people who are not depressed.

Wade Schuette expresses the apparent paradox of diagnosis as a prerequisite for treatment.

If depression is largely an internal phenomenon, caused by genetics and bad wiring in the brain, that leads to one type of intervention - drugs and CBT. If depression is largely a social phenomenon, related to the well-documented collapse in social interaction documented by Putnam and the group at Duke, then personal intervention will simply deal with symptoms, and result in an ever growing prevalence of drug-dependent victims of social dysfunction - precisely the observation we find about the USA today.

The truth is all of these viewpoints have merit. Major Depression can be conceptualized and described in many ways, none of which are sufficient to explain the phenomena without considering all other viewpoints. Diagnostic categories are scientific models for communication. They are not readily amenable to measurable criteria because the concepts are complex and largely abstract constructs that fit a theory.

Sadness is an abstract concept designed to communicate a common human experience associated with grief and loss. I believe sadness is an emotion that is a critical component of a productive grief process that helps us survive and adapt to major loss. Sadness is normal and healthy. Major Depression may include sadness, maybe associated with loss, but it is a clinical syndrome that includes significant functional impairment, a loss of survival skills. Sadness is an emotional motivation that ENHANCES survival.

The Journal of the American Medical Association [February 21, 2007--Vol 297, No. 7] published an important article on grief, Maciejewski et al (2007). While it's hardly definitive research, it represents an exciting trend in research that I've seen in recent years. Researchers seem more willing to take some risks with the rigor of their research models to produce information that is immediately relevant to practice. While, we are a long way from having clear guidance towards an evidenced-based practice in psychotherapy, testing models in active use in the field provides immediately useful information.

Grief is one of the most common issues that emerge in psychotherapy. Grief unfolds in a purposive and meaningful way from the first awareness of loss. The grief process guides us through the painful reassessment and renegotiation of our needs and goals. What that process entails appears to have not been researched empirically before Maciejewski et al (2007) made their ground breaking attempt. They did a great job of researching an abstract and difficult to define topic and made a meaningful attempt at measurement. They also managed to validate, for the most part, a widely held belief about grieving.

A four stage theory of grief was first discussed by Bowlby [Bowlby J. Processes of mourning. Int J Psychoanal.
1961;42:317-339.]: shock-numbness, yearning-searching, disorganization-despair, and reorganization. Kubler-Ross E. in her widely read book, On Death and Dying, adapted Bowlby's model into a 5 stage theory. Jacobs Pathologic Grief: Maladaptation to Loss asserted that a normal grief process is completed within 6 months following the loss of a loved one. He also postulated a five stage theory: numbness-disbelief, separation distress (yearning, anger, anxiety), depression-mourning, and recovery.

Maciejewski et al (2007) took an odd combination of Kubler-Ross's and Jacob's model as the hypothesis to be tested. The study interviewed only persons who experienced a death of a loved one that was from natural causes, not trauma. Here I think they made a good judgment that difference causes of death would complicate the experience of grief. The interview method was described as a "single item interview screening" which was not defined clearly. The researchers took a single item from the Inventory of Complicated Grief-Revised and used a five point rating scale and asked participants to rate their experience of grief on each stages: disbelief, yearning, anger, depression, and acceptance at some point between 1 and 6 months, 6 and 12 months, and 12 and 24 months post loss.

Ideally, all individuals would have been assessed immediately after the loss rather than beginning at month 1 post loss. Due to respect for the initial mourning period and institutional review board concerns about harm to participants, we did not interview individuals within a month of the death. In addition, it would have been better to analyze data that reassessed individuals each month from 0 to 24 months postloss. However, no such data exist nor does the stage theory specify in what month postloss each stage would predominate. And, although we acknowledge that other grief indicators might have been used, the various proxy measures (ege.g.stunned for disbelief, bitterness for anger, hopelessness for depression, quality of life scores for acceptance/recovery) all revealed remarkably similar patterns to those presented herein. We chose to present the items that fit most closely with the stage indicators illustrated in the literature.

The authors reported that they partially confirmed the Kubler-Ross/Jacob model. Click on the image to enlarge.

Reflected in their data, the authors found a surprisingly similar stepwise process of recovery at least partly confirming the stages, even the order by each each stage was addressed. "The odds of each of these indicators peaking in this exact sequence by chance is miniscule."

But they also found some inconsistencies. Acceptance and yearning were endorsed most frequently beginning from the first interview increasing through the 24 month period. Traditional grief stage theory postulates that people experience disbelief immediately following the death of a loved one and eventually arrive at acceptance. Given the researchers interview method of a single item, presumably presenting the measures without explanation by the interviewer, it seems likely there was little reason to think that what the participants were identifying as disbelief and acceptance were not consistent with the model. Elizabeth Kubler-Ross defined denial as a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. Acceptance was described as varying according to the person's situation, although broadly it is an indication that there is some emotional detachment and objectivity. It seems most likely, participants endorsed the scales in a socially acceptable way. "Of course I accept that he died." The disbelief or denial in my experience refers to an awareness of the duality of a cognitive awareness of the fact of death, but an emotional disbelief manifest in more subtle ways such as speaking of the deceased in present tense.

It's curious that the authors put so much into the order of the grief process, even though their two models don't agree on any one order. It even seems counter-intuitive that a human emotional process could be assumed to take on even an appearance of linearity. As in the example above, even the extreme ends of the process, acceptance and disbelief, overlap. The other inconsistency is about one of the clinical recommendations. The authors state that the study supports the theory that a six month duration of the grief process would be expected. Anything beyond six months may warrant a clinical assessment to determine if there was a complicated grief process in need of treatment. Their own data (see the figure above) suggests participants continued their grief process for nearly 18 months.

As a practicing clinician, it's hard to imagine either author intended to describe the stage theory as a linear step by step model. Also neither author suggested an appropriate length of time for grief. It has been often stated in my training that grief takes no particular length of time but is unique for each person and situation.

The final comment I have is about the use of the word "depression" in all the grief models. It appears to me that the general use of the word "depression" has been confused by the concept of clinical depression. A normal feeling has been confused with pathology. I'd like to see the word "sad" used in this context. Sadness is a normal part of grief. Normal grief may have some things in common with depression, but it is harmful to pathologize grief. Our culture has too much trouble with accepting intense negative feelings as "normal" and go to great self-destructive lengths to escape them. Sadness provides us with an intuitive guide to recovery if we listen closely and feel it fully.

Regardless of these comments, it's the kind of research I love to see. Anxiety Insights had a recent post on another great sounding article about grief.

There are two guarantees in every person's life: happiness and sadness. Although lost opportunities and mistaken expectations are often unpleasant to think and talk about, these experiences may impact personality development and overall happiness. A seven-year study conducted by Laura King, a University of Missouri researcher, indicates that individuals who take time to stop and think about their losses are more likely to mature and achieve a potentially more durable sense of happiness.

"People are generally in a hurry to be happy again, but they need to understand that it's okay to feel bad and to feel bad for a while," said King, who teaches psychology in the College of Arts and Science. "It's natural to want to feel happy right after a loss or regrettable experience, but those who can examine 'what might have been' and be mindfully present to their negative feelings, are more likely to mature through that loss and might also obtain a different kind of happiness."

Unfortunately, I can't get a free copy of this article for a year! It sure sounds like the authors made another attempted to unfold the process of grief. As with all emotions, there is a duality of process between the cognitive and emotional. The more we know about the emotional aspect, the more we can make sense of the emotion and apply it meaningfully our lives.

Here is a quote I've used before from a former psychiatrist blogger shrinkette on the process of grief. I think it illustrates well the emotional challenge of grieving and how difficult it is to put it into words.

You go on. You go on. You bring the person you love inside you. That is how you cope. You make him or her live within you. The whole experience I had with my children is in me. It is nowhere else I can see. I can see a photograph, I can feel sad, I can read a poem, but the experience of having them within myself is what matters.

Sometimes there is just nothing more to say.

Maciejewski, P.K., Zhang, B., Susan, B.D., Holly, P.G. (2007). An Empirical Examination of the Stage Theory of Grief The Journal of the American Medical Association, 297(7), 716-723.

From the outstanding site of Anxiety Insights, there is a summary of a recent research study that produces results questioning conventional wisdom about income, poverty and depression.

None of the socio-economic indicators studied was found to be significantly associated with an episode of common mental disorder at follow-up, after baseline psychiatric illness was taken into account. The analysis of separate diagnostic categories showed that subjective financial difficulties at baseline were independently associated with depression at follow-up in both groups.

In other words, it's the subjective experience of stress rather than the experience of poverty that predicts a higher rate of depression. That is consistent with my own clinical and life experiences. I teach my clients that we control our reactions to whatever happens to us. While, we also have a lot of input on our successes, mainly by the persistence and willingness to make adjustments and keep going, but there are other factors that effect the outcome that are beyond our control in whatever we do.

The period from high school graduation until the mid-twenties, or around the completion of college, has always been the highest risk period for developing mental illness of all kinds. A University of Florida Psychologist Jamie Funderburk recently reported that an estimated 53 percent of college students, representing perhaps 26,500 students at the University of Florida, will experience some form of depression. A report prepared by the University of Berkeley Academic Affairs Office for the Committee on Student Welfare cites a

[...]recent poll revealed that 85% of colleges and universities are seeing an increase in mental health problems on their campuses. [Berkeley's The Counseling and Psychological Services reports a] 300% increase in demand for psychiatric visits in recent years [as well as] greater acuity and severity of student problems. While in the past, students presented with relationship break-ups, identity concerns and difficulties with career decision-making, today students more often present with serious clinical depression, bipolar disorder, and psychosis, requiring emergency services and hospitalization.

Rates of suicide in America are highest for college-aged individuals; according to some estimates, suicide is the second leading cause of death for Americans aged 18-24. What is even more alarming is that, in the 2002-2003 academic year, there were at least six student suicides at UC Berkeley*. This is twice the national average for Americans in this age group.

Consumer John McManamy offers some perspective.

Since 1950, the suicide rate has more than doubled for college-age women and tripled for college-age men. According to three surveys reported in US News and World Report, 30 percent of US colleges experienced a suicide last year, 9.5 percent of students say they have seriously contemplated suicide, and 1.5 percent have made the attempt.

[...]American College Health Association survey report[s] that 76 percent of students felt "overwhelmed" while 22 percent were sometimes so depressed they could not function. The situation is borne out by a survey of counseling center directors, 85 percent who report an increase in severe psychological problems over the past five years. Students have grown up in an era of the disintegrating American family, [...] but they are also more used to therapy and are more likely to seek help. In the past, many kids with severe mental problems would never have made it to college, but today, thanks to new medications, they are potential clients of college counseling services.

Student depression is of particular concern. A National Mental Health Association survey reports that 10 percent of college students have been diagnosed with depression. According to Richard Kadison MD, chief of the Mental Health Service at Harvard, in an interview with Psychiatric News:

The lifetime incidence of depression is 20 percent, and the peak age of onset is around college age. So many students have their first incidence of depression while in college, and they are completely surprised by it. They think that it is just that they have become lazy or that they have a sleep problem.

Children are our future. The stress kids feel as they enter adulthood should concern us all. This is not just an American problem, the high incidence of suicide attempts during college age is evident world wide. Japan in particular reports a rate of suicide more than double that of the US in college students, triple that of South Korea. Suicides in Japan have been associated with pressure to succeed and failing grades.

A study in the British Journal of Psychiatry (2000, 177, 360-365) found that the most predictive risk factor for suicides was loss, be it loss of a person, material possession or health. The authors speculate what is lost is an "cherished idea" offering what might be a fruitful approach to intervening with someone who is suicidal.

The recently released "World Map of Happiness" offers circumstantial support to the concept of subjective interpretation of experiences is more closely related how one feels than the affluence of the individual. Unlikely countries like Brunei, Bhutan, Antigua and Barbuda, Malaysia and the Seychelles rank with higher subjective happiness than the US (23rd) with many more modern economies ranking relatively unhappy (35. Germany; 41. UK; 62. France; 90. Japan).

Truly to a large extent, seeing the glass as half full, rather than half empty, has a lot to do with how happy or depressed one feels.

shrinkette

You go on. You go on. You bring the person you love inside you. That is how you cope. You make him or her live within you. The whole experience I had with my children is in me. It is nowhere else I can see. I can see a photograph, I can feel sad, I can read a poem, but the experience of having them within myself is what matters.

Sometimes there is just nothing more to say.