Bill Long 7/2/05
The Promise and Limitations of a Medical Model
In the June 1, 2005 issue of the Journal of the American Medical Association, Dr. Karen Shear (Department of Psychiatry, Univ. of Pittsburgh School of Medicine) and others provide the results of the first randomized controlled trial of therapy targeting symptoms of what they (and many psychiatrists in the past decade) call "complicated grief." Differentiated both from major depressive disorder (MDD) and post-traumatic stress syndrome (PSTD) by its focus on: (1) a continuing and persistent sense of disbelief regarding a loved one's death; (2) anger and bitterness over the death; (3) preoccupation with thoughts of the loved one; and (4) recurrent pangs of painful emotions, including intense yearning for the loved one, Complicated Grief is both struggling for professional recognition (i.e., in the future DSM-V) and clear enough to many professionals so as to merit a specific therapy to deal with it.
Over the course of three years (2001-2004) nearly 100 people who scored high on the "Inventory of Complicated Grief," were divided into two groups--one which was treated in 16 sessions with standard (grief-focused) interpersonal psychotheraphy (IPT) and one which was treated in a similar number of sessions with a new regimen for complicated grief. In the words of Dr. Shear,
This model posits that grief proceeds optimally when attention to loss and restoration alternate, while coping with both processes proceeds more or less in concert...In contradistinction to IPT, however, traumalike symptoms were addressed using procedures for retelling the story of the death and exercises entailing confrontation with avoided stiuations.."
Thus, the heart of this new method is the retelling or re-experiencing of the death of the loved one. Especially important were exercises that would try to "promote a sense of connection to the deceased." The therapist would record this story and then give the tape to the patient, who would be told to listen to the tape at home during the week. At the end of the therapeutic sessions, those who were treated with what we might call the "complicated grief therapy" showed a measurable, though not stunning, improvement, as measured by a series of wellness scales that I am not competent to evaluate. This improvement exceeded the improvement rates of those treated only with IPT.
The preliminary results of this first clinical study might indicate two things: (1) that there is, in fact, such a thing as complicated grief--grief that persists and continues to "stab" a person long after the death that provoked the grief--but (2) that the therapy pursued in this trial only included one of several (as yet undiscovered) elements that might help a person "improve." But it is a first step only; the authors are aware of several methodological and practical limitations to the study (such as the fact that nearly half of the sample was on psychotropic medications during the study or that some kinds of losses, such as violent death or loss of a child, seemed almost resistent to treatment).
Reflections on Deep (i.e., Complicated) Grief
Anyone who has dealt in a pastoral or clinical relationship with people over the years knows that there is a grief that lasts for a short time but there is also an elusive, intrusive, debilitating, numbing, deadening grief that seems to ebb and flow and never really go away. While the study focuses on grief as a result of losing a loved one, I would like to suggest that what they call "complicated" grief and what I call "deep" grief is not only not confined to those who have lost a loved one, but can be triggered by divorce, a sense of professional failure, or, even more arrestingly, a loss of faith in God.
What do you do with a person who cannot get over the persistent sense of personal failure, with the person who has been shocked by the cruelty of the world into a loss of faith in a good God, with a person who never has been able to put her life together after a divorce? These losses can be as pronounced and powerful as the loss of a loved one. Instead of simply a "talking" therapy, derived from one's personal story, I would suggest that a therapy based on a multi-part study of the Book of Job will not only get a person talking, but will help them understand the contours and potential for healing of their griefs.
The Book of Job and Complicated Grief
The Book of Job helps the therapist dealing with complicated/deep grief in at least three ways. First, it can help the patient focus on another's loss. Though the complicated grief model, at this point, has the person only recount his or her own trauma, the Book of Job will enable a person to tell his/her story in the context of another's loss. When we study and teach Job's loss in chs 1-2, it has a remarkable ability not only for people who have suffered to understand the contours of Job's pain and the feelings attendant upon his loss, but also to clarify the nature of their own grief. Skillful retelling and questioning of the Job story can even energize those who are most numbed by grief.
Second, the Book of Job helps people understand the deep emotions of grief. When Job begins to tell of his anguish in ch. 3, he goes through several emotions in excruciatingly wrenching images of assault, shattering, oppression and hopelessness. By studying these speeches of Job, people not only hear a person who suffered extreme loss narrate his grief, but they begin to see how these losses might "stack up" against theirs. The text of Job empowers those who are deeply burrowed in their loss.
Third, the Book of Job gives a realistic portrait on the mechanism that might lead to a person's restoration. This comes through the often-overlooked speech of Elihu in Job 32-37 and frequently-studied words of God in 38-41. The words of Elihu portray someone who actually hears Job, and the words of God challenge Job to conceptualize his grief and world in different terms than previously. Together these words challenge the therapist to be an active participant in the interpretation of the patient's grief.
There is a lot of money to be pulled down by researchers who want to use a medical model. Drug companies stand poised to fund these efforts, for example. There is no money available for those who want to teach the Book of Job to those suffering deep grief. Yet, the Book of Job can fire the imagination of both sufferer and therapist, and heal the soul of those long gripped by the enervating power of grief.
Copyright © 2004-2009 William R. Long