Mental Health

Rehabilitation is a forward-moving process in which adaptive tools and exercises enable patients to re-establish attainable levels of function. The majority of patients come to this process following loss. Understanding the psychological process of loss, grief and recovery can equip OTs to support patients through difficult moments and to fully benefit from their treatment.

The Psychological Process of Loss

Psychologist Dr. Daniel Gottlieb has had extensive personal experience with loss. He lives with quadriplegia as a result of a near-fatal car accident in 1979. In the years following, he struggled with depression and despair; and he suffered many more losses-his wife left their marriage, passed away some years later, and then he lost his parents and a sister.

Today Dr. Gottlieb counsels families on how to find meaning in the face of suffering. He is an author and host of Voices in the Family, an award-winning radio talk show aired on the Philadelphia public radio station WHYY 90.9 FM. "The heart doesn't really care if it is health or a loss of a partner, the emotions are the same," Gottlieb notes, "but we do heal from loss; and when we look back at our lives, we do heal through a remarkable array of human experiences."

How we grieve, how long we grieve, and how we experience loss is deeply personal for each of us. Losses can be practical-changes in mobility or the loss of ability to perform activities of daily living can drastically impact an individual's self-concept. Patients may also focus on loss of roles (e.g., "I am not a dancer anymore" or "I cannot cook for my family anymore"), loss of future expectations (e.g., "I cannot take the vacation I had always planned on") or loss/changes in relationships (e.g. "I am now a burden to my family" or "my friends do not call as often as they used to").  In addition, the experience of loss of health can be exacerbated by what a person feels they have lost prior to entering treatment-private traumas, lost opportunities or lack of social support.

Elisabeth Kubler-Ross set the model for understanding loss across the spectrum in her 1969 book On Death and Dying. She outlined five stages of grief.

Denial: "I am okay," or "I can't connect to what is happening to me." This can be adaptive up to a point, as a patient adjusts to the complexity of what he is coping with; but in extremes, it can prevent a patient from engaging in the care plan.

Anger: "Why me?" In this stage, an individual can feel cheated, resentful, rebellious. Allow room for these feelings-it can be easy to overlook this form of experiencing grief.

Bargaining: "I understand this is happening to me, but if I only would have avoided my trip, I would not have gotten into an accident." An individual at this point may be wavering between coping and shutting down.

Despair: "I am feeling sad about what is happening to me; I don't have the motivation to cope with what I am going through." In this stage one may be feeling sad, or lose motivation to engage in self care. It is critical to be mindful of more severe forms of despair that can signal depression, such as change in self-care habits, hopelessness or suicidal thinking.

Acceptance: "I recognize that this has happened to me. I can't change it, and I have to cope with and accept it." In this stage one is in the place of contending with the loss and may have more energy to engage in self-care.

Gottlieb notes that patients may experience more than one stage at the same time or in varying orders. "The only linear process in life is the journey from birth to death" says Gottlieb, so staying observant to the signs of how people grieve is critical.

Another way of considering this process is that people go through a variety of emotional states, and that how we grieve is connected with our personalities, temperaments and previous experiences with grief. The process of loss is, first, experiencing a complex set of reactions; second, adjusting to those reactions by negotiating or coping; and then integrating what is lost, gained or learned through the change in health status.

In a minority of cases, patients may get stuck in their grief or loss reactions, and those responses become the totality of their lives. Currently, there is research and discussion on a condition called complicated grief or prolonged grief disorder, for patients who are so inhibited by their feelings of grief that they are unable to re-engage in any healthy aspects of life. The diagnosis is under consideration for inclusion in the 2012 edition of the DSM (http://www.nytimes.com/2009/09/29/health/29grief.html).

A referral to counseling resources can be helpful in any phase of the adjustment and loss process; but if patients are exhibiting marked breakdown in their functioning or mood, or exhibiting hopelessness or suicidal ideation, then a referral for a mental health evaluation is essential.

Recovery and Acceptance

There is a number of aspects of therapeutic support OTs can provide to patients during treatment, based on the individual's experience of grief and its impact on the patient's function.

Empathy

Empathy may seem obvious, but Gottlieb emphasizes empathy as the foundation of emotional healing. The practitioner's attitude should be one of "stepping inside the patient's shoes."

"What is it like to be you?" asks Gottlieb. "A common tendency for those listening to those in grief is to rush the process with platitudes, or saying like 'bad things happen to good people.' I think it is an effort to manage our own helplessness," he says. "The key is caring, not just compassion, [and in] trying to imagine what it is like to live in that person's skin at that point in time."

Coping with Difficult Feelings

The next aspect of working with loss is validating the intense and difficult feelings that patients may experience. "Most people in the throes of difficult experiences don't see that all
feelings don't last 24 hours a day, and that they do pass, and that they will survive it," said Gottlieb. "There is a difference between 'I am sad,' and 'I feel sad.' .We are not our feelings, [but rather] we have feelings."

Mindfulness (see "Mindfulness," ADVANCE, Aug. 18, 2008) can be a helpful coping tool in the grieving process if you observe patients who are overwhelmed by their feelings. 

Hope through the Support of Human Connection

Gottlieb, in remembering his own recovery and in recounting his life experiences in his writing, emphasizes the critical aspect of human connection. Some patients may have no supports, and others' support systems may be strained during times of loss. This is where health care providers become the critical link to hope.

Although grief may ultimately be a solitary process to each person, Gottlieb is a firm believer in support and connection from others as a catalyst for healing:

"When people sat with me, cried with me, when they opened up their vulnerabilities to me, I felt human again. Human connection helps people go forward."

Supporting the Whole Person in Recovery

Each patient is equipped with a specific reserve of resilience, coping capacity and social resources. Previous articles in this mental health series have reviewed numerous stories of how people found their way through the recovery process through various mechanisms: setting small goals, re-establishing a valued identity, having specific skills such as mindfulness, managing anxiety, establishing a mind-body connection, maintaining a positive attitude, or engaging in the expressive arts (see all of Dr. Mathew's articles in the Mental Health Center at
http://occupational-therapy.advanceweb.com/Article/MentaHealth Center.aspx). These divergent and unique solutions enable people to cope with traumatic loss and to find meaning again.

Post-traumatic Growth

No one in life escapes loss. Acknowledging, recognizing, and supporting patients through the losses they experience is an essential ingredient in their acceptance of the forward-moving benefits of rehabilitation. 

Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. She is a disability advocate and freelance writer. The main focus of her work is to promote coping skills education for persons with chronic illness and disability. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via e-mail at her website: rejimathewwriter.com.