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eLetters: Electronic letters published:
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Peaceful Acceptance and Implications for Psychiatry
- Prakash Gangdev (24 January 2009)
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Acceptance, Grief & Meaning
- Santosh K Chaturvedi (19 February 2009)
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Spirituality, Grief, and Emotional Acceptance of Loss
- Holly G. Prigerson, Paul K. Maciejewski, PhD (30 March 2009)
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Prakash Gangdev, Psychiatrist Associate Professor, Department of Psychiatry, University of Western Ontario & Regional Mental Heal
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Prakash.Gangdev{at}sjhc.london.on.ca Prakash Gangdev
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Prigerson and Maciejewski's editorial reminds me of the 1971 Hindi movie Anand, directed by Hrishikesh Mukherjee, depicting peaceful acceptance of death due to cancer. An agenda has been proposed for future research on acceptance of death. They have argued from a viewpoint of psycho-oncologist. However, there are wider implications in that if loss of any kind, not just through death, is similarly conceptualised, it could pave ways for peaceful acceptance as a treatment in a more general way. For example, a relationship break-up could also lead to similar grief characterised by yearning, bitterness, sadness, and so on. Wakefield and colleagues 2 have made similar suggestions in a paper, followed by a book. The conventional approach is to diagnose depression and 'treat' the patient with antidepressants. Acceptance of the loss does not feature as a treatment recommendation in modern scientific evidence based treatment guidelines. This is not to say that depression may not evolve and antidepressants should never be used. Broadening the frontiers of acceptance may more effectively serve the needs of a number of our patients experiencing a loss. References 1. Prigerson HG & Maciejewski PK. Grief and acceptance as opposite sides of the same coin: setting a research agenda to study peaceful acceptance of loss The British Journal of Psychiatry 2008; 193: 435-437 2. Wakefield JC,Schmitz MF, First MB,Horwitz AV. Extending the Bereavement Exclusion for Major Depression to Other Losses: Evidence From the National Comorbidity Survey.Arch Gen Psychiatry 2007;64(4):433-440. No conflict of interest. |
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Santosh K Chaturvedi, Professor of Psychiatry National Institute of Mental Health & Neurosciences, Bangalore, India
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chatur{at}nimhans.kar.nic.in Santosh K Chaturvedi
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Sir, Acceptance, Grief & Meaning Prigerson & Maciejewski 1 assert that the resolution of grief coincides with increasing acceptance of loss, mainly cognitive and emotional acceptance. The role of spiritual acceptance has not been mentioned directly, though experiences like inner peace, tranquility and letting go or regaining what is lost or being taken away are more spiritual rather than emotional or intellectual. Moreover, some of the features which can be considered spiritual are included as criteria for prolonged grief disorder 2, like, confusion about one’s identity and feeling that life is empty and meaningless since the loss. Issues related to culture and meaning and value of death 3 are relevant to both grief and acceptance, and I wonder if these should also be considered. Patients diagnosed with terminal cancer often confront existential issues. Experiences with patients with advanced or terminally ill cancers indicate that not only cognitive and emotional acceptance are essential, spiritual aspects are equally important. Spiritual acceptance of grief will help the grieved to understand the meaning and purpose of the loss. As Frankl 4 states ‘suffering ceases to be a suffering as soon as it finds a meaning’. Longitudinal studies should clarify not only the way in which grief resolution relates to acceptance of dying and death, but also whether grief relates differentially to cognitive, emotional, and spiritual acceptance. Prigerson & Maciejewski 1 conclude that decline in grief-related distress appears to correspond with an increase in peaceful acceptance of loss, which I feel could be enhanced by addressing issues related to purpose and meaning of the loss. There is some small change besides the two sides of the coin ! References 1. Prigerson HG, Maciejewski PK. Grief and acceptance as opposite sides of the same coin: setting a research agenda to study peaceful acceptance of loss. The British Journal of Psychiatry 2008; 193: 435-437. 2. Prigerson HG, Vanderwerker LC, Maciejewski PK. Prolonged grief disorder: a case for inclusion in DSM–V. In Handbook of Bereavement Research and Practice: 21st Century Perspectives (eds M Stroebe, R Hansson, H Schut, W Stroebe): 165 –86. American Psychological Association Press, 2008. 3. Byock I. The meaning and value of death. Journal of Palliative Medicine. 2002; 5: 279-288. 4. Frankl VF.Man’s search for meaning, fourth edition. Revised & Updated, Washington Square Press, New York, 1985. |
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Holly G. Prigerson, Associate Professor of Psychiatry Brigham & Women's Hospital Harvard Medical School, Paul K. Maciejewski, PhD
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Holly_Prigerson{at}dfci.harvard.edu Holly G. Prigerson, et al.
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We thank Dr. Chaturvedi for highlighting the potentially important role that spirituality plays in the acceptance of loss. Recent research attests to the powerful influence of spirituality and religious beliefs in shaping patients’ cognitive acceptance of terminal illness, treatment preferences, and even in determining the receipt of intensive, life- prolonging care in the last week of life. 1 Nevertheless, we wish to differentiate between components of grief (e.g., yearning) and factors affecting the intensity and course of grief (e.g., spirituality). We posit that grief is on the same continuum as emotional acceptance – opposite poles of a unitary dimension. We contend that both spirituality and cognitive acceptance are distinct from, but related to, emotional acceptance and grief. Spirituality might foster emotional acceptance; cognitive acceptance might exacerbate grief. Identifying factors affecting grief and emotional acceptance may suggest ways to enhance an individual’s mental health and well-being in the face of death, and offer ways to minimize loss-related suffering. As a further distinction, we consider the loss of meaning in the context of Prolonged Grief Disorder 2 to represent the emptiness experienced by the absence of an attachment figure. It is not intended to refer to a broader existential crisis. The sense of emptiness felt in grief may well lead a person to question the meaning of life. It may heighten an individual’s sense of anomie (i.e., a feeling of disorientation and alienation from society caused by the perceived absence of a supporting social or moral framework3) and affect a person’s will to live. The meaning derived from spiritual beliefs may buffer individuals from the emptiness that follows a major interpersonal loss. Still, we do not consider spiritual beliefs to be components of grief. Rather spirituality may be a powerful antidote (perhaps, social support and social integration are others) to the pain of grief and elixir promoting emotional acceptance. References 1. Phelps AC, Maciejewski PK, Nilsson M, Balboni TA, Wright AA, Paulk ME, Trice E, Schrag D, Peteet JR, Block SD, Prigerson HG. Coping with Cancer: Religious Coping Predicts Use of Intensive Life-Prolonging Care Near Death. JAMA. 2009; 301:1140-1147. 2. Prigerson HG, Vanderwerker LC, Maciejewski PK. Prolonged grief disorder: a case for inclusion in DSM–V. In Handbook of Bereavement Research and Practice: 21st Century Perspectives (eds M Stroebe, R Hansson, H Schut, W Stroebe): 165 –86. American Psychological Association Press, 2008. 3. Marshall G. "anomie." A Dictionary of Sociology. 1998. Retrieved March 22, 2009 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O88- anomie.html |
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