Psychiatry / therapy

Shock and Denial

I review the 5 Stages of Grief with my patients all the time.  Yet, no matter how many times I review them, nor how many patients or people I lose in my life, experiencing these stages never gets easier nor avoidable.

Stages of Grief:

  • Shock/Denial
  • Depression/Sadness
  • Anger
  • Bargaining
  • Acceptance

The following was written last week:

Today, I shall focus on shock/denial.  Why focus on the shock/denial stage?  I received a call from the medical examiner (aka coroner) today.  I hold my breath each time I answer my office phone in fear that the medical examiner’s office is on the other line.  The worst sentence to hear upon answering the phone is “Hi doctor, this is (insert name here) from the medical examiner’s office.”

My biggest fear became a reality today, yet again.

Currently, I am in the shock/denial phase and I’m coping by intellectualizing (a defense mechanism that many of my colleagues employ to deal with difficult news; mostly because I’m more comfortable processing the loss clinically rather than emotionally at this point, hence, the reason I am focusing on writing a blog post that teaches the stages of grief), carrying on with work, and going about my day, with the occasional few tears and blank stares when I have downtime.  These moments of sadness are periods that I try to avoid, especially after glancing at my fully-booked patient schedule.  According to the medical examiner, “cause of death is not known, the toxicology results are still pending.”

Each and every one of us go through this phase when we experience loss.  I blogged about the subject of grief recently when I lost a patient to suicide two months ago.  I am aware that my demeanor is currently “off” because I’m quite tense and impatient right now as well.  I might be going through the motions of a regular day, but in no way am I taking this loss lightly.  I know the anger stage will approach soon.  For me, the worst stage is sadness/depression because I generally want to isolate and hide.

The following was written today:

One week has passed since hearing the tragic news about my patient.  I enter the clinic, greet my usual “good morning” as I observe everyone going about their busy day as normal.  I enter my office and suddenly have a desire to punch my computer as it takes forever to reboot.  I settle for slamming my palm against the keyboard instead.  Note that this is my usual morning routine, minus the angry/”I wanna punch something” part.  The anger stage is here.

I see my first few patients and notice a decline in my usual empathetic statements, my mind drifts more frequently, however, I remain fully aware of my thoughts and am able to re-focus.  The 20 minutes that I have with each of them is their designated time and I must not let my grief impact any medical decision.  I take my lunch break and run into one of the therapists, who was also involved in my deceased patient’s care.  I decide to open up about the struggle I’m having today, in hopes that we can provide comfort and support each other during this difficult time.   Instead, I get a remark that pisses me the hell off, or at least that’s how I interpreted her curt comment.  I essentially wanted to tell her she was an insensitive idiot and to f*** off, but I held my composure.  I normally wouldn’t be bothered by such a comment, but I’m clearly more irritable than usual.  I let it go and tried to have compassion for her especially since she might be grieving as well, or thought that perhaps she’s a cold witch and doesn’t care, then thought that perhaps I misinterpreted her comment.  Perhaps I feel that nobody understands, and maybe no words can make me feel better at this moment anyway.

23 thoughts on “Shock and Denial

  1. Hey there,
    Losing a patient is never easy. You’re admirable in that you care about your patients and at the same time you demonstrate an incredible compassion for yourself in this post. You are letting yourself feel and at the same time not letting that interfere with the care you give your current patients. Somehow, I don’t know how, I find myself relating to you a lot in this post. I think you’re really smart, brave, and strong. Sending you lots of strength during this difficult time.

    • Hi Laura,
      Thank you so much for your kind words & comment. And I’m glad u can relate in some way…that way I don’t feel alone! 🙂 Before i posted, i read it to my brother and asked if i came off sounding harsh or like a bitch, and he said to keep it because i’m being real. perhaps me & u relate in that sense…based on the posts i’ve read of yours, i definitely think u keep it real 🙂
      ~ Vania

  2. hey girly girl….this profession is brutal and you are having more than your share of that. although i believe the stages of grief are a useful ‘outline’ for what to expect my experience personally and otherwise is that there is not a neat and tidy progression. additionally i am very clear that there are some unresolvable losses……some that can never be reconciled yet we must learn to accept them simply as a fact. some losses are fundamentally unacceptable regardless if it is ‘part of life’. this is one of life’s paradoxes from my perspective.

    make sure to take time…get out in nature with hikes the ocean whatever…let that mind seek the wisdom that is in our universe…let nature wrap its arms around you…….

    xoxoxo cindy

    • thanks cindy. yes, each time i experience grief, i realize more and more that the experience isn’t so clear cut as i learned in our textbooks and in residency. i definitely process and cope with it better since allowing myself to take time…went bouldering earlier this week and the beach yesterday.

  3. So very sorry for your loss. True, everyone suffers losses, but I would think yours
    have particular kinds of pain–the dreaded call from the ME, for instance. The nature
    of your relationship with the lost one, for another. I’m just guessing, but I think these particular aspects would contain their own sources of frustration and anger.

    Good that you’re letting yourself feel some anger. But, I can see you have difficulty
    with that. I’m not criticizing, of course. Actually, feeling and expressing anger
    is a lifelong issue to me, too. I remember being in therapy myself many years ago and
    telling my therapist I felt bad about “losing my temper” after being provoked by
    someone else’s negative comments. After I finished my story, my therapist smiled a little and said, “You call that losing your temper?”

    BTW, if you ever feel like sending me an email, my address is on my blog page.

    Take care.

    • hi tom. you’re right – anger isn’t easy for me. i think blogging about it was a step in the right direction (baby steps). i appreciate u sharing your own issues with expression of anger; i’m pretty sure at some point somebody told me the same thing your therapist said 🙂

  4. Hi, I just stumbled on your blog about grief. I hope you don’t mind if I follow you for a little bit, and offer a few tid bits to help you on the grief journey. 1st why are you back at work so fast? Would you offer that advise to a patient if they lost someone, return to work within a week? I would agree with Cindy and say you need to get back to nature for a while, though you have to be aware of the moose, wolves, and bears that live in the woods. I wouldn’t put so much faith in RK and the 5 stages of grief, it’s really pretty much a gloss over on grief, I would say it really depends on the amount of distance that existed in the relationship with the deceased when it existed and the distance between the relationships of the survivors. That’s all for now, peace and comfort to you, and the family of the deceased.

    • Hi Bob, i appreciate your comment. I’m definitely open to having you follow and provide thoughts along the way. I thought twice (okay, maybe 3x) about posting this, but proceeded in hopes to validate or normalize anger, or whatever complicated, confusing emotions people may experience from grief. i’ve experienced loss in this field multiple times and have grown a lot in the process, which is why i allowed myself to relax during my 2 days off this week (in the past i continued working without taking time off, which caused horrible build up of suppressed emotions). As for KR’s stages – i agree, i mostly use it as a guide to help myself and my patients make sense of it. I’m open to learning, so any tid bits you can provide would be welcome.

  5. I’m not sure if I would call “it” anger, maybe “destruction” is a better thought or way of expressing the emotion of death (I’m meaning an untimely or un-natural death, like your call from the medical examiner). We all have “anger” and the other emotions before we entered into the “5 stages”, and “we” have for the most part learned to cope with the anger stage as well as the rest of them before entry, it’s just the intensity that we are unprepared for. The intensity that comes with the anger/ destruction is something that is so unfamiliar it’s unrecognizable as anger, just destruction. I’ve found the distance in the relationship determines the intensity of the destruction / anger. The farther away from the relationship with the deceased, the more it resembles anger, the closer to the deceased the more towards destruction it becomes. We have words like widower, widow, for the loss of a spouse and orphan for the loss of parents, but for the ultimate loss, the loss of a child, we have no label, no word that I know of, that describes the intensity of it, except it’s the destruction of all that was. KR does not offer any way to “cope” with the emotions only re-identifies what was already there, and doesn’t go into the intensity. KR may work for the relationships with distance between them, though it’s pretty ineffective for the relationships that don’t have a label. That’s my tidbit for today.

    • I can definitely appreciate the difference between anger – destruction spectrum and its correlation to distance in the relationship. I really like this distinction and assume I can apply this to other emotions, such as depression related to grief? A question I have is how would you explain a delayed grief reaction (for example, I have a patient who lost her father approx 10 yrs ago, seemed to defend herself from the emotional pain via suppression and distraction by throwing herself into work, then had a significant worsening of mood after a recent loss of a distant aunt. My assumption is that she is not only experiencing the current loss, but more so the unprocessed grief of her father)?

      So out of curiosity, can I assume grief is your specialty?

      • I don’t know I would say the woman who lost her father is having a delayed reaction; she had a reaction, and a very strong one, she became a workaholic by the sounds of it, maybe to put some “distance” into the relationship she had with her father, until she is ready to immerse herself in the re-building (living again) process. The loss of a “distant” aunt may have hit home that adding the distance to her fathers’ relationship brought no comfort or relief to her and the time she spent is water under the bridge when she should have immersed herself in the grief. But there is no “time” when grief is involved just small steps and set backs

        Grief is not my specialty, mechanical engineering is, grief is just my experience, I / we (my family) lost our 17 year old middle son (3 sons and a daughter) 3 years ago next week (2/16). I’ve become an avid reader since my son was killed. I (I sent him to get gas in my wife’s sports car, he never came back) read anything I can get my hands on about grief trying to make sense of his death. Maybe in some odd way it is a specialty of mine, one for sure that I never wanted though, engineers are very analytical and I’m no exception. It was 29-30 months after the accident before I could function at work (industrial gasses), though I did switch positions within my dept, which was a great relief. By the sounds of the woman you describe she has kept her job which is a relief in some way keeping your job means food on the table and making the mortgage payment, most parents that I’ve met have lost their job after the death of a child within 6 months, and some have lost their house, but they don’t care. My wife had to leave her job because of the stress, it was impossible for her to sell life insurance and annuities after our son died. The Compassionate friend has been a life saver for me, really opened my eyes. At first it was for support, now it’s to support others. Enough for today.

        • Thank you for that theory on my patient — applying the word “distance” seems to be quite useful in application to the concept of grief.
          I was saddened to read about the loss of your son. Yet, in some way, you’ve also given me hope. Based on the info you’ve given me thus far, I have a bit more knowledge, understanding, and empathy, esp towards my patients who have lost a child. I already have two patients in mind (who lost a child) whom I feel more confident in supporting. In my short career thus far, I feel that >80% of being an effective psychiatrist is based on experience gained from meaningful human connection more so than knowledge learned from books.

    • Hello, I wanted to let you know that i was able to relate some of the tidbits u gave me on grief during a case conference today w/ other clinicians where the topic was loss/grief. Even though our contact was brief via this forum, I truly appreciate it and thank u for reaching out to me during my process.

  6. Hi “Daktari”. I didn’t know there were 5 – classified – stages of grief. Interesting. maybe the’re not as lineal as they sound. Now, about losing a patient… I don’t think any human doctor ever gets used to it. Maybe you get used to “dealing with it” which is another ball game entirely. My daughter, on a Médecins sans frontières mission in Kenya told she would lose patients every days to TB and Aids. And she had to make do. Because the living still needed her. But once she “lost” a little 9-year girl to Aids and respiratory failure. She cried the whole day. 😦
    So we no matter what you will lose patients. Sometimes. Not always. I guess crying helps (Not in your five stages!) Then strap a smile on your face: you’ve got the live ones to take care of!
    🙂
    (And take some time off with friends… and don’t let no B.I.T.C.H. affect you!)
    And who am I to give advice to you right?
    Be good. And don’t be too hard on yourself. You are most certainly a great Doc.
    😉
    Brian

    • Brian, i think you’re highly qualified to give advice 🙂 Especially, from life experience and observations of your own daughter. I commend her for the work she does in Kenya. And we think we have it hard! that would definitely impact anyone’s perception of death and dying. Thank you for your kind words and comment.
      best,
      Vania

  7. Love the name of your blog. I look forward to reading more from your perspective; it seems courageous to me to reveal your experiences. Thanks for the follow. Aspergerhuman

    • Thank you – same to you as well as I can definitely learn from your experiences. As you know, not too many people in my field have experience nor feel comfortable working with people with Aspergers (or autistic spectrum in general), however, I am constantly seeking experiences to better understand and relate as we can only learn so much from our textbooks.

      • Yes, and the textbooks are, well, inadequate to say the least. “If you want to know about gardening, ask a gardener; if you want to know Asperger’s, ask an Asperger,” is what I tell people. It seems so obvious! But then, I’m Asperger. LOL I’m looking into an Autism Certificate (about 15 hours of grad school) so that I can help families to handle the overwhelming confusion, fear, possible wrong diagnosis, and prejudice. I have a science background and I’m good at “interpreting” between ASD and social types. I live in a rural county with little healthcare of any kind. One private psychiatrist for the rich or well insured; one chaotic overworked clinic for everyone else. Asperger people are so unlike social typical people that they need someone (like me) who “literally” knows how their brain works and that it’s not broken, but experiences reality and processes information in a unique way. Anyway! Glad to meet you.

        • true about the textbooks. i worked 6 mos in an adult developmental disabilities clinic and did 1 month at OHSU child & developmental rehab center…i definitely learned a lot and find it easier to relate to my patients with developmental “disabilities.” in a sense i believe society might be the one w/ disabilities for having difficulty relating to those other than social types. but anyway, i think that would be wonderful to get a certificate…good clinicians and advocates are needed for the ASD population.

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