“Sooner or later, some of those who avoid all conscious grieving, break down—usually with some form of depression” (Bowlby, 1980. p. 158).
Despite the mountain of material written about depression, the different types of depression, its diagnosis, symptoms, and treatment, I continue to be struck by the number of clients who front to therapy with a diagnose of depression, with what I can only describe as unresolved grief.
Time and again when I work with clients with a diagnosis of depression, sooner or later, we touch on some aspect of loss: loss of a loved one sometimes but more often than not, it’s loss of a different kind. It’s the loss of a job, loss of a friendship, loss of a relationship, the loss following the ending of a period of one’s life (e.g. empty nest syndrome), loss of health, loss of income, etc. Once it was even about the loss of a series of houses (from a person who had never really had a permanent home).
I began to wonder. If you don’t deal with your grief, can grief lead to depression?
Upon mentioning their loss, almost immediately, many clients experience an associated change in mood. Often there is a a crack in their voice, a discernible distress across their face, sometimes a few tears. Then almost in the same breath, they try to shut down this connection with their sadness, often apologising for their ‘emotional’ response, describing it as ‘silly’ or saying something about how they ‘shouldn't feel this way’.
It’s often quite difficult to catch such clients in these moment with their emotions so good are they in quickly disconnecting and keeping the feeling at bay.
Moments later as we attempt to identify what just happened, they often comment that they ‘don’t know’ or that such emotions from time to time ‘catch them off guard’. Some are even annoyed by their emotional ‘hiccup’. Almost always in these moments, I ask if they could put a name to the feeling, what would it be? “Sad” is by far, the most common response. So I then ask ‘“What have you done with this sadness?” More often than not people respond with a quizzical look. “Done with it? What does that mean?” Or they reply with something along the lines of “Nothing. I just got on with it” meaning following their loss, whatever it was, they continued with the demands of their daily lives, continuing to care for children and/or ageing parents, going to work, meeting deadlines and doing the hundred and one things required to keep a family going.
Remember, these people turned up in therapy with a diagnosis of depression. Can grief lead to depression? Any kind of grief? And why are they in such a hurry to disconnect from their lingering sadness?
What is Depression?
Training in diagnosing depression for a psychologist is often focused on a checklist of clinical symptoms, their intensity and/or frequency over a period of time. Typically these symptoms include a general withdrawal from usual activities, an overall negative change in mood and a decrease in physical activity or energy. Stressful life events such as those mentioned above often also examined in association with a diagnosis of depression but the idea of ‘grief’ as linked to such events is not a usual consideration. Historically the term ‘grief’ has only been been used in relation to the loss of a person and this type of grief (bereavement) was historically excluded from a diagnosis of depression.
Depression and bereavement (the loss of a significant person) often look very similar in relation to symptoms. Feelings of sadness, anger and anxiety are often common in both situations. There is often a marked decline in physical activity and feelings of fatigue. Thinking may also be effected in relation to experiencing confusion and/or disbelief. And in relation to behaviour, there are the shared symptoms of changes in sleep patterns, a withdrawing from social activity, changes in appetite and often periods of crying.
Over the years however in sitting in quiet rooms with hundreds of people, this one particular question kept presenting itself time and time again? Can grief lead to depression? What is the relationship between unexpressed sadness associated with a stressful life event and the onset of depressive symptoms? Do those who fail to process their grief end up depressed?
Stuck in grief
Martin was admitted to a psychiatric hospital due to his altered mood and aggressive behaviour at home. Martin had in his own terms been a ‘workaholic’ for most of his life, starting each day around 5am and often not finishing till 7pm. He had accrued all the rewards along the way with promotions, a secure retirement fund and a large and beautiful home which he and his wife had designed. Six months into his retirement he was still rising early, wandering around the house, and according to his wife “interfering in her day”. His attempts to engage himself in golf or volunteer work had held little attraction for him and since ending work, he had little contact with anyone other than his wife, adult daughter and her family. Martin was irritated most of the time. He reported little to look forward to (the occasional family birthday party or barbecue) and had little interest in anything. He was losing weight and his sleep was poor. After his initial reluctance to engage in any therapy, he met with me to discuss his hospital discharge. As I asked about his working life, he gradually became more animated, telling story after story of challenging moments and singular achievements. As I made mention to missing his work, he came over with a marked change in demeanour and replied that it was ‘stupid to miss working yourself into the ground’. What also caught my attention was the cracking in his voice.
Martin reported he had ‘no reason’ to be depressed, had ‘more than most people living on the planet’ and was reluctant to connect with his feelings over the loss of his working life. When I asked him about his previous experiences of grief, he replied that he had lost both parents in his late forties. Being the eldest he had organised the funeral, the solicitor and the support of his two younger sisters. He had not shed a tear at either funeral but had returned to work after one day off.
I have learnt over the years that this is typical of many Australians dealing with grief. Many believe a ‘no tears’ approach is a ‘good’ (strong) way to cope and that ‘indulging’ in crying or having more than a day or two off work would be ‘weak’ or indulgent. Stoicism it would seem is highly prized by most people and anything less, particularly engaging in the emotions of grief are viewed as unhealthy, or as ‘giving in’. “Carrying on” as before would appear is the aim, if not the motto of many people following significant stressful life events.
What Martin wasn’t aware of however was that he carried the loss of losing his career. Although no one had died, he carried this loss with him everyday, regardless of where he was or what he was doing. In his own words, his ‘pretending’ that all was well, was in the long run exhausting and untrue. Martin believed wholeheartedly that to engage with his sadness was a sign of weakness, unmanly and the road to depression. In truth, the exact opposite was true.
After speaking to Martin on several occasions, it was then he who asked me “Can grief lead to depression?”
Stages of grief
“Each man’s grief is like no other man’s grief” (Allport, 1957)
In an attempt to better understand the universal but unique grief experience, researchers have attempted to describe the healthy grief process as involving a number of stages or phases (e.g., Kubler Ross). Others however have suggested that grief, rather than being a passive process which we pass through, is something that a person must actively engage in. Worden (2009) describes that healthy grief process involves four main tasks:
Though Martin had not suffered a bereavement, the loss of his career, the loss of his identity and the loss of meaningful activity were major and though Martin thought he was doing the best thing by ignoring his sadness, in effect he had steered himself down the path to depression.
Processing Grief to deal with depression
Never in a million years had Martin considered his retirement as a loss requiring a grieving process. After all, he had planned his retirement for years (at least the financial aspect). Initially the idea sounded ludicrous though as he talked more of what he missed about work, he too began to notice the sadness this triggered in him. Due to some fortuitous timing, he met two other men who were reeling from the unexpected demise of their careers (one in the armed services and one due to a the collapse of a family business). Similarly these men had not experienced the loss of a loved one, but again were depressed over the loss of the livelihoods. When the ex-service man had spoken of his loss of career, he had been overcome with grief and cried openly. So many years of training, sacrifices, moving around the country had come to nothing. Martin began to see that the loss of a career could indeed bring much sadness.
Over several sessions with these other men, Martin began the process of allowing himself to feel his grief, a thing he would have previously described as ‘weak’. Each man wept over what he had been, the challenges he had faced, the failures he had experienced and the funny moments he had enjoyed. Each was able to acknowledge the other’s experience. Each was able to offer support. All three were surprised by the depth of their grief, the anger that came with it and the relief in expressing such emotions.
One of Martin’s main concerns was the void which appeared to be the rest of his life. He had entertained notions when working that he would do volunteer work but had done little to pursue this and then had fallen into depression. Part of his therapy involved talking about what the next chapter in his life might be. Did he have any interests? Were there things he wanted to do? Passions? Like many men, Martin didn’t have a clue, had never had time for hobbies or interests and his one time to the golf course had been less than exciting. When Martin invited his wife to attend a session, she had talked of giving the idea of a ‘grey nomad’ a go. Martin was not keen but realised he at least needed to consider it an option or return home and resume his pointless wanderings around the family home. He had several sessions with his wife where he explained his growing understanding of the sadness and anger that had interrupted their life together. She had then asked him “can grief lead to depression?” They had discussed a mutual strategy whereby he agreed to no longer withdraw in silence but speak with her about what he was experiencing. She too agreed to voice her concerns if spending too much time together was ‘driving her around the twist’.
Before hospital, Martin had put his working life behind him. On returning home, he made a space in his study which included photos and memories of his lifelong career. There was a photo of his first real office, photos from his final farewell and some pieces of old machinery they had used and then removed when the new machines were introduced. A life time of activity reflected in a few photos and mementoes. He began to realise that while no one else was particularly interested in what he had done or achieved, he was and these continued to make him feel good about himself.
When Martin did leave hospital, his life was not ‘perfect’ and there were still many issues to resolve, particularly around how we might spend the next twenty years of his life! But the difference in him was tangible. Martin was now engaging in the loss he had experienced and had learnt to engage in his emotions. Rather than believing them to be a sign of weakness, he had learnt that engaging with his emotions, while unpleasant had provided relief and a growing sense of regaining his psychological and mental strength. He was no longer isolated and pretending that all was well. The strain in his relationship with his wife was replaced by a greater intimacy.
What about you?
If you have experienced depression ask yourself the following questions:
Have you experienced the loss associated with a stressful life event? Loss of job? Health? Home? Relationship? Finances?
What did you feel following this event?
Did you acknowledge these emotions as genuine or did you keep quiet about them and try to ‘carry on’ as before?
Did those around you acknowledge your loss, your feelings or did they (with the best of intentions) encourage you to ‘be strong’?
Did you find yourself ‘putting on a brave face’, saying things are ‘fine’ when on the inside you felt anything but this?
What have you done with those emotions associated with the stressful life event?
Loss and grief come in an endless variety of shapes and forms and all need to be processed in a healthy, affirming manner. Ignoring your sadness, pretending your not sad or trying to focus on the positive are all short term distractions that may lead to depression.
If you are looking for answers to the question “can grief lead to depression?”, then come to the free seminar on Depression and Unresolved Grief.
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