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Dependency, attachment, and relationships

(Advice: “Just Ask Me”…Originally published on The Daily Muse)

Hi Fran,

I have been in individual therapy for a few years. I have been dealing with depression for four years, with a few seasons of “remission.”

I also have issues with loss and abandonment. I have also gone to group therapy and learned some tools for relating to others in a healthier way. Yet, it seems that depression sneaks up and overtakes me at times.

I pay cash for therapy, and I have had times when finances have caused me to go every two weeks, or sometimes three weeks or more between sessions. I have considered canceling therapy altogether a few times. Mostly due to finances, but also because I get so upset at the idea of not meeting for therapy that I think I am too dependent on my therapist. I have read a few articles that talk about the therapeutic relationship and unconditional positive regard, blah, blah, blah. My therapist reassures me that it is OK and that having someone hear me—someone to bear witness—is healing. I just wonder if I will ever not get teary at the idea of terminating therapy.

How long does dependency, neediness, attachment, whatever it is, last?

Truly,

Dependent

Dear Dependent,

How wonderful that you’ve allowed yourself to become attached to your therapist. Attachment (i.e., “loving”) is always a risk after loss, partly because when you love someone, you risk another loss. But aren’t our relationships and attachments what make us human, what sustain and drive us, what nurture us? In that sense, shouldn’t our relationships be long-lasting?

Your letter brings up many questions. First, you say you have “loss and abandonment issues.” You don’t say what these are, but certainly loss experienced in early childhood can be quite traumatic and can have lifetime consequences. These types of losses can interfere with the basic security needed to have confidence that others are there for us and we are there for them; that we “belong” in this world, that we are loved and can love.

A second question has to do not with your relationship with your therapist, but rather with your relationships with others in your life. You say you have been in group therapy and learned “tools to relate to others in a healthier way.” That is terrific, and I would encourage you to keep using them. In therapy, we also learn to observe our own behavior and reactions in the presence of someone who offers “unconditional positive regard,” as you say. I am amused by the “blah, blah, blah” that follows the phrase in your letter. It strikes me as a certain cynicism on your part about this very important aspect of therapy.

In real life, unconditional positive regard is very hard to come by, except perhaps with a parent. In therapy, we work out these issues in a place where the neediness and dependency created by our earlier life experiences don’t interfere with the relationship. In other words, a therapist will offer you unconditional positive regard no matter how dependent on her you are, whereas if you approach your other relationships with excessive neediness and dependency, it will interfere with the relationships. Think about that.

The hard part is moving beyond neediness and dependency on another person into relationships in which both people are mutually dependent on each other, while each knows how to cope with the reality that nothing really does last forever. As we mature, we aim to make friends, love and hold people close, enjoy what we have, and know that when and if there comes a time, we are whole enough to go on without them, too.

I would also like to comment on your therapist’s statement that it is healing just to have someone hear us and bear witness. I agree with that 150%. The Buddhists say: Compassion is willingness to be close to suffering. To simply listen to someone, to “be with” suffering, or to bear witness to it, is honestly the greatest gift we can give someone. A great deal of research has shown, and I have seen in my work with therapeutic writing, that just writing about trauma is healing, but more healing comes with having another person hear—bear witness to—what we have written.

I feel I would be remiss if I didn’t mention your depression. You don’t really say much about this, what you think its source is, or even what issues in your life it centers around, but I would encourage you to keep talking about your dependency and neediness with your therapist, as well as any other issues you have that seem related to your depression. At the same time, you might think about whether medication might help. You can discuss it with your therapist or and possibly consult a psychiatrist.

I think you’re doing fine, and quite honestly, given your loss and abandonment issues, I would be more concerned if you didn’t feel somewhat dependent on your therapist.

I wish you peace and happiness, along with many mutual, long-lasting relationships, and thanks for asking.

Fran

Advice: Am I in an Abusive Relationship?

 Just Ask Me, by Fran Dorf (Originally published on The Daily Muse.)

Dear Fran,

I’ve been dating a guy for almost two years, and lately we’ve been talking about living together, leading to marriage. We both have great jobs, love outdoor sports, and dogs (we each have one). He’s in finance, and I’m an account executive at an advertising agency. We seem perfectly matched, and I’m thrilled that we’re going to make a life together.

The problem? Last week we got into a fight about his older brother, who I can’t stand. My boyfriend wants him to be his best man and I can barely stand to be in the same room with the guy. He’s loud, uncouth, and I hate the way he talks to his wife. Anyway, I said some things I shouldn’t have said, and everything got heated and my boyfriend ended up pushing me against the wall. I hit my head, but I’m fine.

My best girlfriend says she thinks my boyfriend is “abusive,” even though he’s never touched me before. I do love him, but sometimes he can be stubborn, which drives me crazy, and I say things I know I shouldn’t say, which gets him upset, and that’s why he gets out of control. He apologized profusely, and the next day sent me beautiful long stemmed yellow roses.   

What should I do? I love him, but I really think I’m right—don’t I get to have a say in who will be the best man at my own wedding?

Upset

Dear Upset,

I’m sorry to have to rain on your parade, but I think you may be asking the wrong question. I understand that you love your boyfriend, but before you marry him or even consent to live with him, I suggest you get some serious couples counseling. In a way, I’m glad this pushing incident happened before you got married rather than after, because it gives you a chance to see if he’s so stubborn that he’s unwilling to address this very serious matter.

I have several reasons for saying this.

First, I agree with your girlfriend: Pushing someone—even one time—is abusive. What’s more, past behavior is a good indicator of future behavior, and unless he gets some help learning to deal more appropriately with his emotions, it’s likely that this abusive behavior will continue, and possibly even worsen.

Next, you say he “gets out of control,” as if it happens often. I suspect you mean that he becomes verbally abusive when he is frustrated or angry. It also sounds as if you do, too, since you admit you “say things you know you shouldn’t.”

One of the things you will learn (or should learn) through counseling is that “anger” is an internal state that everyone experiences. This is a different issue from aggressive behavior, which is a result of anger. Aggression is saying or doing things that hurt another person to try to control, humiliate, or get what you want. Frequent or intense bouts of anger, along with verbal, emotional, or physical abuse or aggression, need to be addressed in therapy, where you will not only discuss the root causes of this anger, you’ll learn some alternative behaviors to cope with it.

(As a side note: The fact that his brother is abusive to his own wife may mean that anger and frustration was handled this way in the household where they both grew up, and this is what was modeled for them. All the more reason that you should be addressing this in therapy.)

Now, it may make you feel better temporarily that he apologized. But unfortunately, that behavior is part of the cyclical four-stage process of domestic violence.

In Stage I, tension builds as the abuser becomes edgy and reacts in a more hostile or psychologically abusive way. Stage II is the explosion, represented in this case by pushing. And Stage III is the reconciliation, often called the “Honeymoon Stage,” in which the abuser becomes remorseful, sometimes overly so, apologizes for harming the victim, and assures her that it will never happen again. After the violence, it is very common for abusers to shower their victims with love and affection, buy expensive gifts, send flowers, and so on.

And finally, there could be the calm stage, in which the abuser really tries to control him or herself. But if he (or she) hasn’t learned coping skills and alternative methods to deal with anger and frustration, or faced the reasons and antecedents for the anger, conflicts will inevitably arise and the cycle will start all over again.

Look, it’s possible an incident like this will never happen again, and your boyfriend will be a model husband who never pushes or hurts you or gets out of control again. It’s possible, too, that you’ll be a model wife who never again says things she doesn’t mean. But my question is: Do you really want to take that chance? I am not saying you need to break up this man, but I am saying, again, that you need to deal with these very serious issues, and sooner rather than later.

As for your question about whether you have a right to a say in who the best man is at your wedding, I think it’s not a matter of whether something is universally right or wrong. In a healthy marriage, decisions are made based on mutual respect, compromise, and communication. You must be able to calmly discuss the conflicts that inevitably arise, and come to an agreement that works for both of you.

In this case, your boyfriend may learn in counseling that his brother’s behavior toward his wife is inappropriate. You may in fact actually need to say that to him, not because he can change his brother, but because you need him to know that you won’t put up with such behavior from him. Similarly, he needs to know that you’re going to make an effort to curtail your own inappropriate behavior. Maybe, once your husband sees how inappropriate some of his own behavior is, he may begin to agree with you about his brother.

On the other hand, it is his brother, and it may cause a lifelong rift in all of your relationships to take a stand on whether he should be your husband’s best man.

I wish you the best, and thanks for asking,

Fran

Read more: http://www.thedailymuse.com/health/am-i-in-an-abusive-relationship/#ixzz2KqKQwD5L
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Storytelling and Reading with the MouseMuse troupe: Join us

I had a beautiful experience doing writing to heal last night with a group of courageous and wonderful people. Now it’s on to storytelling on December 6… Six of us on the same theme, “Planes, Trains, and Automobiles” for 10 minutes: Fran Dorf, Tom Finn, Josh Kaplan, Chad Kinsman, Hugh Samuels, Rebecca Toon plus 3 brave volunteers.  While my story is on its face about a car crash a few years, what it’s really about surviving all my “tsuris.”  All my stories are about that.  Join me.

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                                                                    * * * * * *

And for this one on December 11th, I’m getting back on stage to read a few bits from my memoir: “How I Lost My Bellybutton and Other Naked Survival Stories.”  Also, of course, about surviving “tsuris.”  Can’t help it.  I’m the “tsuris” queen.  Thinking about reading a relatively serious bit about breast cancer called “Plastic Man,” and a lighter bit about my Grandma Rose, she of the vast bosom and orthopedic shoes.  I don’t know….is a bar the best place to read this? Well, whatever.  It seems Ina has adopted me.   14381_494841040550674_311216169_n

Compassion Roundup, Part I: Who cares if your surgeon is a jerk?

Huckabee at the Republican National Convention

A few weeks ago, Mike Huckabee, making a medical analogy about the alarmingly jerky Mitt Romney, told Howard Kurtz of the Daily Beast: ““The sicker the patient, the less important is bedside manner.  If you’ve just been diagnosed with a brain tumor, you honestly don’t care if your neurosurgeon is a jerk.”  Now I admit that Mike Huckabee is a personable, often funny, natural, and authentic guy, sort of the un-Romney, even though I disagree with him on nearly every political idea he ever expressed including this one.  I disagree with this one so much that it’s been stuck in my head for the last three weeks. Reason? My own personal experience with jerky doctors

Most commentators, including Gail Collins of the New York Times, commented on the weird “damning with faint praise” aspect of that quote, since presumably Huckabee meant to praise (if faintly) our Presidential candiate, who has proven himself even more jerky this week by among other things commenting on an ongoing violent international crisis before knowing the facts, and by suggesting that a statement put out by the American Embassy in Cairo condemning a hate film undermined American values.  Coming from a man who would be President in a highly dangerous, complicated, and non-black-and-white world, this was so misguided and jerky in so many ways that I can’t possibly mention them all in a blog in which I want to comment on Huckabee’s medical analogy.  So for the moment, I’ll simply wonder why Romney, or anyone, thinks it’s not an American value to ALWAYS condemn hate speech, counsel calm, tolerance and compassion, and support the forces of tolerance, understanding, and compassion in every situation and society.  To me this is among the highest of human values.  More about that in my next blog.

So back to Huckabee’s analogy. After endlessly fussing I’ve finally shipped off my memoir, “How I Lost My Bellybutton and Other Naked Survival Stories, to my adorable new literary agent.  While I’ve met many amazing and wonderful doctors during all my medical woes, the memoir details my experiences with some incredibly jerky doctors, including my late son Michael’s neurologist and the surgeon I call only “Plastic Man” whom I encountered during my breast cancer experience.  I think their jerkiness made them less rather than more skilled, that’s for sure.  I won’t talk about the neurologist here, but Plastic Man was jerky mainly because he lacked compassion, and I suffered mightily at his hands, not because he isn’t or wasn’t a skilled cutter. I assume he is, he certainly has a good reputation on that score. But bedside manner? The man was rude, stiff, abrupt, aloof, childish, petulant, and defensive, and became even more so when I developed an infection and became quite sick.  As I detail in my memoir, his jerkiness may have increased because he was afraid of being sued.  This doesn’t excuse it, of course, and in any case research shows that doctors who tend to the doctor/patient relationship lessen their risk of being sued. This makes perfect sense, of course, since people tend to give back what they receive.  The most important thing is, he made my situation even worse than it probably had to be, thereby affecting his skill not just as a cutter but as a physician, who after all should be a healer.  I say this not just because I was terrified and needed reassurance when I was so weak and sick and vulnerable, but because if that surgeon had LISTENED to me, his patient, as a good compassionate, non-jerky physician would do, he might well have been able to spare me all or at least some of that suffering, both mental AND physical.

So I say yes, I guess I’d prefer a jerky surgeon who’s a skilled cutter to a compassionate, non-jerky surgeon who isn’t a skilled cutter, but like almost all things in life it isn’t (or shouldn’t be) an either-or, black-and-white choice.  Why wouldn’t we want physicians—and politicians, and filmmakers, and everyone else–to think of having compassion for the weak (ie non jerkiness), as an important part of their skill and to be BOTH compassionate AND skilled?  As Gandhi and others have said, “The measure of a civilization is in how it treats its weakest and most vulnerable members.” Substitute the word “doctor” for “civilization” and “patient” for “member,” and I think you see how this applies to the medical situation on which Huckabee is commenting, in my view utterly incorrectly.

So here’s a survival tip I learned the hard way.  I put it in my (hopefully soon-to-be published) memoir, “How I Lost My Bellybutton, And Other Naked Survival Stories”:

Survival Tip #17:  Compassion and empathy aren’t luxuries for a doctor, they’re prerequisites. Especially if things go wrong or you’re really suffering and really need compassion and empathy. So if you have a choice, find one who has some.

Mr. Huckabee, I know your analogy was meant to suggest that Mr. Romney has the skill to fix the economy, thereby lifting all weak boats in the trickle-down sense, but I think that the weaker and more vulnerable the patient (or the citizen, for that matter), the more I need and want to be tended to with compassion rather than jerkiness.

Creativity and Healing: Let The Little One Inside You Sing

Physicians, medical students, psychologists, poets, and other helpers, healers, and writers interested in the healing power of writing hugging a giant Cypress tree at the “Healing Art of Writing” conference in San Rafael, California, July 18, 2012. The guy in the light print green shirt looking away is the gifted John Fox, author of one of my favorite books on this subject, “Poetic Medicine.”

Why do we feel so satisfied when we engage our creativity?    Why is singing, writing a play, cooking a wonderful meal, designing a building or outfit, composing a song or sonata, capturing a particular moment in a photograph, or coming up with a new idea, method, or a way of looking at things in the brainstorming session at work so fulfilling?  Why does using our imagination feel so wonderful? Why does making the metaphor that perfectly describes something by comparing it to something else feel so gratifying?  Why do people make art anyway?  Why do people write?

A man is struggling to go on after losing someone he loves.  A beloved wife.  I ask him to try a simple writing exercise, and he runs with it.  He is not a “poet,” but he produces poetry, beautiful and true.  He has turned pain into beauty, and he finds the process satisfying, cathartic, healing.

Or take my own experience.  I was already a writer when I lost my son in 1994, and yet afterward I simply refused to write for a number of years.  I refused because writing was what I did before, and that life seemed over.  But the problem was I was cutting off my most available path to self-healing: my writing, my own creativity.   It was only out of sheer desperation that I began writing again three years later.  It turned out that the process of writing (my novel, Saving Elijah) was the very thing that helped me free myself from the prison and the merciless solitude of my sorrow.  Writing that book saved my life.  Everything I write now contributes in some way to my own self-healing process.

And it isn’t the applause we might crave at the end of our creative process that drives us, or that heals us.  It’s the process itself.  A writing mentor of mine always says, “Writing is a process, not an event.” This is, of course, true of all creative acts.  If you’re worrying about how what you’re doing will be received, your desire for acclaim, or your fear of rejection, you simply aren’t in the process.

I was recently honored and thrilled to be a part of an extraordinary gathering in San Rafael, California called The Healing Art of Writing.  The conference drew physicians, medical students,  psychologists, social workers, poets, a musician or two, and other helpers, healers, artists, and writers interested in the healing power of creative expression, in this case writing.  Just being in the presence of so many people accessing their own creativity or learning to facilitate creativity in others to heal was incredibly moving and healing.

Why is the creative process so healing?  I’m convinced that when we engage in creative expression–through writing, art, coming up with that new idea, or in whatever way we can–we feel healed because we have moved back into or toward our original state of creative bliss, a state from which we gradually separated in response to the reality of life and the demands of a sometimes harsh world.

Consider my grand daughter.  She’s two, and her creative spirit is still completely pure.   Every moment of every day she is deep into her own creative process, she lives in a wellspring of pure joy at her own imagination and creativity. When she walks down the street, she doesn’t just walk, she claps, dances, or skips, and she sings or tells herself a story at the top of her little lungs.  Her song might be one she’s making up or one my daughter taught her, and her story might be about the moon and stars, or Elmo, or a purple cow.  She doesn’t care that cows are black and white, in her mind and creative imagination they can also be purple. Everyone on the street smiles, as if to acknowledge how adorable she is, maybe to share in the knowledge that children are such creative little souls who unlike the rest of us can live so in the moment, so in the creative process, unconcerned with outcome.  Watch my granddaughter now as she becomes angry and has a tantrum when you tell her to do something other than the incredibly creative thing she is doing at this very moment.  She doesn’t care that you might be trying to save her life when you insist she stop clapping and hold your hand because you’re going to cross the busy street. All she knows is that you’ve interrupted her creative process, her joyous in-the-moment creativity.

You can see the effect this kind of interruption has as a child gets older.  Few ten or fourteen-year-olds would skip and dance down the street singing at the top of their lungs, for fear of the outcome, the rejection.

A loving, nurturing, encouraging environment in childhood supports a person’s ability to appropriately access his or her own creativity as a source of self-healing. I always feel so sad when I sit with people who were subjected to a non-nurturing, restrictive, neglectful, abusive, traumatic, or rigid environment that stifled their once-brilliant creativity, and even made them lose their ability to connect back to it as a way of self-healing. Some are virtually paralyzed by self-condemnation, just as I was after my son died.  Some cannot even begin imagine their lives differently.  They continue to think the condemning thoughts and feel the hurtful feelings others have foisted upon them, a process that destroys rather than creates.

So remember that no matter what field you’re in, or where you are in your life, or what trauma you’ve experienced, you always have the power to connect to your original state of creative bliss, and even use the process of creating as a way of self-healing  That little child is still in there, singing blissfully at the top of her lungs.  All you have to do is find her.

Next post: Ways to find her.

Just Ask Me – She’s Pregnant, He Wants to Move–She Doesn’t

Originally published on The Daily Muse

Fran!

I really need some advice. I met my fiancé about two years ago and we got engaged on New Year’s Eve. I’m also eight months pregnant. Even though everything has been going so fast in our relationship and my life, I’m happy as can be.

We live in western Maryland, close to my family, and his family lives in southern Maryland, but he wants to move to Florida when our lease is up in December. He feels we would have a good life and more opportunities for our growing family. We have talked about moving, and I really want to, but I didn’t expect to move away so soon. I’d prefer to stay around here a little longer with my family, especially with my newborn.

I’m only 22 and he’s 24, and I’m just scared. I’ve tried explaining it and he doesn’t see what the big deal is. He said we will visit all the time, but I don’t see that happening. I don’t know what to say or do and I don’t want to fight about it. I just don’t think I’m ready to move! 

From,

Stressed and Scared

Dear Stressed and Scared,

Congratulations! This is a very exciting time for you, but, I’d also say it’s appropriate to be a little scared and stressed.

I’m not sure what to assume about the job situation if you’re giving birth next month, and your fiancé wants to pack you and the baby up and move to Florida because there are “more opportunities there.” Does that mean that neither of you have a job right now, and he thinks he—or both of you—will be able to get jobs there, rather than where you are?

This is a key issue, because when the baby comes—wherever you live—someone is going to have to take care of him or her. So first, you have to decide mutually who’s going to do that. If you both have jobs now, are you planning to quit? Is he? Have you discussed this? One benefit to staying where you are is that your families might be able to help with the care of the baby.

Next, it worries me that you say you don’t want to “fight” about this. Does that mean that you don’t think you have the right to express your opinion or concerns? Or that you’ve tried in the past to express yourself, about this or other matters, and found that it always turns into a fight? Does he always dismiss your concerns as “no big deal?” Have you gotten into a pattern of swallowing your feelings about important matters like this just because you don’t want to “fight?”

The truth is, conflict in a marriage is going to occur. A mature, healthy, lasting relationship requires negotiation, mutual respect, and compromise, and there is no need to fear fighting if you learn, practice, and implement fighting “fair.”

I think it’s important that you and your fiancé sit down and really sort this out. Here are some basic “fighting fairly” rules to review before you begin:

1. Be Honest With Yourself

It is essential that you understand your own feelings before you can begin to resolve any conflict. Many women are stressed and scared when they’re pregnant, and adding a move (particularly one away from family) to that is understandably overwhelming. Be honest with your fiancé when you confess your struggles, pain, and insecurities. Let him know what you’re going through so he can have the opportunity to support you.

2. Speak Quietly

No yelling. When you yell, your partner only hears you yelling, not the content of what you’re saying. This doesn’t mean that you can’t express your opinion passionately, but remember that the louder your words, the less you’ll be heard.

3. Discuss the Issue, Not Each Other

Name-calling, character assassination, cursing, insults, threats, or accusations—even as a so-called “joke”—are strictly forbidden. Stay on-topic and remember that your goal is to reach a solution to the issue at hand.

4. Use “I” Statements

Rather than saying “You always…” or “You never…” stick with something like, “I fear that if we move to Florida, such-and-such will happen,” instead. Remember that you are the expert on how you feel and he is the expert on how he feels. Neither of you should be dismissive of the other.

5. Listen Carefully

When one of you speaks, the other should focus on really listening, not just planning a rebuttal. Remind yourself not to interrupt while the other person is speaking. You might even try the “mirroring” technique and each of you try to repeat what the other says verbatim to be certain that you are hearing each other.

6. Keep it Private

Don’t bring up your parents’ or friend’s opinions, or ask for his friend’s and family’s thoughts. The two of you are the ones who are in this relationship and parents to this child. It’s important that the two of you bind together and unite. Auntie Em’s dislike of Florida is irrelevant when it comes to what’s best for your new, and growing, family.

7. Take Timeouts, if Necessary

If either of you finds you’re raising your voice or getting angry, walk away, take some deep breaths and calm things down. This is a serious discussion, and it’s going to get passionate. But you need to take steps to ensure that you’re not getting overly amped up and losing sight of the matter, or impeding your own ability to discuss it civilly.

8. Look at Each Other

Keep the setting for this conversation casual and comfortable. Make it so you can really engage each other. Look your fiancé in the eyes when you talk, and do the same when you’re listening. Hold hands and stay physically connected.

9. Fight for a Solution, Not to Win 

This is important. In the end, you don’t need to win the argument or be right. You need to come up with an answer that’s going to be the best thing for you, your soon-to-be husband, and your baby. If the word “fight” comes to mind, think about it as fighting for your family.

As you start to hash things out this way, you may find some sort of a compromise beginning to take shape. Perhaps your fiancé will agree to put off the move for a while and you can revisit the discussion after the baby comes. Maybe he will agree to have a job lined up before you move. Truth be told, after your fiancé sees how stressful and exhausting it is to take care of a newborn—the sleepless nights, the constant attention, the strain it puts on a relationship—he may be more amenable to staying put for a while, rather than adding more stress with a move into the unknown right away.

And, I do think you’re right that it’s unrealistic to think that you’ll be making a lot of visits to your families in Maryland after you move to Florida. And so as a final note, I would add to my list of things a mature relationship requires are realistic solutions to problems, not wishful thinking or denial of reality. I’m not sure what to tell you to do if your fiancé continues to refuse to hear your point of view and insist it’s no big deal.

Whatever solution you come up with to the current disagreement, I wish you the best of luck. And for the moment, congratulations. Cherish that wonderful bundle of joy!

Fran


Offending the bereaved: Thoughts on the controversy around the upcoming DSM V proposed “grief guidelines”

Michael Max Dorf, a month or so before.

Who would have ever thought there could be a controversy around grief?

In the last few months, in my other (non-writing) life as a therapist, I have heard the devastating stories of several people seriously traumatized by their past contacts with the mental health system, people with a lasting legacy of pain from being (probably wrongly) prescribed powerful psychiatric drugs or placed against their will on a terrifying psych ward. I’m definitely not a conspiracy theorist, one who says things like “everything happens for a reason,” or assigns existential “meaning” to every happening, and so I’m sure it’s pure coincidence that I’ve heard so many stories like this lately. I obviously recognize that many dedicated people in the field are doing work that manages to be both life-saving and compassionate, yet these awful stories also underscore the need for folks setting the parameters in the field–the task force considering changes in the upcoming edition of the “bible” for clinicians, the Diagnostic and Statistical Manual (so-called “DSM V) to the various “diagnoses” around grief–to at least try to get it right.  It seems to me that those of us working in the field who are honored every day to do this work, to witness people’s deepest pain, have a duty to at least speak out when it appears that a grave and possibly for some folks dangerous injustice is being contemplated.

Partly because of the experience I mention above, and partly as a response to a wonderful “Open Letter to to the DSM Task Force” posted by Dr. Joanne Cacciatore on her own website (which I’m linking to here) , I’d like to add my own voice to all those professionals and offended bereaved people weighing in on this disturbing and upsetting controversy.

As readers of this blog surely know, I too lost lost a child, my son, Michael, who died in 1994, and I’ve been living with, and thinking, studying, and writing about grief ever since. (Let me assure the reader that I’ve also done lots of other things, including recover my sense of humor.)  My writing inspired by this includes a highly acclaimed novel, “Saving Elijah,”  published by Putnam in June, 2000.  After that I (eventually) went back to grad school to get a second masters degree in social work, mostly in order to work with the bereaved, even though I already knew from experience what one bereaved human being needs from another human being.  More recently I’ve been working on a kind of memoir, which I’m calling, “Excerpts: Complicated Grief.”  Included in the memoir is a recounting of the day I first heard in grad school that we were to label grief that lasts longer than two months (now according to all accounts of the upcoming DSM V apparently further reduced to two weeks) as pathology, call it “complicated,” call it a “disorder.”  Even twelve years after my son’s death, this felt like an accusation.  How could it not?  How could they not see that this is damaging to the very people it purports to “help?” It was as if feeling the terrible sorrow I had felt, sometimes even still felt (still sometimes feel now), wasn’t “normal.” Yet I knew full well that it was “normal,” both from my own experience and from talking to scores, even hundreds of other bereaved parents.

I’ve written the memoir in the second person, and it moves backward from the present to the day of the loss, in an attempt to show how grief can (while still being “normal”) reverberate throughout every corridor of a life, sometimes louder, sometimes softer, sometimes as a source of wisdom, sometimes as source of pain or anxiety, but always present.

It opens on what would have been my son’s 21st birthday.

October 22, 2011, seventeen years after. Stand at the dryer, slap in wet clothes, try to form an image of a strapping young man turning twenty-one today.  See only a sturdy toddler.   Like a failed magic trick.

Go to the cemetery, brush away leaves, place stones on the brass and marble marker. Stand in the thick, humid air.  Say Kaddish,  forget the last part.  Try to remember Michael but conjure up only bones in a tomb, shreds of boy and turtle, earthworms, fecund soil.  Say the word fecund aloud, the hard k sound rattling the teeth. Remember your husband falling into the grave. Wonder why you  come.  Get back into your car pursing your lips as if tasting something moldy. Think of old metaphors, new similes. Grief always comes alone to a child’s grave. Grief is no longer a thundering, hissing monster.  Grief is hollow now, like the blunt thud of rock on stone…….

The core problem comes in my view from the pathologizing of the normal human emotion of grief by calling it any kind of a disorder. And so whether you call it an “adjustment disorder related to bereavement,” and give it one year before you dial it up into an even more serious “disorder,” or whether it becomes “major depressive disorder” at two months, or at two weeks, seems to me secondary to the fact that it is called a disorder in the first place.

A child’s death?   At two weeks you’re still in shock. You’re just getting started at two months. Maybe. Actually, it seems to me that it would actually be “abnormal” for a parent who lost a child to not feel overwhelmed and debilitated by sorrow (and to experience many of the attendant symptoms that echo but are not the same as those for depression) at two months out, let alone two weeks out. I would venture to say this is probably true even at one year.  I remember visiting a friend of my mother’s who at age 100 was still talking about her fifteen-year-old son’s death in a car accident fifty years before as if it had happened that day. Personally, I would still call hers “normal” grief. And so the learned people figuring out the DSM seem to have had it backwards all along, and now seem to be doubling down on having it backwards.

I certainly agree that what people who have suffered loss need is (as Dr. Joanne says), human connection, caring, and compassion, or as the Lancet said: Time, Compassion, Remembrance, Empathy.  I believe it’s an insult to think that a pill could be any kind of substitute for that. I remember a good, well meaning friend wanted me to take medication, but even though I was suffering mightily, walking around in my bathrobe (not only figuratively) for three years, I somehow knew that it would do no good at all to try and mask the symptoms, because a certain amount of tears needed to be shed.  Luckily no clinician suggested medication.  I’m not sure what I would have done, given my state of mind, if one had.  The idea that we can “medicate” away the pain of grief isn’t about the bereaved, it’s about those who are uncomfortable with being witness to pain. As Rumi says,

We are pain and what cures pain, both. We are the sweet cold water and the jar that pours. I want to hold you close like a lute, so that we can cry out with loving. Would you rather throw stones at a mirror? I am your mirror and here are the stones.

In other words, the healing from the pain is in the pain.  So it is.

My favorite definition of compassion is the Buddhist one: “Willingness to be close to suffering.”  That’s what I do, what all of us who want to help do, we open our hearts to someone’s suffering.  We witness.  We don’t try to fix it.   I always say: Be present. Be humble. Be patient. Observe. Reflect. Allow silence. Don’t judge. Accept. Listen

It seems to me that this isn’t only about the pharmaceutical industry, it’s even more about the insurance industry, which seems to be in the business of not paying for whatever it can possibly get out of. (And not just in the area of grief.)  In this case the insurance industry seems to want to get out of any paying for anything other than that which has medication as the first line of treatment, and which labels grief a “mental illness,” or a “disorder” of some kind (an outcome that can stay in a person’s record forever, with terrible, terrible consequences).

It’s a sickening conundrum, it puts people who want to provide support for the bereaved who seek it in a terrible position, and of course it puts the bereaved in an even worse position.  Aren’t we trying to help them?  Surely we are. And one of the things we must do to help them is “normalize” what they’re feeling.  Yes, I wailed at the top of my lungs in a hospital room, but so would you.

As clinicians, we have the “V” bereavement code, but insurance generally doesn’t pay for treatment if you use this as a diagnosis. To receive payment from insurance, it has to be a “disorder.” And so to get insurance to cover our effort to help people make their way through grief, we are actually forced to call it some kind of disorder, even when we know it isn’t.  (This is, by the way, actually true for many situations, for example anger management.  Insurance won’t pay for people looking for help with “anger issues” unless you slap on a some kind of a “disorder” label.

Some, no doubt, will think I’m a hopeless idealist, or a radical left winger for believing that Americans, the “richest” country on earth, ought to provide universal health care that enables people to get the health care they need, no matter what their financial or job situation.  I don’t care.  I still must speak the truth as I see it.  And there simply ought to not only be health care for all, there should be some other terminology that acknowledges the debilitating nature of what I’ve called “big time grief,” and also provides coverage for people to get the proper, compassionate psychological support they need in difficult times.

All of us can be hopeful that the outcry from the grief community around this issue will, like the outcry to de-pathologize homosexuality in the 1970s, result in a de-pathologization of grief.  From a practical standpoint, under our current disaster of a health insurance system, we are required to diagnose some kind of “disorder” or there is no insurance coverage for clinical services.  In the absence of a complete rethinking of the whole system (oh, for such an outcome!; let’s just hope the misguided politicians won’t succeed in their threat to repeal the so-called “Obamacare” coverage for everyone), we can only hope that whatever happens, good clinicians (and particularly psychiatrists with their ready-meds) recognize that the DSM is at best an imperfect guide, and can tell the difference between grief and either adjustment “disorder,” or major depressive “disorder,” whatever must be recorded as a diagnosis to get coverage.

I invite you to share your grief story as a comment.