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Should Orpheus have gone to grief counselling rather than the Underworld?

 

 

J’ai perdu mon Eurydice,                                I have lost my Eurydice,

Rien n’égale mon malheur;                            Nothing equals my unhappiness;

Sort Cruel, quelle rigeur,                                What misfortune, oh cruel fate,

Rien n’égale mon malheur.                            Nothing equals my unhappiness.

Je succombe à ma douleur.                            The agony overwhelms me.

 

–          “Jai perdu mon Eurydice” from Gluck’s opera “Orphee et Eurydice”, libretto by Ranieri Calzabigi

 

 

One of the best-known of all classical myths is that of Orpheus, who descends into the underworld to retrieve his beloved wife Eurydice after her untimely death. The story appears in several versions in classical literature, including the poetry of Ovid (Metamorphoses –Book X) and Virgil (Georgics – Book IV).  Over 2000 years on, the myth continues to inspire fresh re-interpretations through varied forms of music and literature. The reason this ancient myth remains contemporary throughout the ages, is perhaps partly because it explores the universal human experience of grief and mourning.  This blog post will focus on how this is portrayed through the recent revival of Gluck’s opera “Orphée et Eurydice”, shown in the 2015 Autumn season of the Royal Opera House.  Is it the ultimate act of enduring love that Orpheus refuses to accept that his wife is really gone and so goes to retrieve her from death?  Or is the more modern idea of seeking acceptance or closure after a bereavement a much healthier approach to take?

The ROH’s production begins with a grief-stricken Orpheus mourning by Eurydice’s funeral pyre, which is dramatically set alight as part of the funeral rites. Amour, the God of love, then appears and brings Orpheus solace by telling him that the Gods have taken pity on him and have granted him permission to enter the Underworld and retrieve his wife.  There is a condition of course – Orpheus must not look directly at Eurydice whilst they are in the Underworld, or explain to her why, else she will be lost to him forever.   Predictably, all does not go well.  When Orpheus is reunited with Eurydice in the Underworld, she is understandably distressed by his inexplicable refusal to look at her, and so faints as he tries to lead her out into the land of the living.   This forces Orpheus to turn back to her, and so she dies again.  Most versions of the story end with this unhappy failure of Orpheus’s quest, however in Gluck’s opera, the lovers are in fact given yet another chance at happiness.  Amour appears again, saying that as Orpheus is grief-stricken for a second time, he has truly proved the depths of his love, and so she brings Eurydice back to life for him.  This is no happily-ever-after ending however; Eurydice’s burning funeral pyre re-appears in the final scene, signifying the inevitability of death and loss.  Eurydice may have been brought back to life, but she is still mortal, and Orpheus will still lose her one day.  Death cannot be cheated in perpetuity.

Thinking it over on the way home from Covent Garden, I found myself increasingly troubled by Amour’s collusion in Orpheus’s refusal to accept the reality of his wife’s death. In modern terms, by grieving excessively and refusing to re-engage with everyday life, Orpheus would probably be labelled as experiencing an abnormal grief reaction.  How can this be defined though?  A standard definition of a clinically significant mental health problem is something that causes significant distress, and/or results in significant impairment to functioning in one or more key areas of life.  This definition does not serve us well when we apply it to bereavement however; grief is by definition distressing, and some impairment to functioning is always expected.  Indeed, if Orpheus had showed no distress, and had in fact carried on with all activities of his daily life completely as normal, this would have been considered more abnormal than the converse.

Can grieving ever really be “disordered”, or only when we don’t do it right? This concern over the medicalization of grief is discussed by Sociologist Nancy Berns in her book on the concept of “closure” after bereavement.

With the medicalization of grief, terms and models emerge that explain normal grief versus problematic grief. We continue to see a growth in labels for grief that indicate something other than “normal”: complicated grief, pathological grief, morbid grief, unanticipated grief, prolonged grief, neurotic grief, traumatic grief, unhealthy grief, abnormal grief, delayed grief, absent grief, inhibited grief, exaggerated grief, conflicted grief, unresolved grief, distorted grief, masked grief, sudden grief, and chronic grief.”

Pg. 33, Closure; The Rush to End Grief and What it Costs Us. (Berns, 2011)

The medicalization of grief continues to be a subject of debate in psychiatry.  The American Psychiatric Association (APA) released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.  According to the website the DSM is ” the standard classification of mental disorders used by mental health professionals in the United States and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system.”   Note the last 3 words – the DSM is important because it dictates what conditions health insurance companies will pay out for; no diagnosis, no claim.  One of the most controversial changes in the DSM-5 from the previous version is the removal of the so-called “bereavement exclusion” from the diagnostic criteria for major depressive disorder.  In the previous edition (DSM-IV), it was not possible to receive a diagnosis of depression within 2 months of a significant bereavement, in recognition of the fact that many depressive symptoms overlap with normal grief reactions (e.g. sadness, tearfulness, trouble sleeping).  The function of the “bereavement exclusion” was seen by many as protection against the inappropriate medicalisation of a normal reaction to a significant life event such as bereavement. The potential harmful consequences of removing this bereavement exclusion can be summed up in the following quote from an online article by psychiatrist Allen Frances.  Frances’ words carry particular weight in this case given his prior role as chair of the DSM-IV task force.

 

“Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.”

–             (Frances, 2010)

 

Why the change then? In fairness, the explanation given in the APA’s briefing document on the removal of the bereavement exclusion in DSM-5 indicates they did it with the best of intentions.  Firstly, they point out that the bereavement exclusion could have unhelpfully implied that grief only lasts 2 months normally, when clearly this is not the case.  Secondly, they wished to highlight bereavement as a significant life stressor that could trigger a new episode of depression in people with a past history of depression, or other vulnerabilities.  This would allow people to access treatment without having to wait 2 months to meet diagnostic criteria for a disorder.  However, this has not allayed the fears of many professionals, that bereavement will no longer be recognised as a normal, and indeed necessary process, but rather as an aberrant reaction requiring psychiatric intervention.

The desire to protect people from unnecessary and potentially harmful intervention (as Frances puts it) is one surely shared by all healthcare professionals. However, denying the possibility that people could ever experience an abnormal grief reaction seems also to be an unhelpfully dogmatic position to take up.   So-called “abnormal grieving” seems to fall into that irksome category of being something that is almost impossible to define satisfactorily, but is easily recognised when you see it.  This is aptly demonstrated by a compelling case vignette from a recent paper entitled “Complicated Grief” in the New England Journal of Medicine (Shear, 2015):-

“A 68-year-old woman seeks care from her primary physician because of trouble sleeping 4 years after the death of her husband. On questioning, she reveals that she is sleeping on a couch in her living room because she cannot bear to sleep in the bed she shared with him. She has stopped eating regular meals because preparing them makes her miss him too much; she still has meals that she cooked for him in her freezer. The patient often ruminates about how unfair it was for her husband to die, and she is alternately angry with the medical staff who cared for him and angry at herself for not recognizing his illness earlier. She finds it too painful to do things that she and her husband used to do together, and she thinks about him constantly and often wishes she could die to be with him. How should this patient be evaluated and treated?”

 

The entire premise of this paper is fascinating – is this woman indeed a patient, and if so what treatment would we prescribe? In terms of psychological treatments, cognitive models of grief do in fact suggest that a target of intervention for this woman might be to address her thinking style.  For example, the woman is described as ruminating about how it was unfair for her husband to die.  Ruminating about injustice is common in people who have experienced bereavement; however a longitudinal study found this kind of thinking is associated with poorer outcomes over the longer term including higher symptom levels of complicated grief and depression (Eisma et al., 2015b). The same study also found that thinking about emotional reactions in a more reflective way was associated with better long-term outcomes.  Randomised controlled trials (RCTs) of grief interventions based on cognitive-behavioural therapy (CBT) do appear to indicate therapy can be helpful in reducing grief severity and improving overall well-being (Eisma et al., 2015a, Rosner et al., 2014, Shear et al., 2014)  However, such research is still at an early stage, and the existing studies have methodological limitations, including high therapy dropout rates (Eisma et al., 2015a) and small sample sizes (Rosner et al., 2014).

The idea that we need to treat grief at all, let alone conduct therapy trials on it, is certainly a modern one. Orpheus’s reaction to the death of his wife was perhaps culturally sanctioned, hence the sympathy of Amour and others to his plight.  Nowadays, we tend to respond to the bereaved by encouraging them along a process of gradual acceptance, with the aim of helping them find some kind of closure or peace.  The most famous model of grieving is attributed to Elisabeth Kübler-Ross, who described stages of grieving in terminally ill patients, including anger, denial, bargaining, depression and acceptance (Kubler-Ross, 1969). This model has been commonly misunderstood and misapplied over the years however. Kübler-Ross herself never intended for the stages to be seen as some kind of check-list for efficient grieving, and she never asserted that the stages were universal, or meant to be experienced in a strictly sequential manner.  This overly simplistic interpretation of her work was beautifully parodied in one of my favourite scenes from The Simpsons when Homer believes he has been fatally poisoned by a puffer fish.

The stages model of grief is perhaps also present in the Orpheus myth, as his quest involves a metaphorical passing through of different stages, in entering and re-emerging from Hades. In his textbook on grief counselling, William Worden describes four tasks of grieving that must be accomplished in order to complete the process of grieving (Worden, 2009). Worden’s first task of grieving is “accepting the reality of the loss”.  Orpheus falls at the first hurdle here.  At the core of the myth of Orpheus lies the difficulty of being with what is difficult.  For a young man to lose his beloved wife is tragic in any century.  It is always hard to face death, grief and loss.  This perhaps stems from our struggle to meet pain with acceptance.  So did Amour really do Orpheus a favour by allowing him into the underworld to retrieve his beloved?  If we were to follow the stages of grieving model, we would certainly say no, as this is a barrier to acceptance of the loss and blocks the necessary processing of pain.  Amour recognised Orpheus’s pain; but fell into the same trap of trying to avoid it as he did.  When we are grieving, those around us may wish to diminish or take away our pain, partly as a way of avoiding it themselves.  Even if we don’t sign up to the idea that there is a right or wrong way to grieve; whether it is seen as a finite road to be travelled, or an infinite chasm that you never truly climb out of, the hardest thing to do of course is just to sit with someone and bear witness to their pain, without trying or needing to “fix it”.  Perhaps Orpheus didn’t need to go to grief counselling, but he found no solace in the Underworld either.  What should he have done?  Perhaps he could have tried applying Winston Churchill’s advice:-  “If you’re going through Hell, keep going.”

Cruse Bereavement Care is a national charity which offers free support to anyone needing additional help in coping with grief. The Samaritans also offer free support to anyone who would like to talk to someone in confidence about anything that is troubling them, including issues around grief and bereavement.

References

Berns, N. (2011). Closure: The rush to end grief and what it costs us. Temple University Press: Philadelphia.

Eisma, M. C., Boelen, P. A., van den Bout, J., Stroebe, W., Schut, H. A., Lancee, J. & Stroebe, M. S. (2015a). Internet-based exposure and behavioral activation for complicated grief and rumination: A randomized controlled trial. Behavior Therapy.

Eisma, M. C., Schut, H. A., Stroebe, M. S., Boelen, P. A., van den Bout, J. & Stroebe, W. (2015b). Adaptive and maladaptive rumination after loss: A three-wave longitudinal study. British Journal of Clinical Psychology 54, 163-180.

Frances, A. (2010). DSM-V: The Medicalisation of Grief. In Psychiatric Times.

Kubler-Ross, E. (1969). On Death and Dying. MacMillan: New York.

Rosner, R., Pfoh, G., Kotoucova, M. & Hagl, M. (2014). Efficacy of an outpatient treatment for prolonged grief disorder: A randomized controlled clinical trial. Journal of Affective Disorders 167, 56-63.

Shear, M. (2015). Complicated grief. The New England Journal of Medicine 372, 153-160.

Shear, M., Wang, Y., Skritskaya, N., Duan, N., Mauro, C. & Ghesquiere, A. (2014). Treatment of complicated grief in elderly persons: A randomized clinical trial. JAMA Psychiatry 71, 1287-1295.

Worden, W. (2009). Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner. Routledge: London.

 

 

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