Reflections on Death, Mourning, and Meaning

Share thoughts and ideas regarding what can be done to meet contemporary humanity's need for rites of initiation and passage.

Moderators: Clemsy, Martin_Weyers, Cindy B.

Cindy B.
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Post by Cindy B. »

Hey all.

I'll also be back to this thread as soon as I can manage, today I hope...

:)
If the path before you is clear, you’re probably on someone else’s. --Jung

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Post by JamesN. »

While waiting for Cindy's take on these diagnostic concerns - via the new edition; I came across this interesting piece about 10 patients. This gives a small window into the wide spectrum of the different types of mental conditions there are of people living all around us everyday. ( Also how difficult it might be to detect what the individual problems they may be suffering from may be. ) This small sample illustrates just " one " of the reasons why I think this concern about " diagnosis " is an important issue. :idea:

http://news.yahoo.com/photos/faces-of-m ... slideshow/
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Post by Cindy B. »

JamesN. wrote:For anyone interested in this area of topical concern here is an article I came across that I think has very serious connections to any societal understanding of not only what grief means; but more important what it's relationship to depression is.

http://news.yahoo.com/blogs/lookout/fig ... 09787.html

( Cindy as a professional do you have particular thoughts on this? )

To me it seems to raise a red flag towards ( both ) the public's lack of understanding and what the clinical " interpretation " might be of ( what depression is ). Not just the " grief process "; but separating the diagnostic determinations from this larger medical " debate"; ( if I'm asking this correctly ). :?:

Is it tied into some of these misconceptions concerning the larger public discourse about mental behavior connected to " psychosis "; or is it tethered more to a clinical diagnostic issue or both? ( I'm thinking in terms of the loss of hope, loss of a love one, or loss of self-esteem, or any connection with the ability to " cope " with depression and grief. ) I realize this may be a little nebulous and my articulation may be somewhat lacking here. :roll:

I'm addressing this concern to the larger overall picture of individual patient care ( and ) the greater public good; as well as treatment and it's surrounding conditions; ( not just classifying the bereavement period ). Again if I am phrasing this clearly.

Again to be clear: " What is the relationship of depression and grief? " Not just separate definitions; but in interaction or interplay. I realize that there are plenty of journals covering different dimensions of this subject; but the article seemed to raise very " specific " concerns about diagnosis and even more concerns about " definitions of interpretation ". ( Am I on the right track here with this? ) :? ( Carl Jung or Joseph Campbell may have interpretations you can use. ) Your thoughts; ( ambivalent or otherwise ); would be of great assistance.

Seems like " very serious " murky water here to me; but I am not really as informed or trained as you are in this area. :wink:
Okay, James, just to put this into perspective, since 2000 and the publication of the DSM-IV-TR, Bereavement has fallen within the category, Other Conditions That May Be a Focus of Clinical Attention and has not been categorized as a mental disorder. From the DSM-IV-TR:
V62.82 BEREAVEMENT

This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal," although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of normal bereavement vary considerably among different cultural groups. The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. (*C: See below about Complicated Grief.) However, the presence of certain symptoms that are not characteristic of a normal grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. These include 1) guilt about things other than actions taken or not taken by the survivor at the time of death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.
So what are the DSM-IV-TR critieria for a Major Depressive Disorder and a Major Depressive Episode? And note the bereavement exclusion: http://www.guiasalud.es/egpc/traduccion ... -IV-TR.pdf

Also, while not a distinct diagnostic category, the clinical presentation of Complicated Grief is important to consider when assessing whether a normal grief reaction has evolved into a depressive episode: http://www.mayoclinic.com/health/compli ... ef/DS01023



I checked on the web to see if any new DSM-5 criteria were already listed online, and they are not, and as I mentioned, I've yet to see the manual. Yet your linked article here indicates that in the DSM-5, the presentation of a normal grief reaction is instead now linked to the criteria of a Major Depressive Episode. Why this change was made I can't say without access to the rationale, but I can tell you that in clinical practice little will likely change. Individual differences are always given consideration--or should be--and the potential emergence of complicated bereavement symptoms must be kept in mind no matter how long a person has been grieving.

And, Clemsy, you mentioned that your psychiatrist friend will be using the ICD-9-CM codes instead of the DSM-5 codes. My understanding is that the DSM-5 includes these associated codes as well as the new ICD-10-CM codes to be instituted next year. It seems, then, that both categorization systems are changing in concert.

So do I think that all this is a mess, too? Yep, and I don't really know what more to offer until I get the opportunity to spend time with the actual manual. When the NIMH, though, also withdraws its support, well, something has to change with this picture. The American Psychological Association has yet to make its own statement on the DSM-5, which tells me that they'll likely tag along as usual with the American Psychiatric Association that publishes the DSMs.

:)
Last edited by Cindy B. on Tue May 21, 2013 3:11 am, edited 1 time in total.
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Post by Cindy B. »

Cindy wrote:Why this change was made I can't say without access to the rationale...
I just ran across the rationale, James, for why the DSM-5 deletion of the "bereavement exclusion" came about regarding Depression diagnoses. (Refer to links above.)

From the apa.org site: Highlights of Changes From DSM-IV-TR to DSM-5
Bereavement Exclusion

In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons. The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode. Thus, although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.
So, personally, I believe that the bereavement exclusion should not have been deleted. It's not unusual to offer more than one diagnosis, anyway, to capture the full clinical picture at a given point in time, and this move clearly muddies the waters further between Major Depression and normal grief reactions. Only when major depressive symptoms significantly interfere with a person's everyday functioning and quality of life should they be labelled a "mental disorder" in this game of diagnostics and whether or not he/she is grieving...in my opinion, of course.

:|
If the path before you is clear, you’re probably on someone else’s. --Jung

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Post by JamesN. »

Cindy first of all thank you for what must have been a big chunk of your valuable time and effort to share your insight.

As I said earlier; I realize I am somewhat out of my depth here; however as I struggle through I would like to ask one small question as to the overall or big picture about your thoughts on this new manual change concerning " diagnosis ".

Given what you know; ( small release of information though it may be ); does your gut or instinctual sense of this seem like there is trouble ahead? I realize this may be conjecture and I certainly don't want to ask anything you may not feel comfortable commenting on. It's just that so much of the medical profession has been absorbed by the influences of the " healthcare " industry; if you see what I'm getting at here. And while I am not directing any blame towards mental health physician care whatever the field of discipline; when I see some of the abuse from the drug companies; the enormous cost of care; lack of political and financial aid towards the support of enough public mental care facilities; social ostracizing of many mental related conditions or disorders; it gives me tremendous concern when these kinds of media alarms go off.

Given the strains already put on an overburdened healthcare system such as government regulations; threat of lawsuits; rising overall maintenance costs; and other similar demands; it just seems like one more attempt at managing something out of control; thereby making your job harder and: ( managing the system instead of serving the patient ). Again I'm not pointing a finger at the physician; but asking an opinion about what is regulating the diagnosis. Does that make sense?
:?

( I hope that has enough clarity; I'm kind of groping to identify this issue a little better and the " bereavement " aspect will definitely help ) :idea:

Again; thank you for sharing your personal time and asistance with this. 8)

Now off to do some reading! :wink:

-------------------

Addendum: As I am attempting to understand some of this issue better I just came across these 8 little examples concerning diagnosis changes over time, how it is related to public perception, and what the the DSM-5 manual is attempting to address:

http://news.yahoo.com/photos/madness-no ... slideshow/
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Post by Cindy B. »

I'll have to come back to this thread again later, James, when I have time to devote to your last post, a rather all-inclusive one, I must say. :wink: How about please breaking it up a bit in terms of issues to be discussed? Over the next few days, too, so you know, I won't have much time for posting, but I will be around.

:)
Last edited by Cindy B. on Tue May 21, 2013 8:20 pm, edited 1 time in total.
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Post by JamesN. »

Hey Cindy.

My main objective is really to get a better layperson's understanding of what lies ahead concerning " mental diagnosis " as in this part:

I said:
Given what you know; ( small release of information though it may be ); does your gut or instinctual sense of this seem like there is trouble ahead? I realize this may be conjecture and I certainly don't want to ask anything you may not feel comfortable commenting on. It's just that so much of the medical profession has been absorbed by the influences of the " healthcare " industry; if you see what I'm getting at here. And while I am not directing any blame towards mental health physician care whatever the field of discipline; when I see some of the abuse from the drug companies; the enormous cost of care; lack of political and financial aid towards the support of enough public mental care facilities; social ostracizing of many mental related conditions or disorders; it gives me tremendous concern when these kinds of media alarms go off.
I'm trying to get in general sense that is; ( your take ) as a professional on what my question that seems to be the overlying concern here from the articles; ( at least to me ): " Does this have more to do with managing the system or serving the patient " or maybe both? :?

The " manual change " seems to be generating this response the way the reaction looks! ( Perhaps I am not understanding this correctly. ) :roll:

Please don't let this burden your time. You have already been more than generous with your efforts on this. :wink:


Cheers
Last edited by JamesN. on Sat Jun 01, 2013 3:44 pm, edited 1 time in total.
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Post by JamesN. »

Cindy said:
["Cindy B." I'll have to come back to this thread again later, James, when I have time to devote to your last post, a rather all-inclusive one, I must say. :wink: How about please breaking it up a bit in terms of issues to be discussed? Over the next few days, too, so you know, I won't have much time for posting, but I will be around.



Hey Cindy.

Well I have finally ( had a go ) at the huge collection of information that you so kindly put together. What I asked was a rather " unfair " question concerning: " How the manual change affects various diagnosis and what it serves. ( Of course not realizing this at first I found out very quickly. ) :wink:

You also supplied a very nice synopsis on " bereavement " that helped a lot:

Cindy said:
So, personally, I believe that the bereavement exclusion should not have been deleted. It's not unusual to offer more than one diagnosis, anyway, to capture the full clinical picture at a given point in time, and this move clearly muddies the waters further between Major Depression and normal grief reactions. Only when major depressive symptoms significantly interfere with a person's everyday functioning and quality of life should they be labelled a "mental disorder" in this game of diagnostics and whether or not he/she is grieving...in my opinion, of course.

Concerning the " manual " data I learned a bunch but certainly did not absorb it all; ( thanks again for that ). There is nothing quite like being out your depth to improve your understanding and appreciation of " not being correct in what you think you know. " :idea:

I will ask this though; and that is: " Do you have any particular thoughts about this change that you would like to share? " ( That is of course when you have time after reading it. :) )
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Post by JamesN. »

It's the Xmas Holidays and I recently have put down a pet of 18 years. And it occurs to me that the interface between life and death comes to us to confront it's meaning whether we ask it to or not. And along with " birth " the profound impact of it's " inner mystery " is without question one of the deepest and most important human beings will consider at a personal level during their entire journey throughout life.

I haven't posted anything on this thread in a while. But I came across this article just now which seems to address certain aspects of this subject that I think definitely relate to it's original intent. It not only addresses the question: " How do we say goodbye? "; but ( how ) within the " letting go " process of " mourning " do we assimilate the " inner import " of it's message?

http://news.yahoo.com/dying-man-dog-pho ... 47361.html
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Post by Andreas »

Hey James and everyone.

http://www.youtube.com/watch?v=V1bFr2SWP1I

This is how Hawaiians say goodbye. This is just to point how important our rites and mythology is.

Thank you so much for your PM James. Just so everyone knows my pet passed away 6 months ago and he was like a brother to me.

RIP bro.

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Post by JamesN. »

Hey Andreas.

That beautiful piece you shared brings up an interesting aspect of mystery on several levels. Because it held a place for certain people as a type of musical connection " this song " was used in several movie soundtracks including one of my personal favorites " Finding Forrester ". This movie speaks to many universal mythic themes metaphorically; which I think addresses this topic in another way.

Death as a vehicle if nothing else; reminds us of this ( reality behind the veil ) that opens to reveal occasional glimpses of this deep inner mystery that we are riding on. This movie; ( which I highly recommend by the way ); is a story about friendship and also of transformation. The scene in this clip is of a letter to the younger hero received after the " passing " of his mentor where he acknowledges both the understanding of the younger's " rite of passage " and also of gratitude for the younger one's personal gift of friendship and it's meaning to him. After which the following is a brief montage of scenes from the film itself presented as a sort of considered reflection.

I think most people at some time or another look back over the course of their lives and see how key moments; ( of which death's occasional visitations certainly play a part ); may help influence how one looks; views, or assimilates their life and this existence or experience of timeless ground which everyone must travel. I also think the deeper the relationship; the deeper the reflection. Pets sometimes form even deeper bonds than some human relationships. And their loss IMHO is absolutely just as profound. ( Carl Jung certainly enters here. ) :idea:

Thank you for sharing this.


http://www.youtube.com/watch?v=NU7ZsSWfeyw
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Post by Andreas »

Thanks James. Yeah I totally agree that pets sometimes form deeper bonds. I heard about it but now I know how it feels. Anyway. Best wishes to everyone.

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Posts moved from humor thread.

Post by Cindy B. »

Poncho recently offered this joke in the humor thread:
For sale:
Dead canary. Not going cheep.

Cindy said:
:(

Not funny for me today. I'm nursing a sick parakeet that on top of things had a stroke a week ago, and things aren't getting better as hoped since seizures have cropped up.

Tweet


P.S. The Rainbow Bridge.


...Just this side of heaven is a place called Rainbow Bridge.

When an animal dies that has been especially close to someone here, that pet goes to Rainbow Bridge. There are meadows and hills for all of our special friends so they can run and play together. There is plenty of food, water and sunshine, and our friends are warm and comfortable.

All the animals who had been ill and old are restored to health and vigor. Those who were hurt or maimed are made whole and strong again, just as we remember them in our dreams of days and times gone by. The animals are happy and content, except for one small thing; they each miss someone very special to them who had to be left behind.

They all run and play together, but the day comes when one suddenly stops and looks into the distance. His bright eyes are intent. His eager body quivers. Suddenly he begins to run from the group, flying over the green grass, his legs carrying him faster and faster.

You have been spotted, and when you and your special friend finally meet, you cling together in joyous reunion, never to be parted again. The happy kisses rain upon your face; your hands again caress the beloved head, and you look once more into the trusting eyes of your pet, so long gone from your life but never absent from your heart.

Then you cross Rainbow Bridge together...

--Anonymous


Currently I have nine pets waiting. The loss of two of them in particular still tugs at my heart since they were my oldest and closest pets when they died. (And sorry for the downer post, but it's helped me sharing this with you, so thanks for listening. :))

romansh said:
Cindy B. wrote::(

Not funny for me today. I'm nursing a sick parakeet that on top of things had a stroke a week ago, and things aren't getting better as hoped since seizures have cropped up.
Hi Cindy
I can't tell from the quote, but sincerely hope it is the parkeet with the seizures and stroke. But I suspect not.

Good luck with the meds.

rom

James said:
Thank you Cindy.

What a beautifully poignant thing to share. A relationship with one's pet is truly one of the deepest and most meaningful experiences a human being is privileged to know. From childhood to one's last breath few bonds are so pure; so devoted; and so deep. They ask little but to be near us; and require so little effort for the total unconditional love we receive in return. We carry the memory of the light they bring into our lives with us always. So perhaps their memory is like the echo of a long forgotten song's refrain that comes to visit once in awhile when clouds seem dark to remind us of life's sweetness and makes life's living more worthwhile.


Namaste

Cindy said:
romansh wrote:I can't tell from the quote, but sincerely hope it is the parkeet with the seizures and stroke. But I suspect not.

Do you mean my signature Jung quote? Yuk-yuk. :)


And, James, I hope that things are going reasonably well these days with your furry companion. :)


Ciao, guys!

James said:
Cindy:
Just this side of heaven is a place called Rainbow Bridge.
( Thanks for posting that Cindy; I just got back from saying farewell at " the bridge " this morning. Third trip this year. :( )
Last edited by Cindy B. on Sun Apr 13, 2014 4:39 am, edited 3 times in total.
If the path before you is clear, you’re probably on someone else’s. --Jung

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Post by Cindy B. »

Oh, no! I'm so very sorry for you, James. Take special care, amico.

:cry:
If the path before you is clear, you’re probably on someone else’s. --Jung

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Post by JamesN. »

In the 2001 movie of the 1999 Pulitzer play: " Wit "; Emma Thompson " plays a brilliant scholar stricken with stage four Ovarian Cancer coming to terms with the meaning of her own life and the approach of her impending death. It is a powerful and deeply poignant exploration into the process any individual may be called upon to consider into this most personal of all life experiences. To me the metaphor of punctuation in this clip is used as a vehicle to illustrate the author's interpretation of the " insuperable " veil behind which an individual's realization of existence itself is cloaked.

https://www.youtube.com/watch?v=FXpl_yvmKKA

https://www.youtube.com/watch?v=ND1-r3beO6k

( Towards the end of the movie part of the main theme emerges ):

From Wikipedia:
Late in Vivian's illness, the only visitor she receives in the hospital is her former graduate school professor and mentor, Evelyn Ashford (Eileen Atkins), who reads her excerpts from Margaret Wise Brown's The Runaway Bunny. As she nears the end of her life, Vivian regrets her insensitivity and realizes she should have been kinder to more people. In her time of greatest need, she learns that human compassion is of more profound importance than intellectual wit.
https://www.youtube.com/watch?v=j2jCPwdgAWs

This work is a tough; gritty, and uncompromising look into the face of death. But IMHO the issues that it raises and the way they are handled and portrayed are some of the most important and daunting of modern times; ( the dehumanizing of human beings ). And they are exactly the kind of issues that Joseph Campbell's work addresses. It is a perfect example of what many people are being asked to face within the paradigms of modern life; and raises many of the questions they are called upon to ask as they navigate what it means to be a human being going forward within today's modern healthcare system. :idea: For those interested this movie is tough to watch; but the points it makes are significantly applied.

https://www.youtube.com/watch?v=u0PPvYlGqL8

As to the larger picture of how one can approach the living of life and how to face death I think Joseph states this really well here:

( From " Pathways to Bliss "; page 25. ):
For example, when you face great calamity, what is it that supports you and carries you through? Do you have something that supports you and carries you through, or does that which you thought was going to support you fail? That is the underlying myth by which you live.
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