There Is No Blueprint For Grief

All of our knees buckle in the wake of tragedies. From the terrorist attacks of September 11th, 2001 to the COVID-19 pandemic to natural disasters and senseless acts of gun violence, the list goes on and on. The heartbreak is unimaginable.

"Unfathomable" is the word that keeps coming to mind. Merriam-Webster defines "unfathomable" as not being capable of being fathomed, immeasurable, impossible to comprehend. As a psychiatrist, I wish I had some way to help make sense of these tragedies, some therapeutic tools to offer, some deep insight to share, some data driven wisdom about the grieving process, some promised silver lining, or at least some comfort for these shattered families. But there are no words.

There is no blueprint for grief of any kind. All I know is that telling people how to grieve or insisting that they talk about their feelings is not the answer.

When something horrible occurs, crisis counselors are often summoned to conduct what is known as a psychological debriefing.

Psychological debriefing is a crisis intervention designed to alleviate immediate distress and prevent post-traumatic psychopathology following an exposure to a traumatic event. A typical debriefing session occurs in a small group setting and is led by a counselor or facilitator.

Over the course of three to four hours, the leader encourages the trauma-exposed individuals to go around the room and talk about their thoughts, feelings and reactions to the incident.

What aspects of the situation cause you the most pain? What was the worst part of the event for you personally? are typical questions participants are expected to answer. A core aspect of debriefing is sharing emotions and distress with participants going through a similar experience.

While well intended, there is no evidence that debriefing interventions actually work. In fact, there is reason to believe that a debriefing session may do more harm than good. As George Bonanno, professor of psychology at Columbia University, observed in a research article in the American Psychologist, "Growing evidence shows that global applications of psychological debriefing are ineffective and can impede natural recovery processes."

It's possible that asking people to talk about their emotional experience too soon may make them feel even worse. They might begin to worry that something is wrong with them.

Moreover, listening to the heartbreaking stories of the others in the group may be comforting. It may also be further traumatizing.

I sometimes worry that we have over-professionalized distress and over-pathologized how people respond to trauma. A few years ago, I attended a talk given by a man who was severely burned during the 9/11 attack on the World Trade Center. He had been in an elevator in the north tower when the first flight crashed into the building and was engulfed in flames as a ball of fuel tunneled down the elevator shaft.

The last thing he remembered was a nurse removing his wedding band from his swollen ring finger in the emergency room. Two months later he awoke from a medically induced coma in the burn unit. In addition to being in terrible physical pain, disfiguring scars, and disability, he learned of the tragedy of 9/11, including the loss of close friends and co-workers. He recalled being angry, upset, and deeply sad.

A few days later a psychiatrist arrived at his bedside, suggesting they talk about his trauma and asking if he was depressed. At this point, he looked up from his notes and stepped back from the podium: "If there are any psychiatrists in this room, please stop asking people who have been through hell to talk about their trauma and if they are depressed? Of course we're f****** traumatized and depressed." I cringed.

How often had I been that psychiatrist, convinced that my clinical interventions were necessary to help someone navigate the unthinkable?

There is no right or wrong way to grieve. Bereavement is no place for finger-wagging or "shoulds." Of course, self-care and seeking social support are beneficial but processing loss is personal and can get messy.

We have all heard about the five stages of grief: denial, anger, depression, bargaining, and acceptance. While this model provides a neat and tidy conceptual framework, even Dr. Elizabeth Kubler-Ross, the model's creator, never argued that bereavement was a linear process or unfolded in a steady progression. Dr. Bonanno coined the term "coping ugly" to underscore the reality that grief takes many forms and countless paths, some of which may seem counterintuitive.

According to Bonanno, coping in ways that appear awkward or unhealthy on the surface may help an individual feel better. Having a few glasses of wine or a few beers may be just what the person needs. Holding onto anger may be a source of comfort and not something to let go of. Who's to say what "normal grief" should look like?

Talking is good but when and with whom should be up to the individual. Not everyone wants to speak to a professional and that's okay. As Dr. Simon Wessely, Professor of Psychiatry at King's College London, argues:

"There is no problem of course if people want to talk, fine, but we should be careful. We should not impose this on people. We should remember that, first of all, it should be when they want to do it, and all the evidence is immediately after the greatest shake-up and tragedy of your life is not the best time. It should be with who you want to talk to, preferably those who know you before and afterwards, who can put this in the context of your life, but if it is an organization, it should be people who are part of your organization, who understand you and your culture and we should never forget there are people, my father's generation for example, who don't want to talk for whom reticence is more important than emotional expression, and there is nothing at all wrong with that. There is no correct way in dealing with these things. They come in fashions, and there is no reason to think that reticence is any better than emotional expression or any worse. It is doing what comes naturally."

We live in a country awash in grief. It is said that every death leaves approximately 9 people bereaved. Gun violence, COVID-19, and deaths of despair compound our collective mourning.

In my experience, there is no "moving on" after unspeakable loss but it is possible to move forward with the support of friends, family, and community.

What helps loved ones who are going through hell? Showing up. Bearing witness. Listening. Sometimes there are no words but there are always ways to show love.