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.

A couple months back The Frontal Cortex had an interesting article about the seemingly contradictory nature of humans. The author is a neuroscientist and so has more than an average faith in the scientific method.

1. Jeff Lewis, the incredibly entertaining lunatic at the center of Flipping Out, the real-estate reality television show on Bravo, fires his psychic because she wasn't doing a good job of predicting the future. So what does he do? He goes and hires a different psychic. I'm fascinated by this thought process. On the one hand, Jeff's empirical enough to realize that his psychic sucked. But he never even flirts with the possibility that all psychics suck. I know that we all have our rational blind spots, but rarely are they so elegantly captured on television.

2. I've recently been spending some time, perhaps too much time, with a few professional poker players. In general, these guys are mathematical freaks, able to crunch complicated probabilities in a split second. They tend to look at card hands like an insurance agent looks at a customer: no sentiment, just cruel cold statistics. Bayes would be proud.

And yet, I've never encountered a more superstitious bunch of individuals. (A common quip on the pro circuit is that "It's unlucky to be superstitious".) These guys have more nonsensical habits than Martin Luther. The best story I heard was that Jamie Gold, the 2006 winner of the WSOP, ordered scrambled eggs for breakfast everyday during the tournament even though he's allergic to eggs. But Gold was convinced that eggs made him lucky.

What's the moral? The mind has an astonishing capacity for contradiction. We can be good Bayesians and superstitious at the same time. That reminds me of a story a neuroscientist recently told me, about the addicted gambler who refused to give up his health insurance. The guy was flat out broke - and clearly loved engaging in risky games while inside the casino - but refused to tolerate the risk of a high-deductible. We sure are a funny species.

I suspect the author was quietly noting his own inconsistencies without blogging about them. Actually, humans aren't really inconsistent at all. The problem the author and frankly most of the world has is the assumption that humans are capable of consistent rational thought and objectivity. The fact is, we are not. Not everyone is anxious to embrace this fact due to the required humility. Many people base their sense of security on their perception of consistency in life and a convenient adjustment of objective thought to accommodate the inconvenient details.

From Wikipedia:

The theory of cognitive dissonance states that contradicting cognitions serve as a driving force that compels the mind to acquire or invent new thoughts or beliefs, or to modify existing beliefs, so as to reduce the amount of dissonance (conflict) between cognitions. Experiments have attempted to quantify this hypothetical drive. Some of these have examined how beliefs often change to match behavior when beliefs and behavior are in conflict.

What mediates this process is largely emotional. But you will note that in this article, there is very little reference to emotions. In fact, one alternate theory that seeks to improve on cognitive dissonance is based on the assumption that we as humans have no access to our attitudes and must infer them from our perceived behavior. Later in the article it's noted that theorists have managed to insert "arousal" into the theory and have found some experimental evidence of it. Of course, "arousal" is a reference, albeit oblique, to emotion.

There are two separate networks in the brain, one a bit closer to rational to which we have ready access and the other, largely emotional, with which we have less direct access.

World of Psychology

... the brain consists of two different networks, rather than physical regions. In children, these networks act as one. In adolescence, they begin to separate from one another. And as adults, they are completely separated, resulting in adults' ability to focus on long-term goals while denying short-term gains (something children often have difficulty doing).

The childhood brain merges emotion and thought. The child can't differentiate impulses from complex concepts that might teach delay of gratification. This more primitive network of the brain remains in adulthood, including emotion and intuition. In between the cognitive and emotional networks, there is a complex regulatory system that functions akin to cognitive dissonance that keeps us from feeling totally irrational or crazy. Since emotions and thought often conflict, there has to be some "reasonable" way to handle these contradictions. Otherwise, we might lose confidence in our judgments.

One example of the more primitive brain functions that remain in adulthood is a recognition heuristic.

It's a kind of algorithm for the brain's neural network, a simple, fast formula for a particular kind of decision making.

That seems like a nice definition of at least part of what we call intuition. In a way, the contradictions in our lives might be a "heuristic" way of hedging our bets, playing all possibilities to feel more confident in an unclear situation. After all, when do we ever have all the information we need to make any decision? What can it hurt if we hedge our bets? In fact, we might actually, on occasion, increase the odds of succeeding if we do.

It's fair to say, that one of the challenges of maturing into adulthood is to master our emotional side while retaining it's intuitive value. This maybe described as a coordinated set of recognition heuristics and intuitive "rules of thumb".

The violence goes on and on. Eight innocents were killed by a lone 19 year old gunman people have called "quiet and polite". Clearly there is much more to this story. But here is what there is so far. Robert Hawkins was deeply into drugs, at least marijuana, and alcohol. Although he had one felony for drug possession, his other criminal behavior was limited to misdemeanors.

Quiet and polite behavior can hide incredible violent anger. Many of the imfamous postal workers that shot up their work place also were described as quiet and polite. Children who are abused are often unusually quiet and polite.

Hawkins had been a ward of the state of Nebraska from 2002 to 2006 but had not been associated with violence. The state provided Mr. Hawkins with stays at residential centers and in-patient facilities and also at a hospital. The facilities provided him with addiction counseling and mental-health counseling, among other services. One of the treatment periods came after Mr. Hawkins had threatened to kill his stepmother.He was due for a court hearing in two weeks after the shooting for minor alcohol consumption.

Hawkins obtained the AK-47-style semi-automatic weapon by stealing it from his stepfather. He had twice as much ammunition than he used.

Hawkins had a history of depression but was not on any medication recently. He broke up with his longtime girlfriend about two weeks ago and had just been fired from his job.

A sixteen year old female friend of Hawkins came forward after receiving a death threat from another friend of Hawkins after she told others what a horrible situation it was and "how bad Robbie was on a MySpace". The sixteen-year-old girl used to hang out with Hawkins and his friends. "They're all drug addicts, they have plenty of guns and they're all weird," says the girl. They would hang out in a home the girl's father calls a flophouse for drug addicts. Both adults and teenagers used drugs and alcohol in this house. Hawkins and his friends were alleged to be dealing drugs at one of the Sarpy County high schools.

After hearing their story, Bellevue Police arrested one of Hawkins' friends. Seventeen-year-old David Horvath of Bellevue was taken into custody for making terroristic threats. Police confiscated three guns from his home, two shotguns and a rifle. Police say Horvath described Hawkins as his best friend. There is no evidence to suggest Horvath had any prior knowledge of Hawkins' plans.

Omaha Police are now checking evidence collected at Hawkins' home including computers and any information that may be out on the Web. Another friend of Hawkins' parents took him in after he was kicked out of his family's house.

"He was depressed and he had always been depressed," Maruca said Wednesday. "But he looked like he was getting better." Hawkins, who earned a GED after dropping out of Papillion-La Vista High School, got a driver's license after moving in with the Marucas and five months ago started working at a McDonald's near their home. Maruca said Hawkins was not on any medication for mental illness, but that he had been treated in the past for depression and attention deficit disorder/hyperactivity disorder. Though he had his troubles, Maruca said Hawkins was gentle and loved animals. But he also had a drinking problem and would occasionally smoke marijuana in his bedroom. She said Hawkins liked to listen to music and play video games, "normal teenager stuff." "He was a very helpful young man, but he was quiet," Maruca said. "He didn't cause a lot of trouble. He tried to help out all the time. He was very thankful for everything. He wasn't a violent person at all."

Maruca said Hawkins had lived with several friends for a couple days at a time before landing at the Maruca's house last year. "He was like a lost pound puppy that nobody wanted," she said. "I felt sorry for him. I let him stay and we tried to get him on his feet." Maruca said Hawkins phoned her about 1 p.m. on Wednesday, telling her that he had left a note for her in his bedroom. She tried to get him to explain, but he hung up. She called Hawkins' mother, whom Maruca knows only as "Molly." She went to the Marucas' house, retrieved the suicide note and took it to authorities. In the note, Maruca said Hawkins said, "how sorry he was for everything." He wrote that he loved his mom and dad and other family members and said he wasn't "going to be a burden anymore." He ended the note saying that now he would be famous.

Mental Health America has released a list of advice for holiday shoppers in view of the tradegies in Omaha.

Reuters

Mental Health America developed tips to help individuals ease anxieties they may feel in the wake of this tragedy. Individuals looking for information and support can visit www.mentalhealthamerica.net or call Mental Health America at (800) 969-6642.

• Know that tragedies, like mall shootings, are rare. -- Develop a personal safety plan to ensure your wellbeing in a similar situation.
• Limit television viewing. Watching or reading news about the event over and over again will increase your stress.
• Talk about it. By communicating with others about the event, you can relieve stress and realize that others share your feelings.
• If you feel depressed, anxious or angry, talk to friends, family, ministers or others around you. Likely, other people are experiencing similar feelings.
• Ask for help when you need it. If your feelings of anxiety and worry do not subside or become so intense that they interfere with your daily life, don't try to cope alone. Talk with a mental health professional, spiritual adviser or other person who can help. Seeking help is not a sign of weakness.