The timing of grief

The grief graph shows the usual timing of grief reactions. This relates to sudden loss only, where the death or removal of the person is unexpected and permanent. Where the loss is anticipated such as with a long terminal illness the grief graph is quite different for the bereaved.

When the loss occurs there is the initial reaction of shock. This would rarely be longer than a few days. This is where the Child ego state incapacitates and basically goes into a state of complete non functioning cognitively, emotionally and behaviourally. The person in essence curls up in the foetal position and stays there. The person deals with a piece of very repugnant information (such as the death of a loved one) by collapsing in on self. The information is not being denied instead the information is not even being comprehended in the first place. If this lasted into weeks then one would essentially be in some form of catatonic state.

When this passes the person will be in a state of denial. The information is now comprehended by the person but the Adult and Child ego states deny that it is true. By whatever means, and by some kind of magical thinking the person convinces self that what they are being told is not true.

This also usually passes quite quickly at one level. The Adult ego state usually has to reasonably quickly accept the facts that the person is now no longer there. When this happens on the grief graph one can see the feelings of sadness and grief rapidly rise to quite a high and intense level. At this point the person’s everyday life each and every day is significantly effected by the strong distressing emotions to the extent that the ability to work, relate and recreate can be significantly effected.

This is indicated by Roses comment on the post on Depression and suicide:

“I realise now. Grief isn't about feeling sad or happy or anything like that. Its not like that at all. It, some how, is a physical thing. I can't just shake it off like everything else. It's not like a cloak i have to wear for a time so when i need a break from it, i can just take it off for a little bit and then put it back on when i need to. No. It's inside and it's all the time. Its something we carry on the inside that can't be let go of or put down for a bit. It just is.”

This shows the ever present nature and strong presence of the grief in the very early days after the loss.

Even though the Adult can not stay in denial for too long the Child ego state can remain in denial for very long periods of time, indeed years at a time. The Child magically sort of somehow believes that the person is not really gone or really dead. The individual sort of talks about the person like they are still alive. The person refuses to remove the deceased’s clothing from the cupboards or when walking along the street they catch sight of a person in the corner of their eye and they quickly think they have seen the deceased.

Indeed the very function of the period of grief and sadness in the grief graph is to break down the attachment and for the Child ego state to come to realization that the person is really dead. To end the denial.

It has been widely noted that the symptoms of depression are also commonly found in normal grief reactions. The two are quite psychologically similar. This is why depression often involves some kind of unresolved grief. Thus in the treatment of many, if not most depressed individuals one needs to find the time(s) when they did not grieve properly in childhood and redo the grief and goodbye work about the losses experienced. Depression often is an unsophisticated attempt by the Child ego state to resolve past grief reactions that it never successfully concluded. Depression is a recreation by the Child of process described by the grief graph.

If the grieving proceeds normally in a Free Child manner then over time the intensity and frequency of sadness and grief slowly decrease. After 6 months there will be a significant drop in the intensity and frequency such that there will be a noticeable difference experienced by the bereaved. By 18 months the vast majority of the painful grief is gone and life continues onward. Full psychological readjustment after the death of a very closed loved one probably occurs about 4 years after the death.

Those who report significant grief beyond these times are getting some form of significant secondary gains from the grief and loss process. Thus the process is dragged out much longer, even for a lifetime in some instances.

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Depression and suicide

7. Depression as an indicator of suicidal thoughts and actions. One sees a great deal written about suicide and depression in the literature and unfortunately it is quite a misunderstood area. All sorts of statistics quoted. For instance George (2008) states, "A retrospective study of 132 young people who completed suicide in Western Australia found that nearly three quarters had shown definite signs of depression in the weeks prior to their death"(p.25) Or, "Depression increases the risk of suicide by 15 to 20 times, and about 4% of people with depression die by suicide."(p1373), Hawton, and van Heeringen, (2009). This of course means that based on this research ninety six percent of people with depression do not die by suicide. Other research has varying figures. Clark and Fawcett (1992) estimate that fifteen percent of those with a diagnosis of major depression will complete a suicide. The statistics tend to waver around the ten percent mark which means that the vast majority of those with depression will not complete a suicide attempt. There are many depressed people who are not suicidal at all. Of course this does not mean that one forgets about making an assessment of suicide with the person reporting depression but one needs to be realistic about its occurrence which is not often found stated in the literature.

Key symptoms of depression related to a risk assessment

In real terms depression is merely a collection of symptoms, it is not so much that depression is linked to suicide it just happens that people who are suicidal have symptoms which are not uncommon in depressed people as well. In using this measure in a suicide risk assessment one does not enquire about depression per se but one enquires about some of the symptoms found in the depression that the person is displaying.

The DSM-IV provides a list of symptoms which define depression, these being:

1. Depressed mood most of the day which can include a sense of hopelessness.

2. Loss of interest or pleasure (in all or most activities, most of the day).

3. Large increases or decreases in appetite (significant weight loss or gain).

4. Insomnia or excessive sleeping (hypersomnia).

5. Restlessness as evident by hand wringing and similar other activities (psychomotor

agitation) or slowness of movement (psychomotor retardation).

6. Fatigue or loss of energy.

7. Feelings of worthlessness, or excessive or inappropriate guilt.

8. Diminished ability to concentrate or indecisiveness.

9. Recurrent thoughts of death or suicide.

Taken from, American Psychiatric Association (1994).

In this diagnostic system one needs to have five or more of these symptoms to be diagnosed as depressed. Thus every suicidal person automatically has one symptom of depression already as shown in symptom number nine. The best clinical predictors of suicide in depressed people include previous self-harm, hopelessness and suicidal tendencies. (Beck, Steer, Kovacs and Garrison (1985) and Beck, Brown and Steer (1989) both found hopelessness to be one of the best indicators of suicide risk). If the depressed person reports a loss of appetite, psychomotor agitation, excessive guilt, hypersomnia and increased indecisiveness then they meet the criteria of depression but show none of the best clinical indicators just described. Indeed unless the depressed individual reports the last symptom, recurrent thoughts of death and suicide, it seems safe to say that the person is not a suicide risk at this time. They are not even thinking about suicide at this point even if they have all eight other symptoms of depression. If a person presents as depressed one firstly asks if they have the symptom of thoughts of suicide and if they do then one also enquires about a sense of hopelessness and any previous self harm. If they present with all three one is getting a much more accurate assessment of the current level of risk.

In the literature one finds very little research on the number of people who report depression and who report no recurrent suicidal thoughts. One has to search long and hard and three such research studies were found. The first from many years ago by the 'father' of depression, Arraon Beck (1967). He presented research results which examined the presence of suicidal wishes in the depressed person. He makes the distinction between neurotic depression or the milder forms of depression and psychotic depression or the more severe forms of depression. (This distinction will be discussed more later in this chapter). The results were:

Mild or moderate level of suicidal wishes present:

Neurotic depression - 58%

Psychotic depression - 76%

Severe level of suicidal wishes present:

Neurotic depression - 14%

Psychotic depression - 40%

More contemporary research by Akechi, Okamura, Kugaya, Nakano, et al (2000) reports that in patients with major depression fifty three percent had suicidal ideation. Wada, Murao, Hikasa, Ota, et al. (1998) also report a similar finding of around fifty percent of those with major depression having suicidal urges as well. This allows the conclusion that about fifty percent of those with some form of depression do not report any recurrent suicidal thoughts. Thus it seems safe to say that fifty percent of depressed people are not at risk of suicide as they are not even thinking about suicide let alone planning anything.

Timing of the depressive episodes

If the individual does present as depressed and does show the principle signs of recurrent suicidal thoughts, a sense of hopelessness and previous self harm then of course this is an important factor in the risk assessment and definitely requires more investigation. One of the more important aspects to investigate is the course and stage of the depression. As stated by the Bayley (2004) depressive episodes can be single, recurrent or chronic and this has significant implications for the assessment and management of the suicidal individual.

For about five to ten percent of depression sufferers the depression is chronic. If an individual with chronic depression also has recurrent thoughts of suicide then the level of risk increases and over time it could be seen as continuing to increase. In the longer term this person could be seen as quite a significant suicide risk. One would to be questioning the individual as to their feelings about tiring of life and particularly a sense of hopelessness. These individuals have a poor quality of life with the spirit crushing depression and often quite unpleasant side effects from the medication like obesity, lack of energy and so forth. If they have tried just about every type of medical and psychological treatment with little improvement one would be assessing a definite increase in the risk of suicide.

To make matters worse there is not much one can do in their management. A no suicide contract is of less use as there is no end in sight for the depression. As the suicide risk increases over time one can place them in hospital or on some kind of suicide watch but what does that achieve? It simply relocates them geographically and how long does one keep such a person in hospital as they will be depressed upon release.

However for most depression is cyclical as is shown in diagram 4 with the mood changing over time from a normal level to a depressed level and back.

Diagram 4

The cycles of depression

As stated in the Bayley (2004) the rate of recurrence of depressive episodes is quite high, "50% of people who have had one episode of depression will relapse, 70% of people who have had 2 episodes will relapse, and 90% of people who have had 3 episodes will relapse"(p159). The average duration of an untreated episode is about twenty to twenty six weeks but many can have much briefer episodes of around four to six weeks. If treatment is obtained early then the duration and severity of the episode may be significantly reduced.

Types of depression

In using depression as a measure to assess suicide risk one needs to distinguish a number of different types of depression. As is shown in diagram 4 one can move from a normal mood range into the range of dsythymia. In this phase the depressive symptoms are at a moderate degree. Historically this has also been known as neurotic depression and I use the terms interchangeably. This is seen as less severe than the next level which is called a major depression. In this phase the depression symptoms are at a severe degree. Sometimes this is called 'clinical depression' and the individual is significantly incapacitated and is very depressed. Also at this level one can have a condition known as psychotic depression. This is where the individual has the symptoms of major depression plus some psychotic symptoms. This terminology has been around for many years and psychotic depression is well summarized by Beck (1967) who says it is "...characterized as including patients who are severely depressed and who give evidence of gross misinterpretation of reality, including at times delusions and hallucinations"(p82).

In summary in this model we have:

Normal mood

Dysthymia or neurotic depression

Major depression and psychotic depression

In diagram 4 we have an individual who begins with a period of normal mood who then moves into a phase of depression that is consistent with the diagnosis of dysthymia. Eventually that depressive episode ends and he recovers again for a period of normal mood. Unfortunately at a later time he again moves into a more severe episode of a major depression which he eventually recovers from and moves back to a state of normal mood. To assist with making a suicide risk assessment one can create a graph like this for the person who complains of depressive episodes.

In assessing the depressed person one need to look at four aspects of the depressive cycle W, X, Y and Z. Firstly one is wanting to assess the length of the non depressed periods (W) and the lengths of the depressive episodes (X). Of course this relies on the person having had previous episodes and one simply takes a history of the person in this way. How many have there been and how long were they? Also were there any precipitating factors such as marital problems or financial difficulties that lead to the depressive episode. These can then be charted on a graph as is shown in diagram 4. People tend to behave in patterns and one is obtaining this information to assist in predicting future episodes and thus future times when suicidal urges may increase in conjunction with the depression. Of course future episodes may be different to past ones but this does give some guidance to assist the suicide risk assessor.

For example if there is a pattern in the timing of the episodes one then knows when approach the person for a risk assessment in the future. A good example of this is with what has become know as Seasonal Affective Disorder or SAD. Typically the depressive episode begins in autumn or winter and remits in spring. Alternatively previous depressive episodes may be related to particular events such as examination time at college or when a loved one has to travel away for work. Plotting the 'W' and 'X' of the depressive episodes will allow the risk assessor to improve the timing of their assessments.

Degree of depression and suicidality

One also needs to assess the quality of the depressive episodes by making an assessment of the 'Y' component. Here one assesses how depressed the person becomes, how the person has felt in past episodes particularly in relation to suicidal thoughts. As mentioned before the system being presented here distinguishes between normal mood, dysthymia or neurotic depression, major depression and psychotic depression.

This is an important component to distinguish in a suicide risk assessment as there is some research which concludes that those who are more depressed are more prone to suicidal thoughts. In their research on depression and suicidal thoughts Garlow, Rosenberg, Moore, Haas, et al (2007) report “These results suggest that there is a strong relationship between severity of depressive symptoms and suicidal ideation in college students...”(paragrpah 1). In addition Perroud, Uher, Marusic, Rietschel, et al (2009) state “Increases in suicidal ideation were associated with depression severity...”(p2). Finally Beck (1967) cites research which shows that a severe level of suicidal thoughts were present in fourteen percent of those with neurotic depression and in forty percent of those with psychotic depression. In conclusion, the more depressed one is the higher the risk level of suicidal thoughts. Thus one can see the importance of making the 'Y' component assessment of the reported depressive episodes.

As just noted the person with major depression or psychotic depression is at more risk of suicidal thoughts than the person with dsythymia. However it seems reasonable to conclude that the person with psychotic depression is still at even more risk than the person with major depression as a psychotic depression involves a major depression plus the presence of psychotic symptoms. That is the person experiences severe depression as well as psychotic delusions and hallucinations and thus the features discussed above in point 4, "History of mental illness" become apparent as well. There is sort of doubling effect of suicide risk factors in this instance. For example the person with psychotic depression is likely to be more regressed than someone with major depression because the psychotic features result from very poor Adult ego state functioning and thus there is increased regression. In addition the psychotic is more prone to command hallucinations as well. As a result, of all the types of depression the psychotic depression is probably the one of highest risk value when making a suicide risk assessment.

Finally in diagram 4 one needs to make an assessment of 'Z' in the depressive cycle. Suicide risk may increase as the person improves particularly in a major depression or a psychotic depression. In these depressive states the person is so depressed that they become incapacitated. They are so depressed that they literally do not have the energy to think seriously of suicide or certainly making any definite planning moves. As the depressed state lifts, along with that comes an increase in energy which may bring about an increased ability to act on any self destructive wishes, as they improve one may need to be more vigilant as they reach that part of the depressive cycle.

In addition for the individual with psychotic depression as the depression lifts the psychotic symptoms may begin to subside as well. Their Adult ego state becomes more functional and thus planing a suicide attempt becomes more of a possibility. Most suicides occur in the non-florrid stages of a psychotic episode when the person is relatively free from acute symptoms. Of particular note in suicide risk assessment if the person is at one of the lower points in the depressive cycle such as at stage 'Z' and all of a sudden shows significant improvement, that may be ominous sign. They may have made the decision to kill self and are just getting organized and waiting for the right time.

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Check in therapy

Had a good check in this week. A guy in his late 20s whom I saw for about 2 or 3 years. Once a week regular as clockwork. When I first saw him he was in bad shape heading for a major depression if not being there already. Now he does not even take anti depressants. It’s always good when you get to see one who has done very well. And besides that I liked him at a personal level as well. We definitely had a good connection.

He developed quite a strong transference with me and I was very much a father figure for him. When he finished he went travelling for about 18 months and as I always do I asked him to send me some postcards. Some clients do and some don’t but I have a board in my office where I pin up the postcards that I do receive and I always point it out to clients who are about to go away.

Anywise he got back and I get a phone call from him and he makes an appointment to see me. I like these kind of appointments as I get to hear what has happened in his life. Some times as a therapist I can get to know some one very well and can even play an important part in their life at the time and then most stop seeing you and you never get to hear what happened in their lives or hear how they turned out. Occasionally I will get a letter or these days an email out of the blue from a past client giving me an update on their life which is always nice.

So he turns up at the appointment and I am waiting to hear what his current difficulty is and as it turns out there isn’t one. It was just a check in to see that I am still there, and still the same, and still like him, all of which is true.

Most people who do a check in will make up some sort of dodgy excuse problem to come and see me. They are having trouble sleeping or they had an argument with some one or they had a series of vivid dreams. When the real reason is to do a check in. Well he didn’t even have the excuse problem which was kind of nice.

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Elective mutism and the non-talker

Been working with a guy for the past 6 weeks. He is a non-talker. I never know which is worse, the client who has verbal diarrhoea where you can’t get a word in, to the other client who says hardly nothing.

I like this guy. He has virtually no sense of self worth. I mean unusually so and self deprecating to the same degree as well. Presentation is depression and some history of suicidal ideation.

His natural temperament response to stress is flight - as in fight, flight or freeze. He has a GAF response to a degree that I have not seen before. GAF comes from the life positions and stands for “Get away from”. It means that he will have a tendency to get away from others in his life script and thus he is likely to end up alone or with very few social contacts.

In this instance there is actually no problem with this. He enjoys his own company and can spend long periods of time by himself in the country, which he does. That is not the problem. The problem is that he does not tell anyone anything about what he is thinking and feeling. He never has for as long as he can remember. When ever he has a distressing thought or feeling he withdraws and says nothing to anyone. The technical diagnosis for this is elective mutism.

This worked fine at first except that humans cannot keep doing that for too long and eventually they collapse in on self. They will start to either hit the alcohol, drugs, prescription medication, get depressed, develop anxiety and so forth. The Child ego state simply needs the human contact and communication when it is distressed about something. If it does not get it over an extended period of time it has a ‘nervous breakdown’ as they used to call it.

Human communication. Some try to live without

it for long periods but it never works in the long run

The problem for him (and thus me) is that it is completely and absolutely antithetical for him to talk to anyone about his inner thoughts and feelings. But he comes to see me for precisely that goal, to talk about his inner world and hence he ends up as a non-talker (sort of).

The first sessions were difficult because he said so little and there were often prolonged silences. I thought that he would simply decide that it was all too much and I would not see him again. However at the end of each appointment he has initiated the request for another appointment and there has been another change in the last few sessions.

For the first 45 minutes he is his usual muted self. Then as I am thinking of winding things up (a little early) he starts to talk and even initiate conversation. In the last few sessions he has even gone over time (and I have allowed it). I don’t think it is a game about getting more time but he is starting to not want the conversation to stop. And indeed that is what we are doing. We have done very little therapy in the usual sense of the word. We basically just have a conversation. Mostly about him and his life but we are by no means doing the usual therapy things like setting contracts and so forth.

Some seem to feel like they just don’t fit

in with the rest of the human race

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A study in depersonalization

Depersonalization.

A fragmentation in ones sense of physical self and a sense of estrangement from the body.

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