Childless at 52: How sweet it would be to be called Dad

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childless, Children, disconnection, family, Grief, loss, men, regret, women

Childless at 52: How sweet it would be to be called Dad

A few years ago, I was visiting a friend who has two daughters, a newborn and a two-year-old. Reflecting on his experience of being a father he said that he felt he loved them so much he could “take a bullet for them”. I wept all the way home. If only I could feel that intensely. And here I am, a man who would love to have a child, wondering how I let this happen.

Some people surmise, “It’s different for men. You don’t have a biological clock.” And that’s pretty much the end of the discussion. As a 52-year-old man, can I know something of the anguish of women who long to have a child? The biological clock is, after all, a reality for women – I could theoretically still have a child if I were 70.

The problem is that “it’s different for men” translates easily into “it’s easier for men” and it’s one small step more to “you can’t understand what it’s like for us!” And from this the debate about not having a child is sequestered firmly into the experience of women: women grieve for the children they longed for and men don’t. Maybe that’s true – I can’t claim to be surrounded by men who talk about this. I think that by and large we don’t.

I am not sure what I am allowed to feel and how that differs from what I actually feel. Do men feel grief over being childless differently from women? If so, how? Does it matter?

Daily encounters remind me of what I don’t have. Just this morning, returning from the local shop, I saw my neighbour standing outside the door of our mansion block. Our building is set back off the road and has a communal garden bordered by hedges. There she stood with her two tiny ones, a little boy and girl gazing curiously at the pearled intricacies of a spider’s web spun across the lower branches of our hedge. I say good morning to their mother and then to them. I crouch down to join their wonder, and agree with their mother that probably the mummy spider was having a rest after her hard work and we should not disturb her. I watch their faces, their cheeks the lustre of rose petals, full of wonder at the spectacle. Adorable.

Shopping isn’t easy either. Politely standing aside for the harassed family of four as they pass, trying to manage the strollers, the shopping and the children’s runaround energy, I feel socially inferior. Despite loving my job and enjoying strong friendships, I feel I am not a real member of society – an unmarried man without children. I can’t participate in the hullabaloo about schools, catchment areas, snotty noses, and playdates. I am outside, looking in.

How do I disentangle these feelings? It’s easy just to distract myself. I think the most accessible layer of feeling is a sense of regret – I remonstrate with myself for the chances I missed and sadness for the people I have hurt. I can’t help but replay moments in my life that I wish could have turned out differently. These are so painful. That evening six years ago when I managed in one short hour to say all the wrong things to the right woman, precisely because she was the right woman. I could not bear to have that which I most wanted. So I destroyed something that I really longed for.

Only a few days later, she met someone else and two years later got married. They have a child now. I really wish I didn’t know that. But I do. A little girl. And I can’t help but wonder what it would be like if that little girl were my little girl. Would she have my eyes? My smile? What is it like to see in a child little mannerisms, a way of doing things, moving, speaking, laughing, playing, that remind us of ourselves? Or of course, she may have the eyes of my loved one. And what a joy that would be, to see in our child’s face, our love; to bring into this world a beautiful child that was of us – a child that would grow into her own person but growing out of who we are.

So another part of my sadness is born out of absence – fearing that I will never feel those exquisite joys; that I will never hear my son or my little girl call me dad. How sweet it would be to hear that word from the mouth of my little girl or my small son. To see them take first steps, to comfort them when they cry, to tuck them in before sleep and read them stories. To kiss them goodnight and be with them when the world seems too much. It could still happen. But it feels less likely with each passing year. And just because theoretically I still could doesn’t mean I don’t feel the loss of all those could-have-beens. Also, with the passing of the years, would I now have the energy if it were to happen?

And what of those parents who might answer me and say, “this guy is clueless. Does he have any idea of how hard it is to be a parent?” No. I don’t. I don’t know what it’s like to be short of sleep for a decade. To be exhausted and overwhelmed and have no time for myself. To feel mind numb after reading the same story for the 20th time. No, I don’t understand these things. But I do know what it is like to feel incomplete. To be fit for a purpose that I cannot fulfil. I will probably never know if I could bear the exhaustion and sacrifice that being a father would require but I long to try, precisely because that is the only way I can express something essential about who I am. It is not simply that I would like to be a father. I feel I am made to be a father. And because I don’t have a child, and it saddens me very much to admit this, in some ways I don’t feel fully like a man.

Sometimes, however, I get invited into the club. Four-year-old Archie arrived with his mother, Maggie, for a gathering of friends yesterday. Of course, he didn’t so much arrive as explode through the door. “I’m here!” he shouted as he ran into the hallway. While we adults exchanged smiles, Archie pulled out a dozen assorted soft toys, including a penguin, a lion, a giraffe and a hippopotamus, and left them strewn around the living room floor where he set up camp – a play base from which to launch sorties of boy energy into the kitchen.

Under his arm, too large and perhaps too fierce for any bag, is a pink Tyrannosaurus rex. The first chance I got, I served up food and went to play with him. Once we agreed that Captain America really was the best superhero, we were firm friends for the day, and Lego building and soft toy wars could ensue. Later, as we walked to the local cafe for tea and cake, he took my hand. For so many parents, this must be commonplace – to feel a small hand neatly clasped around the fingers of an adult – but for me it was special. His mother and I swung him, one, two, three, and up he went, until our arms were tired. An afternoon replete with the small joys of spending time with a little boy as he negotiates his way through the world.

And then they go home.

 

Why are men still ignored when we talk about miscarriage?

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future, Grief, men, miscarriage, unborn child, women

Why are men still ignored when we talk about miscarriage?

“How is Julia doing?” That was the question my husband was repeatedly asked after our first miscarriage. And after our second; and third; and fourth. We had lost baby after baby, but it was my state of mind and health – the devastated mother who had lost her child – that was uppermost in the thoughts of our family and friends. Almost nobody asked my husband the other obvious question: how are you doing?

While it is couples who “are going to have a baby”, miscarriages only happen to women. Yet the emotional trauma of the overwhelming sense of loss and grief affects both parents. So it was with great courage that Facebook chief Mark Zuckerberg chose to reveal, as he announced he and his wife are expecting a baby girl, that they have suffered three miscarriages. His deeply personal words will have echoed strongly with everyone who has experienced the loss of a pregnancy: “You start making plans, and then they’re gone. Most people don’t discuss miscarriages because you worry your problems will distance you or reflect upon you. So you struggle on your own.”

And that it precisely what many men do after losing a baby. They struggle on and bottle up their own feelings of loss to keep strong for their partners. Yet, as Mark Zuckerberg explained in a poignant Facebook post, for the couple who have miscarried, it was very much a real baby, containing all their love and hopes for the future, so the grief is very real too. And it needs to be treated like any other grief.

New research by the Miscarriage Association has found that, despite their intense feelings of sadness, anger and loss, a quarter of men whose wives or girlfriends miscarried never spoke about their grief with them because they feared upsetting her or saying the wrong thing. The sheer horror and shock of a miscarriage, and all the bleeding it can entail, can be overwhelming – an emotion that is compounded by a man’s utter powerlessness to do anything to help the woman they love.

Yet – and, importantly, quite unlike women – men are simply expected to get back on with normal life straight away, with no time off to recover. They report returning to work shell-shocked but unable to talk about their loss with colleagues because the pregnancy had been kept a secret. Even when men do attempt to talk about their feelings the response can do more harm. Well-meaning but clumsy comments such as “never mind, you can try again” and “at least you aren’t shooting blanks” underestimate the grief experienced.

The best way to cope with miscarriage is for men and women to talk – to their partners, to their friends, to a counsellor. After a rich, successful man like Mark Zuckerberg publicly shared his grief about his wife’s miscarriages, it may make it easier for more men to finally open up about their own feelings of loss. There is nothing unnatural about grieving for the loss of your unborn child.

What doesn’t kill us…

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adversity, autonomy, avoidance, cognitive processing, compassion, coping, distress, family, friends, gratitude, Grief, intrusion, measures, personal growth, positive changes, post-traumatic growth, post-traumatic stress, psychologists, psychology, PTSD, relationships, resilience, self-acceptance, Self-esteem, support, theory, trauma, vulnerability, well-being

What doesn’t kill us…

The field of psychological trauma is changing as researchers recognise that adversity does not always lead to a damaged and dysfunctional life. Post-traumatic growth refers to how adversity can be a springboard to higher levels of psychological well-being. This article provides an overview of theory, practice and research. To what extent is post-traumatic stress the engine of post-traumatic growth? How can clinicians measure change? What can help people to thrive following adversity?

Suffering is universal: you attempt to subvert it so that it does not have a destructive, negative effect. You turn it around so that it becomes a creative, positive force.
Terry Waite, who survived four years as a hostage in solitary confinement (quoted in Joseph, 2012, p.143)

Scientific interest in positive changes following adversity was sparked when a handful of studies appeared in the late 1980s and early 1990s, reporting positive changes in, for example, rape survivors, male cardiac patients, bereaved adults, survivors of shipping disaster, and combat veterans. Then, the topic of post-traumatic stress disorder (PTSD) was relatively new (following its introduction in 1980 by the American Psychiatric Association), and was attracting much research interest. The relatively few observations of positive change were overshadowed by research on the ways in which trauma could lead to the destruction and devastation of a person’s life.

But interest in how trauma can be a catalyst for positive changes began to take hold during the mid 1990s when the concept of post-traumatic growth (Tedeschi & Calhoun, 1996) was introduced. It proved to be popular and became the descriptor for a field of inquiry attracting international attention from researchers, scholars and practitioners (see, Calhoun & Tedeschi, 2006; Joseph & Linley, 2008a; Weiss & Berger, 2010). Over the past decade it has developed into one of the flagship topics for positive psychology (Seligman, 2011). This article aims to provide a state-of-the-art review of the psychology of post-traumatic growth.

What is post-traumatic growth?
After experiencing a traumatic event, people often report three ways in which their psychological functioning increases:
1.    Relationships are enhanced in some way. For example, people describe that they come to value their friends and family more, feel an increased sense of compassion for others and a longing for more intimate relationships.
2.    People change their views of themselves. For example, developing in wisdom, personal strength and gratitude, perhaps coupled with a greater acceptance of their vulnerabilities and limitations.
3.    People describe changes in their life philosophy. For example, finding a fresh appreciation for each new day and re-evaluating their understanding of what really matters in life, becoming less materialistic and more able to live in the present.

Several self-report psychometric tools were published during the 1990s to assess positive changes following trauma, the first such measure was the Changes in Outlook Questionnaire (Joseph et al., 1993), followed by the Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996); the Stress Related Growth Scale (Park et al., 1996), the Perceived Benefit Scale (McMillen & Fisher, 1998), and the Thriving Scale (Abraido-Lanza et al., 1998). Each of these measures asks respondents to think about how they have changed since an event and to rate the extent of their change on a series of items.

Using such measures of perceived growth, and open-ended interviews, a large number of studies have shown that growth is common for survivors of various traumatic events, including transportation accidents (shipping disasters, plane crashes, car accidents), natural disasters (hurricanes, earthquakes), interpersonal experiences (combat, rape, sexual assault, child abuse), medical problems (cancer, heart attack, brain injury, spinal cord injury, HIV/AIDS, leukaemia, rheumatoid arthritis, multiple sclerosis) and other life experiences (relationship breakdown, parental divorce, bereavement, emigration). Typically 30–70 per cent of survivors will say that they have experienced positive changes of one form or another (Linley & Joseph, 2004).

Practitioners in health, clinical and counselling psychology will encounter patients daily whose lives have been affected by such events. Up to now practitioners may have drawn on theories of post-traumatic stress to help their patients. A pressing theoretical issue therefore is the relation between post-traumatic stress and post-traumatic growth. How can these new ideas improve how we work with patients?

Theory and practice of post-traumatic growth
Research is now untangling a seemingly intricate dance between post-traumatic stress processes and post-traumatic growth. The most successful attempt to date is organismic valuing theory, which explains how post-traumatic growth arises as a result of post-traumatic stress. This is a person-centred theory that draws together information processing and social cognitive theories of post-traumatic stress with research on self-determination theory. The theory shows trauma leads to a breakdown in self-structure, signalled by the experiences of post-traumatic stress indicating the need to cognitively process the new trauma-related information. People are intrinsically motivated towards processing the new trauma-related information in ways that maximise their psychological well-being (Joseph & Linley, 2005, 2006).

Organismic valuing refers to how intrinsic motivation is experienced by the person. One woman who was caught up in a fatal shooting in which her close friend was killed, and who had suffered from considerable post-traumatic stress for several years, said how she woke early one morning after a night of restless sleep and got up to look at a picture of her children:

In the silent wee hours of the morning, I sat staring at their picture and began to sob. Through my sobs, I heard the real voice of wisdom I believe we all possess. It was my voice, the voice that knows me best, but a voice that had become muted. Guess what. No one is coming to change the situation. No one will rescue you. No one can. It’s up to you. Find your strength. I realised that as long as I remained a victim, I too made my family a victim. My anxiety could only teach them to be anxious. I was robbing them of happiness and a positive outlook on the world. I had come to the intersection of intersections. I could choose to end my life or I could choose to live. I needed to live for my family – and later I understood most importantly, for myself. (quoted in Joseph, 2012, p.142)

Post-traumatic growth involves the rebuilding of the shattered assumptive world. This can be illustrated through the metaphor of the shattered vase. Imagine that one day you accidentally knock a treasured vase off its perch. It smashes into tiny pieces. What do you do? Do you try to put the vase back together as it was? Do you collect the pieces and drop them in the rubbish, as the vase is a total loss? Or do you pick up the beautiful coloured pieces and use them to make something new – such as a colourful mosaic? When adversity strikes, people often feel that at least some part of them – be it their views of the world, their sense of themselves, their relationships – has been smashed. Those who try to put their lives back together exactly as they were remain fractured and vulnerable. But those who accept the breakage and build themselves anew become more resilient and open to new ways of living.

These changes do not necessarily mean that the person will be entirely free of the memories of what has happened to them, the grief they experience or other forms of distress, but that they live their lives more meaningfully in the light of what happened.

The implication of organismic valuing theory is that post-traumatic stress is the catalyst for post-traumatic growth. Helgeson et al. (2006) conducted a meta-analytic review concluding that greater post-traumatic growth was related to more intrusive and avoidant post-traumatic stress experiences. As intrusion and avoidance are generally seen as symptoms of PTSD at first glance this result would seem to suggest that post-traumatic growth is indicative of poor mental health, but consistent with organismic valuing theory Helgeson et al. suggest is that these constructs reflect cognitive processing:
Experiencing intrusive thoughts about a stressor may be a signal that people are working through the implications of the stressor for their lives, and these implications could lead to growth. In fact, some might argue that a period of contemplation and consideration of the stressor is necessary for growth to occur. (p.810)

It is in this sense that post-traumatic stress can be conceptualised as the engine of post-traumatic growth. This is also the conclusion of a recent study by Dekel and colleagues (2012), who set out to shed light on the interplay between PTSD and post-traumatic growth. Using longitudinal self-report data from Israeli combat veterans who were studied over 17 years, with assessment at three time points, the researchers found that greater PTSD in 1991 predicted greater growth in 2003, and greater PTSD in 2003 predicted greater growth in 2008.
However, it also seems that the relationship between post-traumatic growth and post-traumatic stress is a function of the intensity of post-traumatic stress. Butler et al. (2005), for example, in their study following the attacks of September 2001, found that greater post-traumatic stress was associated with greater post-traumatic growth, but only up to a point, above which post-traumatic growth declines.

Could there be a curvilinear relationship between post-traumatic stress and post-traumatic growth? Low levels of post-traumatic stress reactions indicate that the person has been minimally affected, thus one would expect minimal post-traumatic growth. A moderate level of post-traumatic stress is indicative that the individual’s assumptive world has in some way been challenged triggering the intrusive and avoidant experiences, but the person remains able to cope, think clearly, and engage sufficiently in the necessary affective-cognitive processing needed to work through. A high level of post-traumatic stress, however, where a diagnosis of PTSD might be considered, is likely to mean that the person’s coping ability is undermined and their ability to affectively-cognitively process and work through their experience is impeded. The inverted U-shape relationship between post-traumatic stress and post-traumatic growth has been reported in several studies (e.g. Kunst, 2010).

Thus, through the above research and theory we are developing a new understanding of psychological trauma that integrates post-traumatic stress and post-traumatic growth within a single conceptual framework which can guide clinical practice. A new constructive narrative framework that can guide practitioners is the THRIVE model (Joseph, 2012). THRIVE consists of six signposts (see box). Starting with ‘taking stock’, the therapist works with the client to alleviate problems of post-traumatic stress sufficiently so as to enable them to engage in effortful cognitive processing. Then follows five further signposts in which the therapist can work alongside the client. Post-traumatic growth provides practitioners with a new set of tools in their armoury for working with traumatised patients. 

New directions
Each of the measures mentioned above provides a particular operational definition of the construct, and they tend to be only moderately inter-correlated. Unlike, for example, the construct of post-traumatic stress disorder, which has an agreed definition provided by DSM around which measurement tools can be developed, there is no gold standard definition of post-traumatic growth. One suggestion arising from organismic valuing theory is to reframe post-traumatic growth as an increase in psychological well-being (PWB) as opposed to subjective well-being (SWB) (Joseph & Linley, 2008b). Traditionally, the focus of clinical psychology has been on SWB, which can be broadly defined as emotional states. Clinical psychology has been largely concerned with the alleviation of negative emotional states. With positive psychology in the background, clinical psychologists are now also concerned with the facilitation of positive emotional states. But post-traumatic growth does not refer to a positive emotional state but to an increase in PWB, defined as high levels of autonomy, environmental mastery, positive relations with others, openness to personal growth, purpose in life and self-acceptance (see box).

The topic of post-traumatic growth has also attracted interest from quantitative researchers in personality and social psychology. People may say they have grown, but have they really? There is a limitation to the above-mentioned measures, which is that they rely on retrospective accounts of change – that is, asking people to report on what positive changes they perceive themselves to have experienced since an event. We might refer to this as perceptions of growth to distinguish from actual growth, as measured by calculating the difference between state measures of psychological well-being before and after trauma.

Research suggests that the strength of association between actual and perceived growth is moderated by the degree of distress: for those who are most distressed there is a weaker correlation, but for those who are less distressed there is a moderate association (Gunty et al., 2011). It may be that perceptions of growth are at times illusory and a way of coping with distress (Zoellner & Maercker, 2006). Therefore researchers do need to be wary of always taking reports of growth at face value, particularly in the immediate aftermath of a crisis when people are most distressed.

However, while we may question people’s perceptions of growth, there is no question that actual post-traumatic growth occurs, as this has been demonstrated in before-and-after studies (e.g. Peterson & Seligman, 2003). What is now needed are more prospective longitudinal studies able to document the development of growth over time, how both actual and perceived growth co-vary over time and how they relate to other variables – both as outcome variables in order to understand the development of growth, and as predictor variables in order to understand the consequences of growth. Research shows that greater post-traumatic growth is associated with: personality factors, such as emotional stability, extraversion, openness to experience, optimism and self-esteem; ways of coping, such as acceptance, positive reframing, seeking social support, turning to religion, problem solving; and social support factors (Prati & Pietrantoni, 2009). But now more sophisticated theoretically informed designs are also called for in which we can begin to understand the factors that mediate and moderate post-traumatic stress and thus lead to post-traumatic growth. As an example of the directions that social and personality researchers may pursue, in one recent study it was found that emotion-focused coping mediated the association between subjective ratings of distress and post-traumatic growth and that emotional intelligence moderated
the association between emotion-focused coping and post-traumatic growth (Linley et al., 2011). While there is much that can be learned from quantitative research, there is also a need for qualitative research to explore new contexts (e.g. Splevins et al., 2011) and interventions (e.g. Hefferon et al., 2008).

Conclusion

The idea of post-traumatic growth has become one of the most exciting topics in modern psychology because it changes how we think about psychological trauma. Psychologists are beginning to realise that post-traumatic stress following trauma is not always a sign of disorder. Instead, post-traumatic stress can signal that the person is going through a normal and natural emotional struggle to rebuild their lives and make sense of what has befallen them. Sadly it often takes a tragic event in our lives before we make such changes. Survivors have much to teach those of us who haven’t experienced such traumas about how to live.

Box

THRIVE
Taking stock (Making sure the client is safe and helping them learn to manage their post-traumatic stress to tolerable levels, e.g. through exposure-related exercises).
Harvesting hope (Learning to be hopeful about the future, e.g. looking for inspirational stories of people who have overcome similar obstacles).
Re-authoring (Storytelling, e.g. using expressive writing techniques to find new perspectives).
Identifying change (Noticing post-traumatic growth, e.g. using the  Psychological Well-Being Post-Traumatic Changes Questionnaire  to track change).
Valuing change (Developing awareness of new priorities, e.g. positive psychology gratitude exercise).
Expressing change in action (Actively seeking to put post-traumatic growth into the external world, e.g. making a plan of activity for following week that involves doing concrete things).

BOX: Assessing growth
Think of how you yourself have been influenced by events in your own life. The Psychological Well-Being Post-Traumatic Changes Questionnaire (PWB-PTCQ) was developed to assess post-traumatic growth as defined by an increase in PWB. The PWB-PTCQ is an 18-item self-report tool in which people rate how much they have changed as a result of the trauma. A short six-item version is shown below.

Read each statement below and rate how you have changed as a result of the trauma.

5     = Much more so now
4     = A bit more so now
3     = I feel the same about this as before
2     = A bit less so now
1     = Much less so now

1.    I like myself
2.    I have confidence in my opinions
3.    I have a sense of purpose in life
4.    I have strong and close relationships in my life
5.    I feel I am in control of my life
6.    I am open to new experiences that challenge me

People may find it useful to use the PWB-PTCQ to gain insight into how they have changed. Often these dimensions of change go unnoticed in everyday life but deserve to be flagged up and nurtured. Clinicians will find the new tool useful as it allows them to bridge their traditional concerns of psychological suffering with the new positive psychology of growth following adversity (see Joseph et al., 2012).

Stephen Joseph is a Professor at the University of Nottingham and Honorary Consultant in Nottinghamshire NHS?Trust
stephen.joseph@nottingham.ac.uk

References

Abraido-Lanza, A.F. Guier, C. & Colon, R.M. (1998). Psychological thriving among Latinas with chronic illness. Journal of Social Issues, 54, 405–424. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd edn). Washington, DC: Author.

Butler, L.D., Blasey, C.M., Garlan, R.W. et al. (2005). Posttraumatic growth following the terrorist attacks of September 11th, 2001: Cognitive, coping and trauma symptom predictors in an internet convenience sample. Traumatology, 11, 247–267.

Calhoun, L.G. &Tedeschi, R.G. (Eds.) (2006). Handbook of posttraumatic growth: Research and practice. Mahwah, NJ: Lawrence Erlbaum.

Dekel, S., Ein-Dor, T. & Solomon, Z. (2012). Posttraumatic growth and posttraumatic distress: A longitudinal study. Psychological Trauma: Theory, Research, Practice and Policy, 4, 94–101.

Gunty, A.L., Frazier, P.A., Tennen, H. et al. (2011).Moderators of the relation between perceived and actual posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 61–66.

Hefferon, K., Grealy, M. & Mutrie, N. (2008). The perceived influence of an exercise class intervention on the process and outcomes of posttraumatic growth. Journal of Mental Health and Physical Activity, 1, 32–39.

Helgeson, V.S., Reynolds., K.A. & Tomich, P.L. (2006). A meta-analytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 74, 797–816.

Joseph, S. (2012). What doesn’t kill us: The new psychology of posttraumatic growth. London: Piatkus Little Brown.

Joseph, S. & Linley, P.A. (2005). Positive adjustment to threatening events: An organismic valuing theory of growth through adversity. Review of General Psychology, 262–280.

Joseph, S. & Linley, P.A. (2006). Growth following adversity: Theoretical perspectives and implications for clinical practice. Clinical Psychology Review, 26, 1041–1053.

Joseph, S. & Linley, P.A. (2008a). Psychological assessment of growth following adversity: A review. In S. Joseph & P.A. Linley (Eds.) Trauma, recovery, and growth: Positive psychological perspectives on posttraumatic stress. (pp.21–38). Hoboken, NJ: Wiley .

Joseph, S. & Linley, P.A (Eds.) (2008b). Trauma, recovery, and growth. Positive psychological perspectives on posttraumatic stress. Hoboken, NJ: Wiley.

Joseph, S., Maltby, J. Wood, A.M. et al. (2012). Psychological Well-Being – Post-Traumatic Changes Questionnaire (PWB–PTCQ): Reliability and validity. Psychological Trauma: Theory, Research, Practice and Policy, 4(4), 420–428

Joseph, S., Williams, R. & Yule, W. (1993). Changes in outlook following disaster: The preliminary development of a measure to assess positive and negative responses. Journal of Traumatic Stress, 6, 271–279.

Kunst, M.J.J. (2010). Peritraumatic distress, posttraumatic stress disorder symptoms, and posttraumatic growth in victims of violence. Journal of Traumatic Stress, 23, 514–518.

Linley, P.A., Felus, A., Gillett, R. & Joseph, S. (2011). Emotional expression and growth following adversity: Emotional expression mediates subjective distress and is moderated by emotional intelligence. Journal of Loss and Trauma, 16, 387–401.

Linley, P.A. & Joseph, S. (2004). Positive change processes following trauma and adversity: A review of the empirical literature. Journal of Traumatic Stress, 17, 11–22.

McMillen, J.C. & Fisher, R.H. (1998). The Perceived Benefits Scales: Measuring perceived positive life changes after negative events. Social Work Research, 22, 173–187.

Park, C.L., Cohen, L.H. & Murch, R.L. (1996). Assessment and prediction of stress-related growth. Journal of Personality, 64, 71–105.

Peterson, C. & Seligman, M.E.P. (2003). Character strengths before and after September 11th. Psychological Science, 14, 381–384.

Prati, G. & Pietrantoni, L. (2009). Optimism, social support, and coping strategies as factors contributing to posttraumatic growth: A meta-analysis. Journal of Loss and Trauma, 14, 364–388.

Seligman, M.E.P. (2011). Flourish. New York: Free Press.

Splevins, K.A., Cohen, K., Joseph, S. et al. (2011). Vicarious posttraumatic growth among interpreters. Qualitative Health Research 20, 1705–1716.

Tedeschi, R.G. & Calhoun, L.G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455–471.

Weiss, T. & Berger, R. (Eds.) (2010). Posttraumatic growth and culturally competent practice: Lessons learned from around the globe. Hoboken, NJ: Wiley.

Zoellner, T. & Maercker, A. (2006). Posttraumatic growth in clinical psychology. Clinical Psychology Review, 26, 626–653.

Normal Grief vs Depression In DSM5- Medicalizing Grief

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Bereavement, DSM, Grief, Major Depression

http://www.psychologytoday.com/blog/dsm5-in-distress/201003/normal-grief-vs-depression-in-dsm5

The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry.  It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label. For example, take the case of a man whose spouse unexpectedly dies. For two weeks after the death, he feels sad, doesn’t want to go to work, loses his appetite, has trouble sleeping and concentrating. Currently, this is normal grief. The DSM 5 suggestion would have this be major depression.

Undoubtedly, this would be helpful for some people who would receive much needed treatment earlier than would otherwise be the case. But for many others, an inaccurate and unnecessary psychiatric diagnosis could have many harmful effects. Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.

Grief is an inescapable part of the mammalian experience and a necessary correlate of our ability to attach  so strongly to other people. Though grief is universal, there is no one right way to grieve. Different cultures prescribe a wide variety of different behavioral and emotional reactions and rituals. Psychiatry needs to tread lightly and have compelling reasons before encroaching with its own rituals  on such time honored and usually effective practices.

Within a given culture, normal individuals also vary enormously in the content, symptoms, duration, and impairment of their grief and in their ability to draw consolation and sustenance from others.  There is no bright line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help.

The numbers on each side of the normal/mental disorder divide are probably very lopsided-most people who grieve do not have a mental disorder. Ever since the dawn of man, humans have had frequent occasions to grieve. Almost all of us come to terms with the loss and the altered conditions of a new life without the benefits of psychiatry-and do just fine on our own. The change in DSM5 would attempt to identify the very small percentage of people who have a complicated grief that goes beyond the average expectable in severity, symptom pattern, and duration – those who would not remit as part of the natural evolution of their grief. But when you use a big shovel to capture a small needle in the haystack, what you mostly get is hay. Any change in the way DSM5 defines grief may gather a very large proportion of false positives who would do better avoiding psychiatric help.

The rationale given by DSM5 for its radical proposal is brief, cryptic, and fails to provide anything like a risk/benefit analysis of  potential effects. DSM5 states that there is no evidence that the depression triggered by the stress of losing a loved one is any different than  depression triggered by other severe stressors (such as job loss or divorce)- thus claiming that there is no justification to withhold the diagnosis of major depression after a loss. This  rationale places the burden of proof in the wrong direction.  DSM5 should make so consequential a change only after a careful and considered evaluation proves with compelling evidence that it will do more good than harm.

Such evidence is simply not available.  The research in this area is interesting but in very early development and we don’t know many essential things. We have no idea how any proposed criteria set would work in the general population.  What percentage of grieving individuals would get the diagnosis (especially once drug companies raise awareness of it)? Among the people who would be diagnosed, we don’t know what percentage truly need psychiatric help, what percentage would do better without it.

Pies and Ziskind (in a recent commentary in Psychiatric Times) have  gone far beyond the meager DSM5 rationale to present the strongest possible case for allowing the diagnosis of Major Depression in grief situations. They cite several lines of argument:

1) There is a clinical need- some individuals have severe, complicated grief that looks just like severe Major Depression and does not get better spontaneously. The longer that diagnosis and treatment are delayed, the greater their suffering, impairment, and risks (eg job loss, injured relationships, lowered treatment response, suicide).

2) The loss of a loved one is not essentially different from the many other serious stressors that abound in life.

3) It is impossible to predict the future misuse of the DSM5 system so we should make decisions based only on the best possible science.

4) The criteria for complicated grief could be tightened to reduce false positives.( They suggest two useful ways described below and I add two others).

5) Education can solve the problem of false positive diagnosis and the risk of providing medicine in milder cases when time, support, and/orpsychotherapy would be more indicated.

The  excellent proposal made by Pies/Ziskind to reduce false positives could be strengthened even further if two additional exclusions were added to the  two(#’s 1and 2 below) that they   suggested . The entire package differentiating grief  from depression would require:

1) An extended duration of one month.

2) A particularly severe presentation that  includes some combination of unreasonable guilt, worthlessness, hopelessness, self loathing, anhedonia, a focus on negative memories of the departed, alienation from others, and inability to be consoled.

3) To recognize the different cultural expressions, the diagnosis of depression would not be made if the person’s grief is within  cultural norms.

4) An exclusion could be added that would take into account the person’s own past experience of grief and its previous outcomes.  If the individual previously had severe grief symptoms, but recovered spontaneously (without going on to a major depression), this would suggest they are now grieving their own way and do not require diagnosis or treatment.

DSM5 has made many poorly thought through suggestions that can be fairly easily dismissed. Though I continue to disagree with the  Pies/Ziskind proposal, it is reasonable and deserves serious consideration. Here are the opposing points:

1) Re clinical need: In appropriate cases displaying  clinically significant impairment, distress, or risk, the diagnosis Depression Not Otherwise Specified covers their false negative problem.

2) I believe there is a difference between losing a loved one and most other life stressors. This  explains why grief is the universal target of communal healing rituals.  It would be unfortunate forpsychiatry to prematurely roam into problems usually better handled by family and other cultural institutions. Cultural biases would be very hard to surmount in making this diagnosis.

3) My disagreement with Pies and Ziskind is strongest on this point. All decisions for DSM5 should follow the injunction-“First Do No Harm.”Although it is impossible to predict precisely how any DSM5 change will eventually play out once the manual is in general use, that doesn’t reduce DSM’s responsibility for the problems that occur, even if they are unintended. All potential risks have to be thought thru and factored into a thorough risk/benefit analysis.  The argument that we should just go to where the science takes us ignores that the science is (as they point out) not definitive, is subject to different interpretations, and is not readily generalizable from research to real world settings. Once the genie is out of the bottle and DSM5 makes it easy to diagnose depression in grief situations, this could easily become an industry propelled fad diagnosis.

4) The tightened criteria would help reduce, but certainly not eliminate, the grave potential harm caused by the massive misidentification of false positives.
False positives and excessive treatment are not be a problem for skilled and cautious clinicians (like Pies and Zisook), but in the real world most of the prescriptions will be written by primary care physicians who have six minutes with each patient, don’t know the fine points of the criteria sets, and want the fastest solution.

The false positive problem is too unknown and potentially far too large to ignore. At a minimum, there would need to be field trials to determine prevalence, reliability, false positive, and false negative rates. I doubt that DSM5 has the time, money, and skill to pull this off.

5) It would be naïve and unwise to rest our hopes that any educational  program  would reduce over diagnosis and the overprescription of medication in grief situations. To the contrary, most of theeducation would go the other way. The drug companies devote enormous resources to “educating” physicians to be quick on the draw in prescribing medication.

I respect the arguments made by Pies and Ziskind  and believe they  work well when applied by experts like them. My worry is the misuse of even reasonable ideas in the real world  situations where most diagnosis and treatment is done. Loose diagnostic and treating habits could lead to the widespread medicalization of grief well beyond what Pies and Ziskind would themselves recommend. There are two ways of avoiding this. The first is to keep things as they are and not to diagnose Major Depressive Disorder in the first two months after the loss of a loved one.

The second is for DSM5 to allow for the diagnosis of complicated grief but with a  criteria threshold set high and including all four protections against false positives outlined above. As recommended by Pies and Ziskind, there should also be a  physician and public education campaign normalizing normal grief and  sharply delimiting the small group of grievers who need psychiatric
help.

Weighing the pluses and minuses, my call is to keep things as they are and not risk an “epidemic” of psychiatric grief.