The Psych Writer: Grief – Phase Six: Depression

This has been a dreary series for some, I’m sure, so thank you to all the readers who are stubborn enough to get through it with me. For others, you understand that death and grief are part of the human condition. It’s worth closer examination. Sometimes it even helps.

Last week as part of The Psych Writer series, we took a look at the fifth phase of grief: anger. This week, we examine depression.

Remember (and for regular readers, say it with me): these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

As clinicians we have a bit of a conundrum on the use of the term “depression” here, because depression is a clinical diagnosis. It’s more than just feeling sad. Depression is an illness that is typically long-term, can be lifelong, and can be hazardous to the patient. Yet we use the term here because depression not only means feelings of sadness, but a patient can develop Major Depressive Disorder in this phase. Not only that, those who already have MDD can face a downturn in mood or behavior. In other words, grief can push them further down the spiral.

Basically, you’ve got a lot of shit to do in this phase, too.

Depression from the Patient’s POV
Life is empty and pointless without X, where X is the source of loss. This is the phase most commonly associated with grief, so chances are, you’re familiar with it. Life is colorless. Bland. Some of the things I’ve heard from people in this phase have been soul-sucking. The depths of despair when facing a loss can be, well, depressing.

“I cannot live without them.”

“Not even food tastes the same.”

“I’ll never be able to listen to jazz again. It reminds me too much of my [loved one].”

“We used to go for walks together every day. Now I can’t even get out of bed. Without X, it’s just not worth it.”

“If I’m dead, then I can join them.”

Anything you can imagine that reflects the loss that’s depressing as hell can be found in this phase. It is utter disaster for a patient. Some believe they will never recover.

Sadly, some won’t recover. Some will spiral into MDD, and some will get worse if they already have MDD.

Depression from the Therapist’s POV
It is up to you to help the patient move away from this phase. It is not done quickly, and there is no efficient magic trick to make them better. Sometimes, you have to call in a psychiatrist’s consultation, particularly if the patient is already on medication for MDD, or they really should be on something for MDD. No, you’re not giving them a magic pill that will take away their pain of loss; nothing will do that. When you suggest medication, it’s because you are using a tool that may help pull them back from the abyss and give grief clarity.

In other words, you are helping them to just grieve, rather than get sucked down into the horrific abyss of MDD.

Remember some of the things I mentioned that I’ve heard from people in the depression phase? Let’s look at them through the lens of an ethical therapist.

“I cannot live without them.” (Silent warning bells. Find out if the patient is suicidal. Find out if they have the plans, and means. You may have to hospitalize.)

“Not even food tastes the same.” (Anhedonia is possible. Discuss what this means for the patient. Find out if they’ve had any unexpected weight loss. Note it. If patient has history of an eating disorder, consult with treatment team. Work with them and the patient. Work with the patient to help them find a way to remember their loved one through food, but in a healthy way.)

“I’ll never be able to listen to jazz again. It reminds me too much of my [loved one].” (Anhedonia is possible. Discuss the reasons. Let the patient talk and tell you a story about their loved one’s favored music. Help them remember this is a process and that over time it may become a positive way to remember the loved one.)

“We used to go for walks together every day. Now I can’t even get out of bed. Without X, it’s just not worth it.” (Loss of a physical activity can make depression worse. Discuss and explore alternatives, or how to get back to walking, etc.)

“If I’m dead, then I can join them.” (MAJOR ALARM BELLS BETTER BE GOING OFF IN YOUR HEAD. Patient has suicidal ideation. Check for plans and means. Hospitalization may be necessary.)

What this Means for You, The Writer
Of course it depends on where you’re going with the story. Usually when a writer examines grief in fiction, this is the phase that they start at because it’s the most recognizable and seemingly the one that gets the point across. Your character may have stopped eating. They may overeat. They stopped showering and grooming.

But consider writing from one of the different phases or combining a few instead of starting at depression. If and when you do choose to write this part, don’t forget the impact of show over tell. Show me the uneaten dinner in the fridge. Show me the ashtray full of cigarettes and the character lying in bed with a red face puffy from crying. Show me the dirty hair and stench of two-week’s worth of unwashed laundry, piled up in the corner and threatening to grow legs and walk off. Show me the guitar in the other corner just gathering dust. The darkened room. The unmade bed. The broken mirror.

Remember, it’s not the grief itself that’s interesting, it’s how the character faces it, doesn’t face it, or makes matters worse that is interesting to the reader.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Now go write. Go for a walk, too. Get a little fresh air.


Wow, just one more topic and you can breathe easier. We’ll move onto other subjects too, and I do take requests (you can ask via Facebook or Twitter). If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on grief and loss, grab a copy of Exit 1042.

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The Psych Writer: Grief – Phase Five: Anger

Last week, we explored the guilt phase of grief as part of The Psych Writer series. Thanks for sticking with me thus far, as we’re almost finished with grief, and it’s a difficult topic to face. But after this, there are only two more left in the series, so hang in with me.

So after guilt, the anger phase often follows. Keep in mind the codicil that you can pretty much repeat with me now: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

Now back to anger. The person who is experiencing the anger phase may lash out in a variety of ways. That will depend on the person, the source of loss, and their current circumstances. They get angry with a person for dying, they get angry with the doctors or medical team for “not doing enough” or making a mistake (whether there was a mistake or not doesn’t matter), or they get angry with people for tangential reasons.

While the anger is a natural reaction and completely expected, it is vital that the person doesn’t get stuck in this phase, and it’s probably one of the most addictive phases to get into. You may already know this, but emotions are handled by the amygdala in the brain, and judgment is handled by the prefrontal cortex, and the left prefrontal cortex can shut down emotions. (This is basic information for the sake of brevity: if you want to read more, about anger, check out this article.) When a person is angry, there are a number of hormones released, including adrenaline and noradrenaline. Because those are “pump you up” hormones to get the body ready for a fight, anger can be addictive. It’s like runner’s high without all the knee blowout from running.

Anger from the Patient’s POV
The patient is pissed off royally. How dare X happen? How could grandma do that to you? How dare she die at a time like this?! How dare Phyllis divorce you?! Who does she think she is? Those fucking doctors don’t know anything! They couldn’t save Uncle Phillip and they’re all just money-grubbing bastards. What were they thinking?

There is a touch of the indignant to this type of anger. Remember, the focus of the anger can be anywhere, even at themselves. Grief is necessarily selfish, so the anger is most likely due to the fact that this person has been left alone, holding the bag as they say. There are underlying feelings that are feeding this phase.

Anger from the Therapist’s POV
As the therapist, it is your job to dig with the patient and find out which feelings are feeding the beast. Sometimes it’s fear. Fear of being alone. Fear of loss. Fear of mortality. Sometimes it’s feelings of helplessness. They were abandoned. They lost their sense of control. Or all of the above, plus ones you can’t fathom at the moment.

All of these feelings, and more, are normal and expected. When someone dies, and the patient is angry, it’s important to let them explore those feelings in a safe environment.

Here, you monitor for homicidal ideation even more (although you always monitor for suicidal as well, homicidal should not be forgotten) than before, because people who are angry may not be able to switch on the prefrontal cortex’s ability to stop them from doing something that could ruin even more lives.

Other things you have to watch for is increased substance abuse and self-harm.

What this Means for You, the Writer
This is the perfect opportunity to get your character set up for starting their revenge against whomever caused their loss. It can also be a good opportunity to write about their anger turned inward, and how they fell into a pit of depression, struggled with addiction, or committed acts of self-harm.

If you’re writing an unethical therapist, keeping the patient in this phase can help them orchestrate a murder, create chaos, or other unsavory ends via unsavory means.

Remember, it’s not the grief itself that’s interesting, it’s how the character faces it, doesn’t face it, or makes matters worse that is interesting to the reader.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Good luck, and get writing.


Just two more to go and then we’ll move on to other mental health topics. You’re almost at the end of the grief series, can you believe it? If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on grief and loss, grab a copy of Exit 1042.

The Psych Writer: Grief – Phase Four: Guilt

I want to take a moment to thank my blog followers for sticking with me through these heavy topics. We’re more than halfway through now, and soon, I’ll be moving on to how to write other aspects of mental illness accurately. While it doesn’t mean you can’t take liberties and poetic license, I’ve seen writers bumble through having no idea what they’re writing about. (One of the most woeful examples I can recall is calling a person on the Autism Spectrum a “psychopath.”) The stories are still popular, but for people with the disorders they’re maligning, and the therapists who treat them, it’s cringe-worthy and ruins the story.

Last week, we explored the phase of bargaining in The Psych Writer series. This week, we’ll look at the next one: Guilt.

All together now, say it with me: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

Nearly everyone on earth has experienced guilt and knows how it feels. When it happens in the guilt phase of grief, it manifests in a variety of ways. Here are some of the most common statements I’ve heard from patients in this phase:

“I wish I had spent more time with X before s/he died.”

“I should have been there to take away his car keys.”

“The last thing I said was ‘I wish you were dead,’ and now look what happened!”

“This is all my fault. I had to sign the papers to pull the plug. I killed my X.”

“If I had just noticed sooner, I could have urged them to go to the hospital earlier.”

See a common thread here? The guilt doesn’t typically surround the deceased or the object of loss, rather what the person perceives or feels about their own actions. This is often where the person feels a tremendous burden, a wish to go back in time. Regret. Remorse. As if there was one thing they could have said/not said, done/not done and it would magically change everything.

It won’t.

Guilt from the Patient’s POV
The person feeling guilt has turned inward, usually after bargaining and getting nowhere. Unsuccessful in finding an outward solution, s/he turns inward. There must be something she could have done to change the outcome, right? He will play the scenario over and over in his mind. She will ruminate on what the one thing is she should have changed to prevent “this event” (death, loss, etc.) from happening.

Guilt from the Therapist’s POV
As the therapist, your job is to remind the patient (gently) that loss is not something a person can prevent (unless they actually murdered a person). If there is some reasoning that the person could have prevented it, then it’s your job to bring the patient’s attention back to the present. What is done cannot be undone, as the saying goes. There are no time machines and even if there were, the action the patient believes might fix something may not fix it or even make it worse.

Understand that guilt is selfish, and it’s 100% okay to be selfish in this case. This is also a necessary part of grief as a person recognizes that s/he too is mortal, and not capable of stopping all death from happening.

People are self-centered in the guilt stage, and it becomes about what happened to them or what they could have done to stop the loss. Self-centered attitudes are not necessarily a bad thing as they ensure human survival, and when it comes to guilt, the focus on self is a necessary part of it. If you don’t care for the terms “self-centered” or “selfish,” think of it as “focusing inward.”

What this Means for You, The Writer
This is going to depend on quite a few factors when  you write a character’s guilt over a situation. Did they cause the loss? Do they feel remorse? Are they capable of remorse? Are they traumatized? What level is their involvement in the loss?

As you answer these questions, keep in mind that the character will be focused inward. Keep it to what they believe they “should have” or “could have” done to prevent the loss from happening.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Good luck, and get writing.


All right, just three more of these to go, and then we can get into other wild topics. Hang tough, dear readers! If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on this subject, grab a copy of Exit 1042.

 

The Psych Writer: Grief – Phase Three: Bargaining

Last week in The Psych Writer series, I covered the second phase of grief: denial. This week, we’re onto phase three: bargaining.

Once again, and you may be able to say it with me this time: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

Professionals put bargaining into the third phase because of the extensive work that Elisabeth Kübler-Ross did with death and dying. It doesn’t just apply to death or dying, either. This phase can be seen in grief over the loss of a job, a divorce, or any other loss one can imagine.

Bargaining happens the moment someone says they would “give anything to X,” where X is the former condition prior to the loss. Those who believe in God will bargain with their deity: I will do charity work for the rest of my life if only you’ll take away this disease. Atheists or non-religious folk may present with: If I had a second chance, I’d never tell Lucy she needed to lose weight.

There is a lot of wishful thinking in bargaining. It is natural, and it will pass.

Bargaining from the Patient’s POV
The patient is often feeling desperate in this situation. They have been given their ultimatum, the “no way out but through” feelings are piling up. They cling to the idea that there is some kind of “trick” that will reverse the undesired condition. He or she will make deals, either with a deity or with the target of loss. Those who are not prone to superstitious thinking or have a belief system may find themselves searching for answers through either science or religion. Bargaining may manifest itself then as “I’d do anything to get X back.”

Bargaining from the Therapist’s POV
With a terminal illness, he or she may express feelings of being trapped. Because of this, the patient will bargain as a way to assuage and mitigate these feelings. Your work as a therapist is to check for suicidal ideation/homicidal ideation and ensure the patient is not turning to any former addictive pitfalls. Additionally, as the therapist you need to allow the patient to explore bargaining however they choose, whether they’re an atheist who asks God for a sign, or whether they’re begging anyone who could help to make things “back the way they were.”

As long as the behavior isn’t self-destructive or destructive to another, it’s best to let it play out as it plays out and help them move forward.

What this Means for You, the Writer
If you’re writing out the bargaining phase, be sure to capture those feelings of ‘no way out’ and your only resource is trying to barter to put things back to the way they once were. This can be bargaining with an ex to try to mend the relationship (which may or may not work), bargaining with a deity to bring back a loved one (which may or may not work depending on your story), or even questioning the order of the universe. I once heard a person say, “I want to build a time machine, go back, and tell X not to get in that car.”

That too, is a version of bargaining.

This is a painful experience for the character involved as all phases of grief are for mere mortals. How your character experiences the bargaining phase will be up to you and your story’s direction.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Good luck, and get writing.


Well that was the third heavy topic, I know, but there are only four more to endure, so brace yourselves. If you’re in need of some lighthearted things, check out my Facebook and Twitter. Or for some entertaining fiction that touches on this subject, grab a copy of Exit 1042.

The Psych Writer: Grief – Phase Two: Denial

This is an ongoing series called The Psych Writer. Last week, we explored the first phase or stage of grief: shock and disbelief. This week, we’ll take a closer look at phase two: denial.

This stage used to be lumped into the first stage of shock and disbelief, which makes sense, but over time, therapists have discovered that denial takes on a life of its own.

Now, the standard caveat that you will be able to repeat with me by the end of the grief series: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

This phase is usually the “second phase” because of its proximity to shock and disbelief. It seems easy to fall into denial. Keeping in mind not everyone experiences this phase (see the note above), some people find their shock and disbelief is extended. For some, it becomes more elaborate.

For example, little Tommy was four years old when his mother died suddenly. Unable to accept or cope with the loss of his mother, Tommy begins to believe a story that she’s gone on a trip and will be “back soon.”

Another example: Greta is a 55-year-old who has been diagnosed with a terminal illness. When her husband asks her about it, she says she doesn’t know anything and doesn’t want to know anything about it. She doesn’t want to lose sleep over “worrying about it.”

Denial from the Patient’s POV
This phase is a more elaborate, amplified version of shock and disbelief. The person experiencing denial may appear quite strong to family and friends. They hold their heads high, or say things such as, “I have to keep on going.” They appear to have accepted their fate. Or they act more like Greta, and say things such as “I can’t think about this right now.”

The person in denial often has internal dialog of the wandering mind. They cannot concentrate, or are forgetful surrounding the loss. The person may find himself setting an extra place at the dinner table. She may reach for the phone to call the loved on to tell them some bit of good news. They may leave the person’s room untouched and not sell or get rid of all items (keeping heirlooms and keepsakes do not count), and get livid if you move them or disturb them.

In the extreme, rooms become shrines to the lost one, or the person turns to substance abuse to aid in suppression of pain.

Denial from the Therapist’s POV
Boy, have you got your work cut out for you. As a good therapist (remember to do the opposite if you’re writing a crappy one), it’s your job to serve as a point of reality for the patient. Your reminders for the patient that the loved one is gone or the job will not suddenly return need to be consistent. Be with the patient in his/her denial and empathize without sympathizing (the difference being that this is about the patient and their unique experience, not about you and your own grief).

Here’s an example of how a session might go, and how the therapist would guide the patient into reality:

Patient: I reached for the phone to tell Grandpa the good news about my promotion.
Therapist: What happened?
Patient: I didn’t call. I put down the phone and made coffee.
Therapist: So you didn’t complete the call, and distracted yourself with something else, then?
Patient: I guess I did. I just can’t accept that he’s gone.
Therapist: How do you feel about him being gone, and that you can’t call him with good news anymore?

The therapist is extracting information to find out how the patient is processing the loss and where they are in their grief. How deep is this denial? Do they get tearful in their response? Do they get angry? Confused? Delusional?

Fictionalize it any way you like, of course. What would happen if Grandpa had answered?

What this Means for You, the Writer
If you are writing someone in the phase of denial, you’ll be the one to decide how extreme it is or if there are any paranormal elements. Consider how long the phase will last (the more extreme cases of denial last longer than six weeks and sometimes for years), and the elaborate lengths your character will go do to keep their denial going.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Remember that when you write this phase, it’s important to think of it as a more elaborate trick of the mind to protect your character from pain. If you are writing from the therapists point of view, remember your goals are of a facilitator and you are there to cushion the blow of brutal reality for your patient. You are the bridge back to healthy grief processing, and it is up to you to provide tools for the patient to get beyond this stage so he or she can begin functioning once again. Additionally, remember that you are not to foster dependency on you as the therapist (unless you’re writing a bad or unethical one). You are there with the tools for your patient. If you’re portraying an unethical therapist, be sure to exploit this phase by assisting in expanding patient denial.

Be well and get writing.


Well that was yet another heavy topic, I know, and there will be more to come soon, so brace yourselves. For some lighthearted things, check out myFacebook and Twitter. Or for some entertaining fiction, grab a copy of Exit 1042.