Numerous people are referred to psychotherapy with the diagnosis of
depression. They are seeking relief for experiencing severe sadness, due
to loss of something dear to them. During the first session, they
describe various losses such as: loss of health due to illness or an
accident, financial losses, loss of a job, unwanted divorce, a close
friend moving far away, a home destroyed by a fire or death of a closed friend or relative.
My therapeutic approach in all cases of depression, due to loss of something dear to us, is based on changing the label. My assumption is that such a loss does not cause depression but rather a sense of mourning. When such sad feelings are diagnosed as "depression," it categorizes the person as having a severe psychiatric disorder. As a result, it may affect negatively the self image and the symptom of sadness may linger for a long time. Changing the label from depression to mourning, may have a positive effect since we all know that mourning is a normal feeling, and it diminishes gradually.
The Jewish tradition, as opposed to the Christian one, has a very positive approach to human mourning. In the Christian religion, at the end of the service the mourning family invites those in attendance to a large meal. On the next day the mourners return to their usual routine, be it work or school. In the Jewish tradition, the mourners cope with their pain in three stages, which differ in their length of time and intensity of sadness.
The first stage, called the “Shiva,” lasts seven days. This is shortest stage, in which the emotional pain and its outward expression are the strongest.
The second stage, called the "Shloshim,” lasts the first month. This is a longer stage while the emotional pain is diminished.
The third stage, which lasts the entire first year, is the longest period of time, during which the emotional pain level is the lowest.
There is a basic difference between mourning for a death of a loved one and mourning for the loss of something we hold dear. When mourning for a loved one, we try to keep the framework of time: seven days, one month, one year. However, when we lose something important, the length of time of each stage varies: there are people who "sit Shiva" for many years due, for example, to the loss of a leg in an automobile accident; another person may "sit Shiva" for the loss of his leg only for a few days or weeks.
During any type of mourning, be it the loss of a human being or something we hold dear, the boundaries are not set in stone. As an example: during the Shiva, the mourner sometimes behaves as though it were the second stage; he may laugh or talk about everyday issues. On the other hand, during the first year the mourner sometimes behaves as one might during the first week, the Shiva; he may cry uncontrollably when memories of the loss overtake him.
It is very important that the people close to the mourner not try to stop the feelings from coming to the surface. On the other hand, it is important that the mourner understands that the feelings of sadness are normal and even positive, and that in time they will lessen, although occasionally may resurface again even in the distant future.
A Case Study
The phone rang. A
woman introduced herself. She sounded
very upset, “I would like you to see my daughter no later than today… her
condition is serious… she has been very depressed for a month now… she lost
five pounds… she doesn’t go to school… she cries all day long…” The mother started crying and begged me to
see her daughter.
My gut feeling was that this was not a case I would be happy
working with. In the past year I have
been trying to lower my workload. I
prefer to spend my time writing a new book to taking on new patients,
especially those needing long term treatment.
I suggested to the mother to contact a psychiatrist.
The mother continued her efforts to convince me, “I’m
pleading with you, see her just once… examine her… maybe you’ll be able to help
her without psychiatric medication… until a month ago she had no psychological
problems… she’s an excelling student, friendly, well liked everywhere… since my
father died a month ago she has been in deep depression.”
The challenge convinced me.
If the problem started a month ago as a reaction to the grandfather’s
death, she may be helped without medication and with short term methods. I suggested to the mother that I would meet
her daughter once, at which time I would decide on what might be the best
treatment for her.
Limor and her mother showed up in my office the next
day. Limor, 14, is a very tall and slim
girl. Her face is sad, her eyes
lowered. The depression is prominent in
her appearance. On the other hand, her
mother is plump and her movements are tens. I asked Limor to tell me what she was going
through. “Since my grandpa died, I’m
crying all day long. I don’t feel like
going to school,” she told me in a soft and sad voice. “Were you very close with your grandpa?” I
asked.
“He was my grandpa. I
loved him as I did my other grandpa. I
was sad when he died,” she continued in her low voice.
The mother jumped into the conversation. “I was very close
with my father and he died suddenly of a heart attack,” she said in an animated
tone. “I have a twin sister whose
husband underwent a bypass surgery on the day of my father’s funeral. Right after the funeral I went with my sister
to the hospital and we sat with her husband.
His condition was very serious.
We were unable to sit Shiva [seven days of ritual mourning] for my
father. To this day, a month after my
father’s death, my sister and I are taking care of her husband every single
day.”
The picture became clear right away. I turned to Limor, “Limor, in my opinion you
are not depressed at all, you are still sitting Shiva instead of all your
family members. Your mother and aunt are
busy taking care of your sick uncle, your father must work and therefore all of
the mourning fell on your shoulders.
I asked Limor and her mother a rhetoric question, “Have you
heard of an ancient profession that was very common in the olden days, that of
wailers?” They nodded yes. “In the past, when a family member passed
away, the family would hire a few wailing women whose job it was to mourn in an
exaggerated fashion. They expressed the
family’s feelings and thus lightened their burden and enabled them to go
through the difficult period. The
wailers cried loudly, tore out their hair, scratched their skin, and performed
all the customary mourning rituals of the community at that time.”
“But I did not intend to mourn instead of my mother and
aunt,” said Limor.
“It seems to me that your subconscious volunteered you for
this role without consulting you first.
By mourning so thoroughly you were able to exempt your mother and aunt
from mourning and freed them to take care of your sick uncle.”
I turned to the mother and explained, “Since family members
misunderstood Limor’s contribution, you interpreted her behavior as depression
instead of seeing it as positive mourning.
You should be grateful to Limor for taking upon herself the role of the
family mourner.”
At this point I decided to explain to Limor and her mother
the three stages of morning according to the Jewish tradition. “The first stage
is brief but very intense. The second
stage is longer but less intense. The
third stage is very long but even less intense.
The three stages are: Shiva [seven days], Shloshim [thirty days], and
the first year. Although tradition
assigned a certain time period for each stage, for each person the length of
each stage varies somewhat emotionally.
There are people for whom the Shiva stage lasts ten days, while others
feel the need for intense mourning only two days. The stage of the first month of mourning may
last emotionally several days, a number of weeks and even a few months. This is true also for the first year of
mourning. The length of each stage
depends on the emotional needs of the mourner and very often the stages overlap
as far as the intensity of mourning is concerned. We must respect the mourner’s feelings and
not rush him to move to the next stage before he is emotionally ready to do so. It seems to me that Limor is still in the Shiva mode although a month has passed since her grandfather’s death.”
I addressed Limor in an authoritative tone, “Limor, I
suggest that you don’t stop mourning before you are ready to do so. Once your subconscious feels that the time
has come to move to the second and third stages of mourning, and of course when
it’s time to stop mourning, it will let you feel it naturally. You must trust your natural senses.”
Before we ended our session I instructed Limor to eat easily
digestible food, in small quantities but frequently because the digestive
system is sensitive at times of mourning.
I also suggested that she take multivitamins because in the last month
she had lost some weight and felt weak.
We arranged to meet again in a week.
A day before the second meeting Limor’s mother called. She asked to postpone the meeting because
Limor had a bad pain in her right foot and had difficulty walking. According to the mother, right after leaving
my office, Limor felt great relief. “She
looked like her old self again. She
called her friends, arranged to meet with them, she laughed and even regained
her appetite. In the evening she went
with her friends to a bar-mitzvah party of a close friend’s brother. At the party she fell and since then her foot
hurts and her mood is down again.”
I suggested that the mother bring Limor to my office in
spite of the pain in her foot. When they
came into my office I was surprised that Limor looked and sounded very
calm. I asked her to describe her fall
to me in detail. “I was glad to go to
the party. At the beginning I talked to
my friends, we laughed a lot and I even had a healthy appetite. I ate everything. I felt as if my mourning period was
over. Then the dancing began. I really like to dance. I take ballet and jazz lessons. At parties I like to show off on the dance
floor. On the way to the dance floor
there was a little step on which I fell and since then I’m suffering from
terrible pain.”
Things became clear to me, “Is it possible that your
subconscious was not yet ready to dance at a party? Maybe it felt that it is inappropriate to
dance a month after grandpa’s death?” I asked.
“Do you know, Limor, that our body resembles a car? Every car has two pedals: gas and
breaks. The gas pedal propels us
forward, to grow, to dare, to experience new and exiting adventures. Fortunately, there is also the break pedal,
otherwise we would behave hastily and turn over on turns. When we act in haste, we endanger ourselves
and others. The break pedal helps us
slow down. Sometimes when we drive too
fast we have to press the break pedal very hard and then the car starts shaking
and the breaks start squealing. Is it
possible that your fall and pain were some kind of subconscious breaks that
stopped you from leaping onto the dance floor before you’re emotionally ready
for it?”
“I didn’t think about it,” replied Limor, “but the way you
describe it, it sounds very reasonable.
All my friends know that my grandfather died a month ago and I’m very
sad. I’m trying to imagine what they
would think of me if they saw me dancing happily on the dance floor.” For a
long moment she was lost in thought and then she summed up, “Maybe it was lucky
that I fell.”
We set up another appointment for a week hence. The mother later cancelled the meeting
because according to her Limor recovered and had the feeling that she did not
need additional sessions. I offered my
services for additional meetings, if needed.
At
the end of the first session I thought about John Price’s theory regarding the
contribution of depression to survival, as expressed in his book Evolutionary
Psychiatry: “In the depressed state, the message of the yielding is conveyed
both to rivals and to allies. To the rival competitors it is as if the
depressed individual is saying, ‘I am sick and therefore no threat to you. And to the supporters, ‘I am sick and I need
your help.’” In my opinion Price’s explanation is not applicable
to depression frequently occurring in times of mourning.
I suggest there are three contributors to depression
in time of mourning:
1. In prehistoric times the main cause of death of the
young, old and sick were animals of prey.
As a result of being in a depressed mood, family members were more
cautious, took fewer unnecessary chances, and as a result they survived longer
than people who did not develop a gene that caused them to mourn. This can be equated to a situation where a
person was involved in a catastrophic car accident and for a few months his
family members become much more cautious when driving.
2. When a mourner exhibits a depressed body language, he
creates in his family members a desire to unite and support him. The conclusion is that symptoms of depression
in time of mourning contribute to a rise in solidarity and support among family
members, thus increasing the chances for their survival. In the modern era this phenomenon can be
recognized in the fact that many families gather only for joyous occasions or
funerals.
3. In the modern era, during mourners’ visits, the mourners
and the people consoling them usually exchange memories relating to the
deceased person’s illness and death.
Maybe in the previous era members of the extended families strived to
improve the chances for their survival by exchanging stories about and learning
lessons from the fact that one of the family members was killed by an animal of
prey. The presumption that mourning has
a survival goal for the entire family is supported by the fact that we mourn
only a family member and not a stranger.
The extended family members have similar genetic psychological and
physical characteristics and therefore learning lessons about the event that
caused the death of one of them may bring about better life experience and
survival for the rest of them.
