I believe we are a society living with intense anxiety and fear of trauma.
Clinicians, are you seeing and feeling what I am?
Here are my initial thoughts as a clinical psychologist:
I never went through Kubler Ross’s bargaining phase when my mother died. I didn’t try to tell myself if I did something or acted differently she would not die from pancreatic cancer, or ask somehow to talk to her again. I did dial her phone number after she died to hear her voice mail message. And, since she liked cherry soda, each time I went to the grocery store from then on, I bought her favorite drink.
I think part of this non-bargaining is because I had closure. I was there with family at her side when she passed. I also had brought her to my house with hospice care. Even excruciating emotional despair resolves itself better when you have closure.
She helped create that closure, too. After her diagnosis and with limited time remaining, her brother and sisters all came out for one final visit. She summoned them in, one at a time. She asked each one if there were any unresolved issues in their relationships with her. Each came out of the room with either tears or a smile, but also great admiration for her.
Consider how different each of us grieves a parent or a loved one based on the relationship and factors of our attachment to them. What if you weren’t that close to your mother? What if you do maintain major issues with your mother for past conflicts, from mistreatment, or while coping with her? All these types of factors make grief and grieving more complicated. All of this applies to the loss of any significant person in your life.
Next, consider far worse scenarios. The families of the victims of 9/11 lost their loved ones in a tragedy in which they didn’t even have any remains. Parents who lose their children in a school shooting face a loss so despairing the grief can feel insurmountable.
I submit that, because of the pervasive shootings and violent deaths our society faces, societal psychosocial despair is growing in a cumulative stress bomb that impacts every community in our country. In other words, I believe there is a collective societal prolonged grief that is affecting all of us on a daily basis.
It’s telling to this “national despair” viewpoint that the clinical psychology field has further developed diagnostic criteria for grief and has now added the diagnostic category of Prolonged Grief Disorder (PGD) in DSM-5 TR.
Here is the definition: DSM-5 PGD is present when, after the death of someone close at least 12 months earlier (Criterion A), a person experiences intense yearning or preoccupation (Criterion B), plus at least three of eight symptoms of: identity disruption, disbelief, avoidance, emotional pain, difficulties moving on, numbness, a sense that life is meaningless, and intense loneliness.
For a background and full discussion of PGD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473035/#:~:text=DSM%2D5%20PGD%20is%20present,a%20sense%20that%20life%20is
Prolonged grief disorder is experienced by up to 49% of people after an unnatural loss (such as the death of a child or deaths by accident, disaster, homicide, or suicide). https://www.sciencedirect.com/science/article/abs/pii/S0165032719315083?via%3Dihu
I should acknowledge that the criticism of the PGD diagnostic category is that it pathologizes the process of grieving.
My take is that emergence of the new PGD diagnostic category signifies the complex societal issues of persistent, ongoing and complex loss and trauma we are forced to live with everyday. The data that 49% of persons who endure an unnatural loss experience PGD is significant. This will probably increase with continued violence.
I believe we are a society living with intense anxiety and fear of trauma.
Are other clinicians seeing and feeling what I am?
Written by Dr. Jay Slosar
Commentators
- Adam Buhman-Wiggs
- Ann Becker-Schutte, Ph.D.
- Carolyn Gartner
- Christina Harrington-Stutzmann
- Dr. Stephanie Buehler (she/hers)
- Dr. Stacy Wright
- Dr. Margaret Rutherford
- Dr. Mira Brancu
- Dr. Jay Slosar, Psychologist
- Jeremy L. F.
- John Weaver
- Joshua L Cohen
- Keith Carlson, BSN, RN, NC-BC
- Kristen Markovich, Psy.D.
- Lee Blackwell
- Michael Fiorini, PsyD
- Phyllis Mogielski Watson, MS, PsyD (AZ/IL/CO)
- Ryan C. Warner, Ph.D.
This is my exact experience in therapy sessions for the last few years. Much more so today than at any other point in my career. In my assessment and through what I am hearing, there is a lack of “hope” that society can see itself out of the troubles we hear about on a continuous bases. There is a lack of perceived safety causing a mistrust for others, increasing agoraphobia, & creating intense levels of fear and anxiety about life and others. There is a disbelief that life can and will get better, be less stressful, hold the days of promise for a better life, and return to a time when all levels of society were working together for the betterment of all. I hear a general sense of hopelessness and disillusionment of humanity in my client population. It is worrisome to me as I don’t believe medicating one’s self through this perception is the answer. More action and engagement is necessary. Advocacy and finding purpose again are some ways through this.
There is a difference between grief counseling and grief therapy. The new DSM-5 PGD criteria has been instrumental in guiding me to differentiate between my treatment plan of grief counseling versus grief therapy. The field of grief therapy is exciting with new modalities such as Dr. Shear's evidence based trainings out of Columbia University. I also agree with other clinicians in that it allows for financial compensation and insurance reimbursement. Grievers benefit all around. Separately, anxiety is pervasive. I see in in all my of my clients, my family and myself. There is absolutely a collective anxiety humming in the background for all of us. This certainly affects our mental health.
I believe the literature supports that healthy grief is resolved through connection and communication -- both of which have declined substantially in the past decade. Our lingering, lonely grieving is likely a direct consequence of our loss of connection and safe communication with each other. Therapy is often the last refuge of both.
Frank, empathetic conversations about the complications of grief are important, so I appreciate this article. I also appreciate the framework of a social increase in anxiety and fear of trauma. In my practice, I have seen an uptick in the past 6-10 years of clients who are describing intense anxiety about safety in their daily lives--both physical and emotional safety. The collective, ongoing experiences of the COVID-19 pandemic seem to have intensified these concerns. I share the mixed feelings noted by others about the addition of PGD to the DSM-V-TR. I appreciate any step that makes therapeutic care more accessible, but I am concerned about pathologizing normal and appropriate human experiences. In my practice, I often see folks in acute grief for well over a year after a loss, even if the loss was expected. When loss is traumatic, it makes complete sense to me that intense grief symptoms would persist even longer. Thank you for the thought-provoking article.
I think some of this holds true, and what was pointed out already here speaks to the surface level traumatic events that affect us and hold our attention. Having said that, I also see these events in contrast to our cultural expectations. Namely, the cultural rhetoric normalized in the wake of the sexual revolution that morphed into the yuppie capitalism of the 1980’s that capitalized on the more saccharine and idealized aspects of American culture. It hit a boiling point through the 90’s with the end of the Cold War and a preoccupation with feeling somehow everything was “getting figured out.” The idea that racism even existed at that point was considered, amongst many people, a social faux pas. Then, in 2001, we had a very rude awakening that made, understandably, very little immediate sense to anybody. What all of this says to me is that, during both euphoric and dysphoric cultural periods we tend to have a very short memory, much in the same way that someone with depression has the sense that they will always feel depressed, or in the way someone with bipolar will ride the euphoria of a manic episode believing, on some level, that it can be maintained. I have definitely noticed a collective malaise amongst people, and none of it is surprising to me considering the broader context it’s occurring in. That there’s been a major upheaval in what people can agree on in terms of leadership and a coherent national identity or dialogue is a symptom, not necessarily the fundamental cause of what’s going on. Lasting change in people, or any change, is typically spurned on by needing that change, something I think most of us can confirm is what is present in every intake we have with clients. When we’ve really had enough and the malaise can’t be enabled any longer, things will improve because there’s no other choice. Until that happens, in my view things will continue as they have been.
I think we as a nation had trouble with grief long before we were exposed to horrible events like recent mass school shootings. As a culture, we live in collective denial; even when a loved one dies, many people do not take time to grieve. Instead, what I have noticed is that people often turn to workaholism to avoid feeling loss, heading back to work within a day or two. When you add societal trauma to personal trauma, it is no wonder that people experience prolonged grief.
Let's face it, we all treat grief and just diagnose it as an Adjustment Disorder so we can get paid! This is needed!
Jay, Thank you for your thoughts. When I think about the metaphor of grief applied to our national experience, I think it can guide us toward an important national discussion. First, when I think of what is healthy grief I think about an encounter I have many years ago with a father whose teenage son died unexpectedly from an allergic reaction to a food he consumed. The unexpected tragedy was very difficult for this father. As we worked together, I asked him a question: "If I could take away your pain and suffering, but it would mean that you no longer remembered your son, would you do it?" His immediate and emphatic response was "No!" This changed our conversation, because healthy grief is not about alleviating pain and suffering, it is about identifying what is truly important about the individual (or, in our metaphor, the nation) for whom we are grieving and preserving those memories as well as carrying forward in ways that honor the contributions of that person so that what is valuable is not lost. The national grief could be seen as a call to remember what is truly important about our experience as a country, letting go of those things that are trivial, and finding ways to fully honor our experience. I hope we can do that.
"Even excruciating emotional despair resolves itself better when you have closure" — I could not agree more, and I fully appreciate your take on these salient issues. You also wrote: "I submit that, because of the pervasive shootings and violent deaths our society faces, societal psychosocial despair is growing in a cumulative stress bomb that impacts every community in our country. In other words, I believe there is a collective societal prolonged grief that is affecting all of us on a daily basis." — This "cumulative stress bomb" that you speak of is something we've collectively experienced at various periods throughout history, and I agree that we're currently in a time of extreme accumulation of grief and trauma that are tearing at the fabric of our culture and society. We need as many talented, thoughtful, and sensitive mental health clinicians as we can get, and I thank you for this very meaningful post.
The points made by others here are things I've also witnessed in my thirty years of practice. In general, our Western culture seems to support avoidance and distraction from grief. How many times have I heard from those who've just gone through loss of some kind, "It seems like people expect me to be "fine." Unfortunately, giving prolonged grief a "diagnosis" seems to both a blessing and a curse - it means that its treatment can be covered by insurance and concurrently, it infers pathology. Very thoughtful article.
I feel that recognizing suffering as part of the process in life is post-traumatic growth, and movies and art can help us to better work through that pain and move into growth by suffering in a context by providing a model that has meaning and connection. By coming together through film discussions, group screenings, or collaborative film projects, community members can share their experiences of suffering and happiness, support each other's healing processes, and build a strong sense of empathy and resilience. This act of viewing films and engaging in discussions is called Cinematherapy, a concept coined by Dr. Gary Solomon, a social worker, psychotherapist, teacher, and movie doctor. https://filmandvideobasedtherapy.com/dr-solomon/ Groups like Veterans Media and Entertainment https://vmeconnect.org/ touch upon societal issues, personal struggles, and the complexities of human suffering, combining them with entertainment for an enjoyable experience. #FilmTherapy #CommunityBuilding #PostTraumaticGrowth #Happiness #WellBeing #EmotionalResilience #MediaPsychology #therapeuticadvertising
Grief needs to be categorized and seen as pathological.Their is a lot of misinformation out there on grief, and separating it from how mental illness is financially supported can be challenging. Unfortunately, living in society is getting more expensive, and resources can be limited without insurance companies' "support".The PGD diagnosis gives financial compensation for grieving patients and their systems, time off from work, and a break in responsibilities to heal from their loss.Individuals who are experiencing intense grief can have difficulties with sleep, miss payments and deadlines, disrupt relationships, and keep up with other responsibilities in their life during that time of intense loss. Recognizing intense grief this way can increase individual's assess to treatment longer and give them other extra support that are necessary for healing.As mental health providers, it is our responsibility not to disenfranchise their grief. Especially, as you point out here, there is more intense anxiety and fears of trauma in our society. We should not be adding to this by our own lack of awareness of how systems are operating here together and our own mortality personal views. Isn't this a national trauma? #emotionalliteracy
I see this as global human burnout in addition to prolonged grief. As a clinician of kids, teens, and adults through the “pandemic time warp” (as I like to call it), the amount of relapse among clients, burnout of clinicians, healthcare workers, teachers, police officers, basically EVERYONE (yes I’m using an all-or-nothing term here ?) is unbelievable. It seems everyone is living in a post-war type of brain fog… the tik tokkers may loosely toss around the term “dissociation” to describe what I’m seeing as a mass societal numbness and demoralization. Like… What. Just. Happened?! The past few years were far from anything we’ve ever been through in this lifetime and we will continue to see the negative impact socially, emotionally, psychologically and culturally as we try to recover. Not only was it a pandemic, but wars have broken out, school shootings are out of control, distrust of the medical system and govt has erupted. Political battles are incessant not just in DC, but in our own classrooms, dining room tables, etc. Layer in some record-breaking earthquakes, fires, hurricanes, train derailments, media wars, and oh yah, a recession. The amount of overwhelming burnout and collective trauma is a Real. Big. Problem.
I am hearing about fears of shootings and stabbings by lone wolves, and that our society is fragmented and in danger of social upheaval or even civil war. People are avoiding malls, theaters, and other public places where there are large numbers of people. When vicarious trauma of violent deaths here and around the world are added in, our ability to process it all can overwhelmed. Our brains defer maintenance during stress, and in chronic stress the lack of maintenance shows in the form of blue mood, appetite problems, sleep problems, sexual problems, brain fog, and ultimately, clinical depression. Certain beliefs can help, such religious faith, or belief that humanity will find solutions to our troubles. Right now, we don't have a national or world forum for processing it all. Thank you for starting this thread, Jay
I really appreciated this post! Prolonged grief disorder may at times be difficult to differentiate from major depressive disorder. Additionally, this diagnosis may unintentionally pathologize the natural process of grief and put a firm timeframe on how long a “healthy grieving process” may look. We understand that the healing process may vary on the individual and their unique characteristics. As clinicians it is essential that we consider how cultural factors (e.g., gender, race, upbringing, trauma history, environment, etc.) may impact how this diagnosis is conceptualized, assessed, and treated.
I think what might be difficult to tease apart is the overlap In symptoms and experiences between prolonged grief and trauma (which can also be experienced at the national/societal level in addition to the individual). What are your thoughts on that?
We sure do--Thank you.
Yes it poses a dilemma. Once we create a DSM category, capitalism kicks in. Then look out. It can be discouraging. To me, though, setting the delineators or markers in the definition are helpful. I always answered the question how long does one have or feel grief and loss and I would just say from my own experience that after a year of special days without them somehow you get used to it. Or maybe immune to it? I always cringe and worry when a parent says about their child surviving a loss: “he/she is handling it so well.”
Per your comment about avoidance and distraction--- On the national level--, I am struck with 1 million people died from COVID more than all our wars combined. You know individually people had tremendous grief but we society just seems to say oh well.
This is an issue I discuss with my clients regularly. Collectively, even if we as individuals did not lose a loved one to COVID or gun violence or a natural disaster, we have faced an enormous series of losses. There appears to be an expectation that we just "move on," without holding much space to process these losses.
Joshua thank you for providing all these resources.!!
Overall I think the PGD diagnosis is helpful and the criteria help us put into words how grief is impacting us and lends to therapeutic discussions. But grief is a part of life. However, as I note the unnatural deaths have overwhelmed us. But I have referenced in my book many years ago the book by Judith Viorst- Necessary Losses --self development is related to our coping with loss. https://www.amazon.com/Necessary-Losses-Illusions-Dependencies-Impossible-ebook/dp/B003L77W96#:~:text=She%20argues%20persuasively%20that%20through,and%20fuller%20wisdom%20about%20life.
Grief is not always negative; it's a part of life. Traumatic experiences disrupt our autonomic nervous system and result in suffering. Through the therapeutic use of films, individuals can explore and process their traumatic experiences, derive inspiration from stories of resilience and growth depicted on screen, and embark on a journey toward personal transformation and self-awareness while entertained. Paul Petshek, a film editor, member of the Director's Guild, and a Somatic Experiencing Practitioner, exemplifies how this process can be used in filmmaking to appreciate art and life.
By embracing the power of film and its potential to integrate ideas, foster community, promote post-traumatic growth, and deepen our understanding of suffering and happiness, we can cultivate a more balanced culture that embraces both trauma and healing while providing a fulfilling way of experiencing life through collaborative efforts. Film serves as a model for this process. Through the shared exploration of films, we can find healing, resilience, and a path toward greater understanding, happiness, and post-traumatic growth. Filmmaking and viewing enable us to build stronger communities that support each other's growth and well-being.
Joshua I really do think art therapy has emerged as a vital therapeutic response to the grief and trauma an individual endures but also for us in general living under such fear and anxiety of ongoing shootings. I think art and art therapy should really be emphasized in schools especially with younger children.
I respectfully disagree that it would only be used with children. I've seen firsthand work with adults AND families in the military in reducing symptoms of post-traumatic stress. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234913/ This qualitative research study done by the grandson of General Patton and clinical psychologists from Israel shows how it reduces post-traumatic stress in military populations. Furthermore, virtual reality is also used by the military and documented in my book by the work of Dr. Skip Rizzo from the Institute of Creative Technology at the University of Southern California with the Army. When we are traumatized, we cannot access the language portion of the brain that makes talk therapy possible. Art, sports, kinesthetic, and sensory activities help regulate the autonomic nervous system, making talk therapy possible for any age at any talent level. This is backed up by research by Bessel Van der Kolk, Peter Levine, and many other body-based theorists stating that therapy is about the therapeutic relationship, which all evidence-based therapy is founded on at some level.
The power of interaction and connection should be considered. As esteemed art therapist Cathy Malchiodi emphasizes, the therapeutic relationship is crucial in healing. Whether with a therapist or fellow community members, genuine connections provide a safe and supportive space where individuals feel seen, heard, and understood. Through these relationships, individuals can navigate their healing journey, gain new insights, and find solace in the shared exploration of suffering and the pursuit of happiness.
Thanks Lee. Your conclusion points out solutions and a course of action.
Yes in the long process of developing PGD criteria the critique was it might pathologize grief. Certainly cultural and social factors are at play and each case is unique. The unnatural deaths component is important as to what is happening today leading to my premise. I do think the 8 criteria/components of PGD are helpful in describing the impact/effect on individuals and lends itself to elucidating therapeutic issues.
Sure if the PGD persists it then leads to possible PTSD diagnosis. The research showed the link between PGD with PTSD. My societal level and cumulative stress model is the idea that we are having visceral responses and vicarious reactions that are impacting all of us. This is the society we currently live in. Will we need to become immune to grief to psychologically function?