Editor’s note: This is the second half of a two-part Q&A with Sameet Kumar, PhD, author of Mindfulness for Prolonged Grief. If you missed the first half, you can check it out here.
Following changes to the DSM-5, most significantly the removal of the “bereavement exclusion” from diagnoses of depression and adjustment disorder, is there a potential now for the increased “medicalization” of those suffering with grief?
The removal of the bereavement exclusion is a complex issue. The DSM-5 had the opportunity to include a separate category for “Prolonged Grief,” and there was a lot of anticipation that it would demonstrate some forward-thinking and do so. Unfortunately, this did not happen. Those of us who do clinical work have realized that although there are huge cultural and philosophical issues with the DSM, it is fundamentally really a manual for billing codes. On the one hand, the removal of the bereavement exclusion can make billing for services simpler. However, there is a real danger that primary care physicians will feel now feel that prescribing medication is enough for treatment, and approach grief the same way as many of them have approached depression—which is, essentially, SSRIs for all, despite the evidence this is not ideal for everyone. My fear is that people who go to their physicians in moments of great pain will feel pathologized when what they are experiencing is actually quite normal, even if it feels so excruciatingly difficult at times. People who only get this sort of medicalized approach to grief will miss out on the rich potential that working through any type of grief can bring. To counter this disease model as mental health care providers, we have to make our voices louder in the national and international conversation on how to best help our clients. This requires coordination between clinicians, researchers, and clients themselves in sharing what we know. We need to utilize all means at our disposal, including social media, blogs, and publications, to disseminate accurate, research-based guidelines on what really works. Without our voices, the momentum will automatically go to where lobbyists want diagnostic and treatment guidelines to go, which is what they are paid very well to do.
Do you believe there to be a distinguishable and diagnosable difference between symptoms of grief, and those of major depression?
One of the most consistent experiences people share in grief are the “supernatural” ones. This is very different from depression criteria. People do very often have visions, sensations, and experiences they struggle to explain, and often attribute them to their deceased loved one or loved ones. The most common ones I hear about are people hearing their loved one calling their name or laying down next to them in the middle of the night, or causing electrical malfunctions. All of these phenomena are very normal no matter what your belief system is, but they can feel strange when they occur, and sometimes even more distressing when they don’t occur. This is unique to grief. Something else unique to grief is yearning for someone who has died and the relationship to a loved one’s belongings that results. Every therapist working with grieving people should ask them where they sleep. I think many might be surprised at how few people return to the bed or change sheets after the death of a spouse. These sorts of things distinguish grief from depression.
Are anti-depressants ever useful in coping with prolonged grief, or is there a danger that they may extend the grieving process?
Anti-depressants can be very useful in cases of severe depression and intense, unrelenting grief. But unless people were taking anti-depressants before a loss, I advise most people to hold off for a couple of months after a loss to see how their grief trajectory unfolds. The first hits of shock and pain can feel disorienting. Often the pain will stabilize on its own. If after several weeks there doesn’t seem to be a respite, (people can’t stop crying, etc.), or if they are requesting an anti-depressant, it may be time to consider augmenting treatment with one. Sometimes clients will request an anti-depressant solely to stop crying just so they can go to work. I find, though, that for most people who take such medications, talk therapy continues to play a vital role.
Is there a danger of grievers being exploited by pharmaceutical companies who, as a result of the changes made to the DSM-5, could now target grievers as an emerging market?
Absolutely. But I’m pretty optimistic that we can fend off some of this exploitation because we live in a time when we are more educated consumers than we have ever been. Access to information keeps getting easier, and I suspect in the long run most of us won’t readily assume that the only remedy for grief and for navigating the existential labyrinth it unfolds can be solved just by medication. We as mental health professionals still have to constantly get our voices out there on how we can best help people get through difficult times, and let them know that there is a healthy role for distress to play after loss. I don’t want to live in a world where people aren’t allowed to feel sad or suffer at least a little bit after their loved ones die just so a corporation can increase its quarterly earnings.
Does the reader need a background in mindfulness studies to make use of your book?
No. In fact, I think it’s safe to say that the majority of people who read my books have had a very casual interest in mindfulness, if any. The momentum that the pain of grief brings has an urgency that can be harnessed to help people develop and maintain mindfulness meditation and other self-care practices as a cornerstone of their overall holistic health. The book is structured for beginners, but experienced practitioners can also use it to revisit their mindfulness practice within the context of their grief. I think many readers may be surprised to learn how the development of mindfulness meditation in ancient India was so intimately connected with grief and loss.
Can the processes outlined in your book be applied to other diagnoses of depression and adjustment disorders?
My book is focused on helping people cope with prolonged grief, but many of the core practices it contains are research-based techniques for establishing and maintaining optimal health for people suffering from many different conditions. Mindfulness meditation has been shown to be effective for depression—Dr. Zindel Segal’s research on depression relapse treatment and prevention comes to mind. If readers are experiencing distress related specifically to loss, they many benefit from my book. For conditions not related specifically to loss, there are a host of other excellent resources that may be more appropriate.
Sameet M. Kumar, Ph.D. is the author of the newly published Mindfulness for Prolonged Grief: A Guide for Healing After Loss When Depression, Anxiety, and Anger Won't Go Away, and the best-selling Grieving Mindfully: A Compassionate and Spiritual Guide to Coping with Loss. He is a psychologist at the Memorial Healthcare System Cancer Institute in south Broward, Florida with over a decade of experience in working with end-of-life and bereavement.