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Recovery from grief requires more than grieving, psychologist finds

STANFORD -- When someone close to us dies, we've been told, it's important to let our feelings out. If you bottle up your emotions, your grief will spill out later as severe depression, according to Freud and a host of more recent authors on coping with death.

Now comes a study, however, that finds people who dwell excessively on negative emotions aroused by their loss are also at high risk for long-term depressions. On the other hand, people who are already recovered from a grief-related depression within a month following their loss do not tend to lapse into depression months later.

In their study of 253 San Francisco Bay Area residents who had lost a loved one to cancer, Stanford University psychologist Susan Nolen- Hoeksema and two colleagues found the process of healthy grieving is more complicated than simply expressing your negative emotions.

"Depression is a normal response to the loss of a spouse or parent," Nolen-Hoeksema said, "but there are big differences in people as to how long that depression lasts. Most people show significant recovery from a grief-related depression within six months, but people who are still very depressed after six months are at high risk for remaining depressed for a very long time after that."

Nolen-Hoeksema and her colleagues, Louise Parker at the Institute for Social Research at the University of Michigan, and Judith Larson, a Stanford research assistant in psychology, assessed a number of variables that had been associated with recovery from depression in other studies - studies of depressions not caused by grief. Those include the social relationships people have, the number of stresses in their lives, their general disposition toward optimism or pessimism, and their methods for coping with negative emotions or stress, such as the feelings of sadness and emptiness that often accompany the death of a loved one.

"One of the things we were really surprised about was that, on average, people who had lost a loved one reported four additional major stresses within the same year," Nolen-Hoeksema said.

"These were big stresses, not just daily hassles. Some were connected to the loved one's illness. For example, a number of people lost their jobs because they had to stay home and take care of their spouses."

The number of stressful events in their lives, it turned out, was a good predictor of who would be depressed six months after a loved one's death, she said.

One woman, for example, not only lost her father to cancer but was still caring for her elderly mother, who had Alzheimer's disease. As a result, the woman had lost her job and was in debt. Feeling she did not have the time or energy to look for a new job or find someone to care for her mother, the woman spent her days at home with her mother, worrying about her financial situation and the deterioration in her own physical and emotional health.

While understandable, Nolen-Hoeksema said, such passive, ruminative coping with grief and stress also leads to longer depression.

"People who were prone to focusing on themselves, worrying about their feelings and not doing things specifically to lift their moods, such as talking with other people or engaging in activities they enjoyed, were more prone to still be depressed six months later."

In other words, she said, "we found that those who were initially depressed but who recovered within six months tended to have fewer additional stresses and more adaptive coping strategies."

Adaptive coping, she said, involves "doing things that renew your sense of control and take your mind away from your worries for a short time. People typically use things like sports or hobbies or going somewhere with a friend, such as to a movie or shopping," she said. "A little bit of distraction leads to more motivation to do more pleasant activities. You can start small and build."

Ineffective strategies for coping, she said, include distracting behavior that is reckless, such as drinking alcohol and speeding down a highway, as well as sitting home and thinking, "I just don't feel like doing anything," worrying about your feelings, or repeatedly talking about how "unmotivated, sad or lethargic you feel without doing anything to relieve the symptoms."

The fact that those who passively ruminated about their grief remained depressed longer was not surprising to Nolen-Hoeksema because of her earlier investigations into how people's response styles influence their tendencies to depression. In a number of field and laboratory studies, she has established that introspective rumination - the tendency to ponder one's worries, to focus passively on the depressed mood itself and the causes and implications of it - is associated with longer periods of depression, both among people who are severely depressed and those with more moderate depressions.

In one study, for instance, Stanford students who experienced the 1989 Loma Prieta earthquake were more likely to show depression afterward if they often thought about the moment the earthquake happened, their feelings around the time of the quake or injuries to other people than if they got out and became involved in some form of community assistance efforts.

Those who tried to suppress their distress through heavy drinking also remained depressed longer after the earthquake, she said.

In earlier work, Stanford psychologist Gordon Bower established that depressed moods color people's thinking by giving them greater access to negative interpretations and memories, she said, and her own research indicates that ruminative thinking "pulls your attention to this negative network so you are more likely to use that negative material to interpret ongoing situations."

It may also be that those who try to suppress their emotions with alcohol, for example, are more likely to lapse into rumination, she said, although that has yet to be proved.

Some research suggests that people recover from traumas faster simply if they can talk about them, Nolen-Hoeksema said, but talking about grief repeatedly or with people whom you don't feel understand you may not be helpful.

Bereavement is often a lonely trauma, more like coping with a rape than like experiencing an earthquake, she said, where nearly everyone in a community experiences the event. "For 10 days after the earthquake, it seemed like almost everybody was talking about it."

In the study of people who were grieving, however, many said their conversations with family or relatives were strained and not helpful. Adult children, friends or siblings of the person who died often reported feeling less empathy from others than those whose spouse had died.

Some community mental health and hospice programs offer the bereaved an alternative: meeting together with others in grief and a counselor.

"Simple ventilation of one's feelings may not be enough to help people overcome, but these groups can be helpful if people get some validation for their feelings and stop thinking they are crazy or that there is something specifically wrong with them that makes them abnormal," Nolen-Hoeksema said. They may be the only social support for some people, she said, "especially bereaved men who were never able to tell anybody how they felt except their wives, who are now gone."

Group members can also distract each other from their problems. "Sometimes, members of the group form great social bonds outside of it. You may pair up with someone you really like and start going to the movies and building friendships that are self-affirming, that get you up and going and re-engaged in life."

A depressed person who takes a break from thinking about his or her problems is more likely to come up with better solutions to those problems when he or she returns to thinking about them, Nolen-Hoeksema said. "Self-focusing and contemplation when you are in a good mood can lead to better problem solving." In one study, she and her colleagues found that nondepressed people who were made to focus on themselves for a while before doing an interpersonal problem-solving task came up with better solutions to the problem than nondepressed people who were distracted for a while before problem solving.

"This suggests that self-evaluation and contemplation are good things to do, as long as you are not in a really depressed mood," she said. "Unfortunately, we are more prone to do a lot of self-evaluation when we are in a depressed mood."



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