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Grief and acceptance as opposite sides of the same coin: setting a research agenda to study peaceful acceptance of loss

  • Holly G. Prigerson (a1) and Paul K. Maciejewski (a2)
Summary

Reflections on results of a recent study suggest that stages of grief might more accurately be described as states of grief. Resolution of grief coincides with increasing acceptance of loss. Research indicating how grief resolution promotes acceptance may prove clinically useful in easing emotional pain associated with loss.

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Copyright
Corresponding author
Dr Holly G. Prigerson, Center for Psycho-oncology and Palliative Care Research, Suite 530, Dana-Farber Cancer Institute, 44 Binney Street, Boston MA 02115, USA. Email: holly_prigerson@dfci.harvard.edu
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Declaration of interest

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Footnotes
References
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1 Kubler-Ross, E. On Death and Dying. Collier Books Macmillan Publishing, 1969.
2 Maciejewski, PK, Zhang, B, Block, SD, Prigerson, HG. An empirical examination of the stage theory of grief. JAMA 2007; 297: 716–23.
3 Bonanno, GA, Boerner, K. The stage theory of grief. JAMA 2007; 297: 2693.
4 Silver, RC, Wortman, CB. The stage theory of grief. JAMA 2007; 297: 2692.
5 Bowlby, J. Processes of mourning. Int J Psychoanal 1961; 42: 317–39.
6 Parkes, C. Bereavement: Studies in Grief in Adult Life. Tavistock, 1972.
7 Jacobs, S. Pathologic Grief: Maladaptation to Loss. American Psychiatric Press, 1993.
8 Prigerson, HG, Jacobs, SC. Traumatic grief as a distinct disorder: a rationale, consensus criteria, and a preliminary empirical test. In Handbook of Bereavement Research: Consequences, Coping, and Care (eds Stroebe, MS, Hansson, RO, Stroebe, W, Schut, H): 588613. American Psychological Association, 2001.
9 Good Grief (Episode 121). Frasier (Season 6). First aired 24 September, 1998.
10 My Five Stages (Episode 106). Scrubs (Season 5). First aired 7 March, 2006.
11 Downe-Wamboldt, B, Tamlyn, D. An international survey of death education trends in faculties of nursing and medicine. Death Stud 1997; 21: 177–88.
12 National Cancer Institute. Loss, grief and bereavement. http://www.nci.nih.gov/cancertopics/pdq/supportivecare/bereavement/Patient/page6.
13 Prigerson, HG, Maciejewski, PK, Reynolds, CF III, Bierhals, AJ, Newsom, JT, Fasiczka, A, Frank, E, Doman, J, Miller, M. Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res 1995; 59: 6579.
14 Prigerson, HG, Shear, MK, Jacobs, SC, Reynolds, CF, Maciejewski, PK, Davidson, JRT, Rosenheck, R, Pilkonis, PA, Wortman, CB, Williams, JBW, Widiger, TA, Frank, E, Kupfer, DJ, Zisook, S. Consensus criteria for traumatic grief. A preliminary empirical test. Br J Psychiatry 1999; 174: 6773.
15 Prigerson, HG, Bierhals, AJ, Kasl, SV, Reynolds, CF, Shear, MK, Day, N, Beery, LC, Newsom, JT, Jacobs, S. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997; 154: 616–23.
16 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 Stroebe, M, Hansson, R, Schut, H, Stroebe, W): 165–86. American Psychological Association Press, 2008.
17 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). APA, 1994.
18 Mack, J, Nilsson, M, Balboni, T, Friedlander, RJ, Block, SD, Trice, E, Prigerson, HG. Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE): validation of a scale to assess acceptance and struggle with terminal illness. Cancer 2008; 112: 2509–17.
19 Ray, A, Block, SD, Friedlander, RJ, Zhang, B, Maciejewski, PK, Prigerson, HG. Peaceful awareness in patients with advanced cancer. J Palliat Med 2006; 9: 1359–68.
20 Prigerson, HG. Socialization to dying. Social determinants of death acknowledgement and treatment among terminally ill geriatric patients. J Health Soc Behav 1992; 33: 378–95.
21 Wright, AA, Ray, A, Zhang, B, Mack, JW, Mitchell, SL, Nilsson, ME, Trice, ED, Block, SD, Maciejewski, PK, Prigerson, HG. Medical care and emotional distress associated with advanced cancer patients' end-of-life discussions with their physicians. JAMA 2008; 300: 1665–73.
22 Erikson, EH. The Life Cycle Completed. Norton, 1982.
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Grief and acceptance as opposite sides of the same coin: setting a research agenda to study peaceful acceptance of loss

  • Holly G. Prigerson (a1) and Paul K. Maciejewski (a2)
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eLetters

Spirituality, Grief, and Emotional Acceptance of Loss

Holly G. Prigerson, Associate Professor of Psychiatry
30 March 2009

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 inshaping 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 faceof 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 absenceof 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.

References1.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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Acceptance, Grief & Meaning

Santosh K Chaturvedi, Professor of Psychiatry
19 February 2009

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 andacceptance, 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 cancersindicate 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 findsa 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 declinein 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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Conflict of interest: None Declared

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Peaceful Acceptance and Implications for Psychiatry

Prakash Gangdev, Psychiatrist
24 January 2009

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 couldpave 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 atreatment 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.

References1. Prigerson HG & Maciejewski PK. Grief and acceptance as opposite sides of the same coin: setting a research agenda to study peaceful acceptance of lossThe 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.

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