Psychology of Sadness [1 ed.] 9781620810101, 9781619429987

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Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Psychology of Sadness, Nova Science Publishers, Incorporated, 2012. ProQuest Ebook Central,

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Psychology of Sadness, Nova Science Publishers, Incorporated, 2012. ProQuest Ebook Central,

PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

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PSYCHOLOGY OF SADNESS

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Psychology of Sadness, Nova Science Publishers, Incorporated, 2012. ProQuest Ebook Central,

PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGY OF SADNESS

EMILE J. LANGLEY Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

AND

ROGER B. KNOWLES EDITORS

Nova Science Publishers, Inc. New York

Psychology of Sadness, Nova Science Publishers, Incorporated, 2012. ProQuest Ebook Central,

Copyright © 2012 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‟ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book. Library of Congress Cataloging-in-Publication Data Psychology of sadness / editors, Emile J. Langley and Roger B. Knowles. p. cm. Includes index. ISBN:  (eBook) 1. Sadness. I. Langley, Emile J. II. Knowles, Roger B. BF575.S23.P79 2011 152.4--dc23 2012002183 Published by Nova Science Publishers, Inc. † New York

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CONTENTS Preface Chapter 1

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Chapter 2

vii Grief, Grieving and Beyond: Lived Experience amoung Spouses/Cohabitants of Persons with Bipolar Affective Disorder Oscar Tranvåg King of Sorrow: Perception and Experience of Sadness in Music Tuomas Eerola and Marko Punkanen

Chapter 3

Grief, Depression and Pregnancy F. Susan Cowchock

Chapter 4

Children’s Knowledge of the Interpersonal Consequences of Sadness Mariève Hurtubise and Pierre Gosselin

Chapter 5

"Combat Veterans and the Search for Meaning: Voices from the Battlefield?" Janice A. Aloi

Index

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1

31 53

81

101 121

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Psychology of Sadness, Nova Science Publishers, Incorporated, 2012. ProQuest Ebook Central,

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PREFACE In this book, the authors present current research in the study of the psychology of sadness. Topics discussed include the grieving process and living with persons with bipolar affective disorder; depression and pregnancy; children's knowledge of the consequences of expressing sadness; the themes of sadness and frustration among returning combat veterans; and the perception and experience of sadness in music. Chapter 1 – Grief, one of oldest forms of suffering in recorded history, is a normal manifestation of human anguish, differing from other forms of suffering by way of origin; an experience of loss. Since loss is a natural consequence of being human, so too are suffering and grief natural aspects of living. The first part of this chapter is dedicated towards illuminating crucial aspects of human grief. Within the literature the authors find contrasting theoretical perspectives concerning what grief is and what grieving entails. Positivism and phenomenology are two scientific traditions with contrasting views on the nature of grief. While these traditions emphasize seemingly incompatible and contradicting perspectives, the authors shall discuss how each of them can enrich the authors understanding of the nature of grief. Then, the authors will consider how new insight may be gained by combining these two paradigms join to form a double optic in an effort to reveal a holistic understanding of grief, beyond what either paradigm alone can accomplish. The second part of this chapter will review the findings of a study exploring the grieving process experienced by a group of family caregivers, namely spouses/cohabitants of persons with bipolar affective disorder. The study reveals how suffering caused by grief over loss was found to be a part of a cumulative process over an extended period of time. Over the years, each spouse/cohabitant experienced various illness-related challenges. Persons

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Emile J. Langley and Roger B. Knowles

living together with their ill partner over the longest periods of time found their process of grief over loss helped them move forward towards dawning acceptance, solace of reconciliation, and finally, a new hope. Gestalt therapy theory was applied to develop a theoretical base of understanding for this cumulative process bound within the psychology of this particular form of sadness. Spouse/cohabitant suffering from grief over loss was attributed to an inner imbalance provoked by the lack of insight and meaning, counteracting their normal organic equilibrium. This imbalance was caused by incomplete intrapersonal and interpersonal gestalts, or patterns. In time, new insight and renewed meaning reduced burdens of grieving over loss, as new and holistic gestalts immerged towards dawning acceptance, reconciliation and a new hope. Inner imbalance was reduced, new foundations established and equilibrium restored. Nurses and allied healthcare professionals can play important roles in the empowerment of spouses/cohabitants. Humane and empathetic care, health-promoting guidance and insight enriching dialogues were found to be important factors towards encouraging grieving spouses/cohabitants to moving forward beyond suffering, towards dawning acceptance, reconciliation and a new hope. Chapter 2 – Negative emotional experiences such as sadness are interesting topic due to their inevitability in the daily lives of people but also for the paradoxical enjoyment related to them in the context of arts. Sadness, for instance, is in principle an aversive affective state but is nevertheless immensely enjoyed in the arts as witnessed by prevalence of the theme in literature, films, and music. Music in particular is a rich and natural source of emotions for a large number of people in everyday situations. Although the induction and recognition of emotions has received a lot of attention during the last decade, negative emotions such as sadness induced by music, has been less frequently explored. In this chapter the emotion regulation strategies of the nominally sad music are presented. Also the mood congruent biases caused by such affective state are reviewed. Sadness and negative emotions in general are also considered in a clinical context, where long-term mood changes such as depression bestows systematic negative biases to recognition of emotions in music. Case examples of the processes and biases of depressed patients‟ during music therapy treatment are given. The diagnostic implications of such results are highlighted. The potential benefits of undergoing negative emotions in a safe context (such as music therapy setting) are discussed in detail. For example, musical improvisation together with a music therapist can offer to a

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Preface

ix

depressed patient a safe, creative and playful medium for expression of negative emotions and aid the patient in learning to utilize more beneficial emotion regulation strategies such as reappraisal and self-disclosure. Chapter 3 – Depression associated with gestation is a major obstetric health problem, affecting as many as 20% of women pregnant in the past year. Depressive episodes are most prevalent in the postpartum period, with some level of suicidal ideation occurring to 9% of women. Half of women with diagnosed bipolar disorder in one series had episodes during the postpartum period. Perinatal grief is a normal response to the 15-20% of pregnancies that end in loss, and may persist until/recur in a subsequent, normal pregnancy. Pregnancy-related grief and depression are often complicated by symptoms of coexistent anxiety or post-traumatic stress. Men, too, grieve pregnancy losses, and up to 10% suffer depression in the post-natal period, but fathers' pregnancy-related sadness has not been extensively studied. Risk factors for depression in the peripartum period include past depression, a past/present eating disorder, anxiety disorders, prior perinatal loss, or a pregnancy complication. Moderating factors may include higher maternal age, religiosity and social support. Maternal salivary cortisol levels correlate with peripartum traumatic stress symptoms and depressive states, and may in the future serve as diagnostic markers and targets for treatment. Treatment of depression and grief complicated by anxiety or symptoms of post-traumatic stress in pregnancy is based on the same modalities as treatment for these diagnoses outside gestation. These include cognitive processing therapies (individual or group), psychiatric drugs, supportive counseling, or (for post traumatic stress) eye movement desensitization reprocessing. Cautions about the use of psychotropic drugs during pregnancy and lactation are reviewed here. There are only a few studies of any other therapies in pregnancy – these mainly focus on group cognitive behavioral therapy for postpartum depression. Chapter 4 – While substantive evidence has been gathered concerning children‟s and adults‟ knowledge as to the causes of sadness, very little information is available regarding their knowledge of its consequences, in particular, its interpersonal consequences. The authors report here on a study in which the authors investigated children‟s knowledge of the consequences of expressing sadness as well as the consequences of hiding sadness. Seventy-six school-age children were read stories describing situations in which a main protagonist expressed sadness and other stories in which he or she hid sadness. The participants were asked to choose, among three possible options, how the other protagonists of the story would react and what they would think. As

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expected, children were found to better understand the consequences of expressing sadness than the consequences of hiding sadness. The 6-year-olds were able to identify the consequences of expressing sadness, but not the consequences of hiding sadness, while the 10-year-olds succeeded in performing the task in both conditions. Interestingly, children‟s knowledge of the consequences of hiding sadness varied as a function of the dissimulation strategy. Children were generally more accurate in identifying the consequences of masking sadness with a smile than neutralizing the expression. Chapter 5 – Ten combat veterans were interviewed to determine the effect of societal acknowledgment on combat veterans‟ ability to assign meaning and benefit to the combat experience using a social constructionist framework. Their perceived lack of societal acknowledgment forced them to rely on veteran peers for the support needed for the meaning-making process. A congruency model, identifying combat veterans as a unique subculture, was designed to explain the role of veteran peers in the post-deployment return to civilian life. The study suggests that a social constructionist perspective on readjustment has implications for the vast number of veterans who will be returning home from Iraq, Afghanistan, and future wars.

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In: Psychology of Sadness Editors: E. Langley and R. Knowles

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Chapter 1

GRIEF, GRIEVING AND BEYOND: LIVED EXPERIENCE AMOUNG SPOUSES/COHABITANTS OF PERSONS WITH BIPOLAR AFFECTIVE DISORDER

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Oscar Tranvåg Department of Nursing Education, Faculty of Health Sciences, Oslo and Akershus University College, Norway Department of Public Health and Primary Health Care, Faculty of Medicine and Dentistry, University of Bergen, Norway

ABSTRACT Grief, one of oldest forms of suffering in recorded history, is a normal manifestation of human anguish, differing from other forms of suffering by way of origin; an experience of loss. Since loss is a natural consequence of being human, so too are suffering and grief natural aspects of living. The first part of this chapter is dedicated towards illuminating crucial aspects of human grief. Within the literature we find contrasting theoretical perspectives concerning what grief is and what grieving entails. Positivism and phenomenology are two scientific traditions with contrasting views on the nature of grief. While these traditions emphasize seemingly incompatible and contradicting perspectives, we shall discuss how each of them can enrich our understanding of the nature of grief. Then, we will consider how new

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Oscar Tranvåg insight may be gained by combining these two paradigms join to form a double optic in an effort to reveal a holistic understanding of grief, beyond what either paradigm alone can accomplish. The second part of this chapter will review the findings of a study exploring the grieving process experienced by a group of family caregivers, namely spouses/ cohabitants of persons with bipolar affective disorder. The study reveals how suffering caused by grief over loss was found to be a part of a cumulative process over an extended period of time. Over the years, each spouse/cohabitant experienced various illness-related challenges. Persons living together with their ill partner over the longest periods of time found their process of grief over loss helped them move forward towards dawning acceptance, solace of reconciliation, and finally, a new hope. Gestalt therapy theory was applied to develop a theoretical base of understanding for this cumulative process bound within the psychology of this particular form of sadness. Spouse/cohabitant suffering from grief over loss was attributed to an inner imbalance provoked by the lack of insight and meaning, counteracting their normal organic equilibrium. This imbalance was caused by incomplete intrapersonal and interpersonal gestalts, or patterns. In time, new insight and renewed meaning reduced burdens of grieving over loss, as new and holistic gestalts immerged towards dawning acceptance, reconciliation and a new hope. Inner imbalance was reduced, new foundations established and equilibrium restored. Nurses and allied healthcare professionals can play important roles in the empowerment of spouses/cohabitants. Humane and empathetic care, health-promoting guidance and insight enriching dialogues were found to be important factors towards encouraging grieving spouses/cohabitants to moving forward beyond suffering, towards dawning acceptance, reconciliation and a new hope.

INTRODUCTION Grief, one of oldest forms of suffering in recorded history [1-3], is a normal manifestation of human anguish, experienced as the deepest form of human sorrow. Grief differs from other types of suffering by origin, namely the experience of loss over a part of life with great individual meaning [4, 5]. But what characterizes this inner suffering? How do human beings experience grief over the loss of someone or something very precious to them? And how do we understand the nature of grief? Surprisingly perhaps, there is no simple or all-encompassing answer to these questions. Several attempts have been made in literature, including nursing literature, to identify and describe variables and their working interrelationships encompassed in the process of

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grieving. A conceptual definition associated with these variables however is missing [4], and to date there is no existing theory which can fully explain grief as a human experience [6]. While some authors argue that certain universal characteristics are present, others maintain that grief is a complex, individual, contextually founded phenomenon. Most agree however, that grief is a normal experience in the life-world of human beings [7]. The first part of this chapter will attempt to illuminate some important aspects often found in the grieving process. Two scientific traditions with contrasting approaches concerning the nature of grief are positivism and phenomenology. The first focuses on physical and psychological signs, diagnosis and treatment. The second attempts to learn through first hand lived experiences of individuals who have suffered grief, and how their process of grieving developed. Here, the question may be asked: Would it be possible to learn more about the nature of grief and the process of grieving by considering both the positivistic and phenomenological perspectives at the same time, forming a double optic? Can so doing give us a more holistic understanding of grief, beyond that which either paradigm alone can offer? The second part of the chapter reviews the findings of Tranvåg & Kristoffersen [8], a research study exploring grief, the process of grieving and beyond, as experienced by a sample of family caregivers, namely eight spouses/cohabitants of persons with bipolar affective disorder. Gestalt therapy theory [9, 10] was initiated to illuminate their grieving processes. Previous studies on individuals with mental disorders indicate that family members often experience their role as every-day caregiver as stressful and burdensome [11, 12]. Alarmingly, in this context many family caregivers of persons with mental disorders develop physical and/or mental disorders of their own [8, 13, 14]. In addition, persons who care for family members with mental illness often experience grief over loss [8, 12, 15]. Research underscores the urgent need for healthcare authorities to promote preventative caring intervention for the health and wellbeing of family caregivers. For this reason, the present chapter also addresses current perspectives on nursing and allied healthcare practice related to grief. But first, a review of the existing literature on the human experience of grief and the grieving process attributed to loss.

GRIEF OVER LOSS As a baseline for understanding, grief is recognized as “experiencing an intense inner reaction over en immense external loss [16, p. 16]. This

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experience of forfeiture will vary in meaning and intensity according to the value of each relationship is question. There are numerous losses which may lead to grief. In the literature a majority of authors discuss grief as a reaction to death and the loss of a significant human being [4]. Grief however can follow many instances where changes in valuable relationships occur [6] or when a valuable object is withdrawn from one‟s life [17]. This is an indication that grief may arise in a variety of circumstances, for example, following the loss of a beloved pet [18] or the deprivation of a limb, bodily function or normal development [16]. Physical impairment or dysfunction, eroding health or chronic illness, often leads to grief as well [19, 20]. Family members may share in the grieving process over the loss of loved ones memory, deviation of personality or others changes which make normal communication and meaningful interaction strenuous or impossible [16]. It is not unusual that individuals experience grief due to loss resulting in increased dependency on others [21] or in connection with the forfeiture of employment or the onset of retirement [4]. Heart wrenching is the loss of hope felt by the woman who knows she can never experience giving birth to her own child due to involuntary infertility [22]. Equally devastating is divorce related loss [23], none the least, that of a grieving child experiencing for the first time a broken heart over the loss of companionship to a beloved parent [24]. The loss of one‟s home can also initiate a process of grieving [25]. In general terms, grief can be understood according to the nature of privation, for example, the forfeiture of material goods, erosion of relationship, or systemic loss, in other words, the loss of shared experiences of members of the same group. Additional categories of loss include intrapsychic loss, referring to painful, subjective recognition of one‟s limitations, resulting in declining self-esteem due to a realization that future dreams or plans may never reach fruition [26]. Grieving may also coincide with symbolic loss, such as lost hope over future possibilities [16, 26]. Gender [27, 28] and age [29] may also influence the grieving process. Moreover, previous life experience, including encounters of previous loss [30] and cultural or religious devotion can impact individual processes of grieving [31]. In this perspective, grief over loss can be seen as a normative process since the socio-cultural context defines the boundaries for what is attributed an expected, appropriate or “normal” grieving reaction [4]. However, categorizing factors leading to grief can never be exhaustive. Thus, the findings of Stroebe, Stroebe and Hansson [6] and Worden [17], suggesting that grief often follows changes in valuable relationships or withdrawal of valuable objects in life, may serve as a basis for our understanding of grief over loss.

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Intense sadness leading to grief can influences an individual‟s life function, shading his or her interpretation of that which has true meaning in life [16]. Grieving is a pervasive experience which affects the person in all aspects of life [4]. Emotional reactions such as an inability to experience happiness or pleasure are not unusual. Feelings of helplessness, anger, frustration, sadness or depressive moods are common. The process of grieving can also result in problems with concentration or preoccupation of thoughts related to the experienced loss. Social withdrawal from others is not uncommon. Reduced capacity to perform activities of daily living due to physical and behavioral changes such as sleeplessness, feeling lethargic, constant crying, change in blood pressure or heart rate, gastrointestinal problems and weight changes are also seen in grieving individuals. In addition, the grieving persons‟ spiritual and existential foundations can suffer as well, resulting in growing ambivalence towards religion and faith, leading to despair over the path for a meaningful future [4].

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PERSPECTIVES ON THE NATURE OF GRIEF Research shows how the experience of grief varies from person to person, and according to the context of one‟s life. Grief can therefore be seen as a unique and personal experience in which an individual undergoes his or her own grieving process [7, 16]. At the same time, the literature emphasizes for generalities and universal aspects of grief in the human experience [32, 33]. In an effort to shed light on this polarization I will draw upon both positivistic and phenomenological paradigm to open our understanding of grief within these diverse scientific traditions; Grief can be perceived as a universal process developing over several phases over time [4]. We can understand grief symptomatically, relating to certain expressions, signs and developmental phases utilizing a positivistic perspective on stress, depression [7] and crisis [16]. Within this paradigm grief is viewed as an object for classification, quantification and utilization of diagnoses according to pathogenesis. According to the positivistic tradition, necessary treatment can be prescribed and initiated [7]. An example of a theory concerns phases experienced due to separation and grief is John Bowlby‟s attachment theory. This theory has greatly influenced our understanding of this phenomenon. His theory is founded upon biological-, cognitive psychological- and system theory, in close association with objectrelation theory as well. According to Bowlby, the human experience of grief

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can be seen in the following phases: numbness with shock and denial; anger, protest and a search for answers; disorganized despair; depression and lack of energy; reorganizing and accept. According to this perspective it is possible for the grieving individual to overcome the dependency of a deceased loved one by enduring the mentioned five phases. Characteristics of beneficial grieving are seen as an individual acknowledgment and acceptance of the death of a loved one and as adjustments to move from dependency to independence [16, 34]. However, it is accepted within the positivistic paradigm that some individuals never experience a normal or beneficial grieving process. Founded on a positivistic scientific diagnosis, some grieving processes may be seen as “pathologic grief” [32, p.51]. According to Bowlby, pathologic grief has four characteristics: A constant, unconscious longing for the lost person or object; an intense and constant anger accompanying an attitude of reproach towards certain individuals or organizations; uses of substitute and alternative objects for grieving; denial over the fact that that which is lost is gone forever [32]. In pathologic grief there is no personal relinquishing of the lost object. The longing for reconnection with that which is no more represses a healthy and normal process of reconciliation [35]. Within a positivistic paradigm, a prolonged and complicated grieving process may eventually lead the development of pathologic conditions such as depression, anxiety, phobia, psychosomatic aliments, sleep disorders, anorexia and social isolation [35]. Some express concern that symptoms of grief can be mistaken for major depressive condition [21]. A recent study of Newson et al. [36] illustrates the ongoing discourse within this paradigm on the characteristics of grief, distinguishing it from all other forms of suffering. In their study, Newson and her collegues found that among 5741 older participating adults, 1089 individuals reported current grief and 277 (25, 4 %) were diagnosed with complicated grief combined with inflated anxiety and depression rates. The vast majority of those experiencing complicated grief remained free from these two most common co-morbid psychiatric diagnostic disorders of ageing. Thus, in line with some previous studies [37-39], Newson et al. [36] indicate that complicated grief is a separate condition with symptoms not attributable to other mental health disorders, thus emphasizing the “need for prevention, diagnosis and treatment options” including the “recognition of complicated grief as a distinct diagnosis” [36, p. 231]. Phenomenology on the other hand, offers another approach for understanding the human experience of grief. Within this scientificphilosophic paradigm the positivistic approach is inappropriate for understanding and describing human experience. The positivistic tradition is

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defined as having reductionist and objective perspectives of humankind. As formulated by Skjervheim [40] reducing an individual to an object, dependent on general laws of nature, is within the phenomenological paradigm understood as an instrumental mistake and an injustice to humankind [40]. Since phenomenology looks at people as intentional, self-interpreting and nonreducible, this scientific tradition does not accept what is perceived as positivistic minimization of humankind and society at large, as one does with nature sciences in considering what is right and what is not [41]. From the perspective of phenomenology, human life-phenomena must be understood as pre-cultural aspects of humankind [42]. As pre-cultural lived phenomenon [42] grief leads to experiences which are particular and typical at the same time. This implies that the process of grieving carries with it inner meaning, both particular to the individual, while at the same time typical for human process of grieving [7]. Grief over loss represents a lived experience over something important and meaningful is lost [7]. This human experience is expressed within the cultural context the individual is a part of. However, from a phenomenological perspective, the grieving individual can never be placed within a normative standard for characterizing grief or expressions of the same. As a lived experience, grief cannot be categorized or defined in plain terms as this would imply a reduction of living beings and the process of grief into something less than the living phenomenon they are [43]. As underlined by the Husserl [44], the methodological founder of phenomenology, this scientific tradition emphasizes the gaining insight into the phenomena of human existence, by attempting to uncover how the lived experience reveals itself for the person experiencing it. This approach entails turning to “the matter itself”, by investigating how this is experienced by the person herself/himself [7, p. 273]. Seeking insight into human grieving processes through experiences from within the grieving individual's life-world is an example of how phenomenology turns towards “the matter itself”, as formulated by Furnes & Martinsen [7, p. 273]. In other words, one must seek out and meet the phenomenon as it is for the one experiencing it. Phenomenology understands grieving as a natural human experience and not as a pathological form of illness. The variety of expression and intensity found in grief, show the phenomenal range found in this human experience. The content of the grieving process, its strength and duration, all depend on the circumstances surrounding its origin, the environment and relational context the grieved party find themselves in, as well as individual circumstances of the grieving person themselves [16]. The experience of grief offers the grieving individual opportunities to develop new insight concerning the meaning of

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life. Finding meaning in suffering implies individual discoveries and acknowledgements towards forming new and invaluable understanding for what it means to be human. The nature of this insight is mature life knowledge, a maturity the individual will carry with them in here-and-now situations as well as during future experiences in life [7, 45].

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CONTRADICTING VIEWS OR “DOUBLE OPTIC”? For lack of a consensus on the nature of grief one may be inclined to obtain a dualistic understanding where the contrasting scientific perspectives involved are considered as opposite and mutually foreclosed. Time and energy can be utilized for arguing how one‟s own perspective is the right frame of reference. However, researching diverse and contrasting perspectives may ultimately lead to the formation of new foundations of understanding from which new questions and new insights may arise. Or as Karl Popper, the wellknown theorist of scientific theory and research methods concluded, ”I may be wrong, and you may be right, therefore, if we cooperate we may come closer to the truth” [46, p. 255]. When concerning grief as our phenomena of investigation in this chapter, perhaps the following questions may be relative: Is it possible that contrasting or polarized views can enrich one another and contribute to a holistic understanding of the grieving process? Are the perspectives concerning the two scientific traditions positivism and phenomenology non-compatible in absolutely each and every circumstance? Can the fusion of these paradigms form a contrasting double optic, a holistic understanding of grief, beyond the either or dichotomy? Can researchers, despite differences in epistemological and ontological principles, identify perspectives which may serve as “bridge builders” between these scientific bastions? For example: Can the grieving individual‟s search for meaning, or in other words, his or her search for meaning as a health-promoting perspective be acknowledged both from a phenomenological perspective as well as positivistic theory perspectives related to stress, depression and crisis? We often declare certain themes or experiences as meaningful out from the circumstances surrounding us. Experience we considered meaningful are far more important than those with meaningless substance. Despite being widely used, the concept of meaning is often vague, defined in various ways by different authors. Derived from the German word meinen, and interpreted “to think”, meaning can be seen as the substance of our understanding, the foundation of how we make sense of our experience and the “significance we

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seek in living” [26, p. 75]. From a positivistic viewpoint, the experience of grief initiated by loss can be understood as a psychological wound, while the healing of such a wound is accomplished through various methods of grief adaption [32]. One form of this adaptation may involve psychological treatment or therapy. As stated previously, within the positivistic tradition, grief is connected to theories of stress, depression and crisis. From this perspective the grieving person‟s search for meaning in the meaningless is apparent. Also the phenomenological tradition views the grieving individuals need for new insight and meaning in suffering made visible [7]. In other words, grief is an inner form of suffering which requires and makes possible new insight, meaning and an expansion of the human experience. Recent studies concerning grief illuminate the fact that a grieving individuals search for meaning is essential to the healing process [47-49]. This new paradigm for grief theory, research and practice is anchored in the postulate that “meaning reconstruction in response to a loss is the central process in grieving” [49, p 4]. Despite difference in epistemological and ontological foundations, one can claim that both positivism and phenomenology provide worthy perspectives, while shedding light over the value of meaning for the grieving person. An understanding of his or her process of grieving will be a valuable lesson for the persons also later in life [7]. Finding meaning in grief can assist towards alleviating existential pain and help the suffering individual move on in life [45], leading him or her towards developing new foundations of understanding, new realities and a new scope for defining self-identity [30]. To nurses and allied healthcare professionals meeting individuals in their personal grieving process, this is an important perspective to reflect on, although challenging to explore. Understanding another person‟s process of grieving or even the nature of grief is a challenging task. Gaining understanding from contrasting theoretical and scientific philosophies can be demanding. However, a search for knowledge through divergent traditions for a better understanding of grief, beyond one‟s own paradigm utilizing a double optic can be a fundamental and necessary initiative for healthcare professionals claiming to hold a holistic view of humankind. In order to improve future healthcare practice there is a need for increased understanding of grief [50] and on the reconciliation of grief [5]. Professional caregivers have a responsibility for both the grieving patient and their patients‟ family. The professional nurses‟ responsibility for helping also patients‟ family to find meaning is emphasized in nursing theory [45] as well as in international obligations and regulations concerning nursing ethics [51]. Therefore, as part of a caring and health promoting perspective, nursing

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science and scientific works of allied health professions play an important role in the development of scientific knowledge, as a fundament developing caring interventions and practices towards alleviating family caregivers‟ suffering from grief as well. Tranvåg and Kristoffersen [8] explored experience of grief in the lives of spouses/cohabitants with a partner suffering from bipolar affective disorder. In this phenomenological hermeneutic study we found that after many years of struggling with various illness-related challenges, spouses/cohabitants experienced a grieving process due to loss. The findings suggest that grief formed part of a larger, cumulative process. Several reciprocal experiences were identified and described as interrelating concepts. The following chapter will portray this cumulative process showing how it helped grieving individuals slowly towards dawning acceptance, solace of reconciliation, and eventually, a new hope based on a more holistic meaning and understanding of that which is most important in life. In addition, a theoretical framework anchored in gestalt therapy theory [9, 10] was utilized to shed theoretical light on their grief-, grieving- and beyond-processes. However, to understand these processes, we first must gain insight into their personal experiences and losses during their pre-grieving lives. Therefore, let‟s first observe how previous illness-related experiences formed part of a cumulative process and set a foundation for the development of grief over loss in spouses/cohabitants of persons suffering from bipolar affective disorder.

SPOUSES/COHABITANTS’ SUFFERING EXPERIENCING PARTNERS’ STRUGGLE WITH MENTAL ILLNESS Eight spouses/cohabitants of individuals with bipolar affective disorder participated in the study (see Table 1). Two Norwegian psychiatric hospitals assisted the researchers with participant recruitment. A strategic selection prioritized participants of different ages to obtain a wide variety of experience within the research focus. The main research question asked was: What experiences have you had in life with your partner, who has a bipolar affective disorder? The duration of their shared lives together with their respective partner varied from 6 to 51 years after onset of the illness. A phenomenological hermeneutic method was utilized [52-54], a qualitative approach emphasizing the methodological movement between phenomenological attitude and hermeneutic interpretation throughout the

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Table 1. Study participants

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The participant with 38 years of marriage did not want information about him or his family to be included in the table and has therefore been excluded here [8].

research process. Qualitative research interviews were applied to gain access to the participants‟ life-world [55]. Two interviews were held with each spouse/cohabitant. The first interview lasted 100–120 minutes and was taperecorded so the dialogue could be transcribed verbatim. 160 pages of transcribed text were available for analysis. Structural text analysis based on Ricoeur‟s phenomenological hermeneutics, as described by Lindseth and Norberg [54] was carried out. Since the participants shared lives after the onset of the illness varied from 6 to 51 years, this made it possible to gain insight into their experiences over time. Participants who lived with their ill partner for long periods of time had many of the same experiences as those participants with a shorter shared lifespan. Yet, spouses/cohabitants who had lived with their ill partner over the longest periods of time encountered additional illness-related experiences not shared by those with fewer years of shared lives. The study found three major aspects that characterized the spouses/cohabitants‟ experiences within this time-dimension: Experience formed part of (A) a cumulative process containing 10 illness-related experiences, followed by up to four cumulative experiences arising from the grieving process. Each experience created preunderstanding that (B) affected how subsequent experiences were perceived. When confronted with a new illness-related challenge, previous experience of burden created presidents for perceiving these as burdensome also. Equally so, good experience in the past, laid a foundation for future beneficial experience as well. In turn, their pre-understanding also affected how they (C) managed to

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master new illness-related challenges (see Figure 1). In the following, the spouses‟/cohabitants‟ 10 illness-related and cumulative experiences will be presented. Thereafter, the following grieving process containing up to four cumulative experiences will be portrayed (see Table 1 for range of severity among the participating spouses/cohabitants): The spouses/cohabitants‟ secure and stable life with their partner took a dramatic turn the first time their partner became ill. They were unprepared for their partner‟s considerable behavioral changes. They could not understand what was happening, or what to do, leading to the illness-related experience (1) Fear and the incomprehensible. Their life situation became chaotic, incomprehensible, unpredictable and frightening. Some experienced that their partner developed a substantial change in activity level, thinking and behavior. Others saw their partner become depressed, withdrawn, desiring only to stay in bed. The spouses/cohabitants often experienced (2) Accusations from their partner, who told them that they were the reason everything that had gone wrong. Their partner attributed hidden, destructive motives to them. The spouses/cohabitants experienced great uncertainty regarding their own capabilities and judgment, leading to (3) Self-doubt and doubt about one’s own powers of judgement. A frightening, incomprehensible life situation and personal recrimination gave rise to uncertainty about their own power of judgment and handling of the situation. As closest family member, the spouses/cohabitants experienced (4) Care and information vs. being overlooked or turned away by health personnel responsible for treatment and care of the ill partner. A number of participants experienced not being attended to by the health personnel. They lacked care and information in a difficult life situation. When their partner was discharged from the hospital, the full responsibility was again transferred to them, often without any follow-up by the health service. Some however, did have meaningful experiences, as healthcare personnel help them understand how this mental disorder affected her/his partner, as well as how to better master their own cognitive, emotional and practical challenges. After their partner became a patient at a “psychiatric hospital” they became the topic of gossip among friends and neighbors, leading to the illnessrelated experience of (5) Stigmatization and loss of social network. This was an additional, painful burden, as rumors had a negative and sensational content. Their social networks were reduced as former associates ceased to make contact, leading to social withdrawal in the spouses/cohabitants as well.

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Figure 1. The cumulative process in which each experience created a preunderstanding that affected how subsequent experiences were perceived and mastered. Experience formed part of a cumulative process containinig 10 illness-related experiences. These were followed by up to four grieving process experiences (here in grey color). Each experience A) created a pre-understanding that B) affected how subsequent experiences were perceived, and C) how they managed to cope with new illness-related challenges in their continuous attempt to adjust. Experience 1, 2 and 3 are here used as examples [8].

Many unanswered questions about the illness, its treatment and the future, caused great uncertainty and a sense of powerlessness. Nonetheless, they retained a small hope that everything would someday be restored as it once was. Their burdensome and equivocal experience led to (6) Uncertainty and powerlessness while clinging to hope. Relationships with their partner changed. Dialogue and cooperation became more difficult and risk of conflicts increased. They often felt a burdensome (7) Loneliness, and longed to be able to share their thoughts and feelings with their partner. The loss of a social network limited communication and socializing with others. They found that other people could not quite understand their situation, so they often found themselves alone with only their own thoughts and feelings.

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The sum of burdens sometimes led to emotional reactions as (8) Anger and despair. Uncertainty, insecurity, powerlessness, accusations, stigmatization, loneliness and lack of care on from health personnel, lay foundation for these burdensome experiences. Recognition that their partner‟s mental illness was not a onetime episode, but implied a risk of future episodes of illness as well, was a burdensome experience as the partner‟s mental health condition then became (9) The persistent threat. They developed therefore a watchful attitude to changes in behavior or signs of illness in their partners. Experiencing such changes in their marital role was perceived as hard and a constant burden. Numerous burdens caused a number of spouses/cohabitants to develop (10) Own health problems, such as tension, muscular pain, tiredness, physical fatigue, insomnia and feeling mentally worn down. Two of them also developed diagnosed depression [8].

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GRIEF, GRIEVING AND BEYOND: SPOUSES/COHABITANTS’ EXPERIENCES The study [8] found that spouses/cohabitants who had lived together with their partners over the longest period of time shared 10 illness-related cumulative experiences, followed by a grieving process containing up to four cumulative experiences. After suffering many years they experienced an increasing sense of sadness in their lives as an awareness of their partner‟s eroding condition evolved and essential aspects of life faded. Over time, this recognition led to a process of grief over emotional and social loss due to their partner‟s long-lasting mental illness. Through a demanding and wistful process, previous illness-related burdens were brought forth and worked through over time. This initiated an emotionally demanding process which gradually made it possible for them to let go of that which was lost and irrevocable. Essential aspects of their grieving process will be presented hereafter, illustrated by participant quotations. The spouses/cohabitants‟ names have been changed to protect anonymity: The partner‟s illness caused the loss of important aspects of life, leading to the experience of (11) Grief over loss. They experienced grief as they felt the illness took the person they loved away. Gone too was the life they once lived together. They grieved over the loss of security, the future they had envisioned

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and friends who had deserted them. Their grief was also related to their children‟s loss of security and stability when growing up, as explained by Mary: I grieved over losing the man I had married, over the children who lost their good, secure father, and over friends who disappeared. I still feel grief over all those who could not stay. I grieved over everything I… we… had lost. It is emotional and leaves permanent scars.

Many years passed before the spouses/cohabitants gradually began to accept the consequences of their partner‟s mental illness, leading them to a (12) Dawning acceptance. The knowledge and insight they had acquired through long experience made it possible to relate to the burdensome experiences of life in new ways, as reported by Mildred:

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Accepting the life situation was difficult. It happened gradually. I got help from a therapist, managed to put things into perspective and reestablished my belief in myself. I saw that my husband was growing, and that our life became more stabilized. We have undoubtedly both grown from the experiences, but I‟m not exactly grateful that this has happened to us.

Gradual acceptance initiated a process of (13) Reconciliation. Reconciling with life as it was involved a deep and genuine acceptance whereby the spouses/cohabitants finally found peace of mind, as expressed by William: I have accustomed myself to it, as a part of life. I feel 100 per cent secure now, after all these years. I know the system and know that I will get help when I need it. My wife needs to be admitted to an institution a couple of times a year. Then we get good help, both of us, you could say.

Reconciliation opened a pathway to new goals and realigned ideals for living together. An awareness of the opportunities life offers gave meaning and a (14) New hope, characterized by positive realism, an awareness of what is most important in life and an appreciation of “here and now”, planning only for the immediate future, as reported by John: After many years, when I finally managed to reconcile myself with how my wife‟s mental illness affected our life, I managed to take pleasure in the

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Figure 2. The cumulative grieving process in which each experience A) created a preunderstanding that B) affected how subsequent experiences were perceived, and C) how they managed to adjust and move forward in their grieving process. small glimmers of light in our everyday life. Now I hope that she will be well for the next six months, that we have some good summer months, do some enjoyable things together, go for a little trip, things like that.

GRIEF, GRIEVING AND BEYOND: A THEORETICAL UNDERSTANDING Theories can shed light on empirical data and can therefore be useful tools for gaining increased insight and understanding concerning the phenomenon under investigation. In this study several theories were considered illuminate spouses/cohabitants grieving processes. Gestalt therapy theory was found to be a meaningful theoretical framework for deeper understanding in this instance. The existential view within this theory strives to explain human experience. According to this theory, the insight and meaning individuals derive from their experiences, are crucial for how their experiences are perceived. High degree of insight in a situation lays foundation for increased understanding and meaning to the person. In terms of gestalt

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therapy theory this strengthens a person‟s ability to perceive intrapersonal and interpersonal experience holistically, or as a complete gestalt. A gestalt can be seen as a pattern, a structure or an organization of the parts it is composed of. A complete gestalt is seen as a holistic experience, made possible by personal insight and meaningful understanding of the individual parts that together make a whole. A complete gestalt contributes to the equilibrium of the human organism. When a person only partially comprehends a lived experience, an incomplete gestalt is formed, counteracting equilibrium and resulting in an inner imbalance in the human organism [9, 10]. Each experience and how it was perceived by spouses/cohabitants formed a pre-understanding, which laid the foundation for how later illness-related challenges were perceived and mastered. In terms of gestalt therapy theory, the cumulative process can be seen as each experience influences the whole and the whole influences the individual experiences. Thus, the whole amounts to more than the sum of its parts. The degree of insight and meaning gained with experience affected whether the event was perceived as a complete or incomplete gestalt. In turn, this had prominent reverberations on the meaning of subsequent illness-related challenges as well. Furthermore, the perceived meaning affected their ability to cope with these challenges. In sum, the individual‟s personal gestalt experience had a crucial influence on the degree of equilibrium within their organism.

Figure 3. The spouses/cohabitants‟ grieving process; a theoretical understanding in terms of gestalt therapy theory. The curved arrows illustrates the cumulative process in which each experience created pre-understanding that affected how subsequent experiences were perceived and mastered.

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After many years of attempting to cope with up to 10 illness-related challenges in every-day life, they gradually developed an awareness and incremental sadness as they perceived that the partner‟s illness led to the loss of important aspects of life. Over time, this recognition developed into grief over loss.Through a demanding and wistful process, previous illness-related burdens were brought forth and worked through over time. This initiated an emotionally demanding process which gradually made it possible for them to let go of that which was lost and irrevocable. In turn, the process initiated dawning acceptance of the partner‟s mental illness and the losses they experienced in life. The dawning acceptance was not resignation, but adjusting towards a new perspective which eased their burdens and opened new ways to master their lives. This gave rise to new meaning and increased consciousness of possibilities through emancipation from limitations. According to gestalt therapy theory, grief is the realization of having lost valuable and meaningful gestalt in life. At the same time, their grief over loss was the beginning of a healing process reducing inner imbalance in their organism. New insights into intrapersonal and interpersonal relationships brought new meaning and an increased awareness of the valuable gestalts, in life. The organism‟s need for holistic understanding towards restore equilibrium can be seen as the driving force in the process towards dawning acceptance, and a renewed formation of complete gestalts. This new pre-understanding initiated a process of reconciliation with the partner‟s mental illness and its‟ consequences. This process included a genuine acceptance of life as it was and life as it can be in the future. Through this process the spouses/cohabitants finally found peace of mind, opening a path to new ideals for living together. They began to appreciate the simple things of life, a change which opened their eyes towards new opportunities. This gave rise to meaningful perspectives and a new hope. Negative experiences of the past were replaced by new pre-understanding obtained through the process of grief over loss, dawning acceptance and reconciliation. Through positive realism, awareness of the important things in life, appreciation of life here and now and planning only for the immediate future, new foundations for courage and joy in the existing possibilities of life together were established. In light of gestalt therapy theory, the equilibrium of the organism was re-established as the reconciliation created harmony within them as well as between them and their surroundings. Previous incomplete gestalts were replaced by a new holistic meaning and recognition of important values in their shared life experiences. A foundation for new hope based on positive realism and their opportunities were established, strengthening their capacity for self-support.

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New insight increased their capability to attend to their own personal needs. Reorganizing inner and outer sensory impressions towards more meaningful intrapersonal and interpersonal gestalts helped their organism to regain a state of equilibrium.

GRIEF, GRIEVING AND BEYOND: PERSPECTIVES ON CARE PRACTICIES

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In order to understand spouses/cohabitants‟ grief over loss it is important to recognize how crucial experiences from the past contribute towards initiating this inner suffering. Exploring past experiences‟ impact on current pre-understanding may help professional caregivers to better understand personal perceptions of each spouse/cohabitant. In this study, up to 10

Figure 4. The spouses/cohabitants‟ 14 experiences as a cumulative process. The model‟s x-axis illustrates the duration of life together after the partner fell ill (6–51 years). Along the y-axis a thematic presentation is given of the participants‟ 10 illnessrelated experiences and the up to four consequent grieving process experiences; Grief over loss, Dawning acceptance, Reconciliation, and New hope. The experiences do not always have a clear starting point. Furthermore, the experiences do not always have a final end-point. This is indicated by a broken line for each topic. The spirals illustrates: The experiences cumulative process over time in which A) each experience created a pre-understanding that (B) affected how subsequent experiences were perceived and (C) mastered [8].

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previous illness-related challenges formed part of their pre-grieving base of experience. How these experiences were perceived and mastered laid foundation for the later grieving process as illustrated by Tranvåg & Kristoffersen [8], (see Figure 4). Nurses and allied healthcare professionals should be aware that a cumulative process involving the discovery of meaning in previous illnessrelated experiences, seemed crucial for generating a meaningful process of grieving. Meaningful grieving processes were predicated on a meaningful preunderstanding, empowering spouses/cohabitants to perceive their experience through a holistic point of view or in other words, as whole gestalts. Caring for the grieving person involves forming bonds and contributing in a relationship that provides a basis for the growth of trust. Compassion, commitment, empathy, sensitivity and respect will help the relationship to grow [56-58]. Spouses/cohabitants who felt good about their experiences with healthcare personnel perceived caregiver awareness, empathy and the feeling of being understood. They were given an invitation to share their grievances‟ with someone who was honestly concerned for their welfare. They were offered information and feedback as to how they had perceived and coped with the situation at hand. The study indicates how grief over loss helped initiate a healing process leading to dawning acceptance, reconciliation and a new hope. These spouses/cohabitants had long shared lives with their partner, and the time aspect could be an auxiliary factor, as working through experiences over time may ease their suffering over loss. However, the time factor alone was probably not an adequate indicator of the magnitude of these experiences. First, the cumulative process of growing insight and meaning led to dawning acceptance, in contrast to dawning resignation. They had gained substantial perspectives making it possible to perceive and master grief over loss in more constructive ways. New and meaningful gestalts seemed to help replace imbalance with growing insight concerning past experiences. A deeper understanding of their current grief, coupled with a realization of their own response to loss, gave increased meaning to their experience [8]. The findings suggest that in helping spouses/cohabitants to understand the foundation of their grief, attributing it to loss, nurses and allied healthcare professionals may contribute towards the easing of burdens, assisting those suffering from grief to move on towards dawning acceptance, reconciliation and a new hope. Professional caregivers should also be aware of the negative effect of “feeling overlooked or turned away” by health personnel, as this experience may increase the burden, reduce one‟s ability to master the strain and lay a foundation for negative pre-understanding of the future [8]. Since grief may

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negatively affect a person‟s psychic and/or physical condition, even leading to ill health over time [4], this underscores the importance of a research based care from a health-promoting perspective concerning the process of grief initiated by personal loss. Humane and empathetic care, health-promoting guidance and insight enriching dialogues seemed to help spouses/cohabitants to work through a demanding and burdensome process [8]. The finding suggests too this is important ways to help empower [59-61] grieving spouses/cohabitants. Guidance on how to maintain social networks can for instance help prevent social withdrawal and loneliness. However, informative guidance cannot cover all aspects of their needs. It is important that they are given ample opportunity to work through cognitive and emotional reactions as well. Nurses and allied healthcare professionals can invite each to share their thoughts concerning the past and the future, offering guidance through dialogue on how to deal with current perceptions over both past and future outlooks. Such meaningful experience may reduce one‟s sense of hopelessness, gradually making possible letting go of that which is irrevocably lost, helping each to move forward in their grieving process [8]. This study acknowledges the complexity of grief experienced as a holistic and cumulative process. Experience of the past are seen as integrated part of the present, and not as isolated incidents, separated from the context at hand. This perspective also recognizes grief over loss as a normal life-phenomenon, an experience founded on the persons pre-understanding and current understanding bases. The grieving process is understood as a fundamental, pre-cultural aspect of life, a human reaction to the loss of something invaluable and irreplaceable. With this perspective in mind, grief is not considered primarily as an outer manifestation of symptoms for an internal pathological condition, but rather as a normal manifestation of severe human anguish. Nonetheless, the literature does indicate how grief can evolve in the direction of increasingly serious health concerns for the grieving party [4]. Healthcare professionals should therefore have respect for the positivistic paradigm‟s perspective of grief, which proposes the possibility that an individual may indeed develop “pathologic grief” [32]. For nursing as a holistic profession as well as allied holistic healthcare professions, an eclectic perspective opens for the cautious application of knowledge derived from a wide variety of professions and scientific paradigms [62]. This generates the possibility for the application of both a phenomenological and a positivistic foundation for understanding. The reciprocation of these contrasting and seemingly contradictory traditions assists in generating possibilities to go

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beyond our limit of understanding bound within each paradigm alone, while contributing towards a holistic understanding of the lived-experience of those who grieve. An approach of this nature, utilizing a double optic may uncover vital data and make it possible to formulate care interventions which are sensitive enough to assist each spouse/cohabitant, regardless of where they are in their cumulative process of grief. A holistic understanding also demands thorough insight into how the spouses/cohabitants understand their own lived experiences. This requires a phenomenological attitude as well as professional humility among nurses and allied healthcare professionals as they seek to understand each individual‟s personal experience of living with grief, existing in the face of grief. Within this context, a three-part relationship [40] involving the grieving individual, the professional caregiver, and their common interests, both in each other as well as towards “the matter itself” [7, p. 273] seems to be crucial. This threepart relationship may lay foundation for a meaningful guidance dialogue, assisting the individual to find meaning in grief over loss, move forward and beyond suffering, towards dawning acceptance, reconciliation and a new hope for the future.

CONCLUSION If our goal is to obtain understanding of the human experience of grief, in all its complexities, one may ask whether or not such an investigation can be limited to just one scientific-philosophic perspective? Will such an approach lead to sufficient understanding of the multi-faceted phenomena inherent in the process of grief? This chapter attempts to cast light upon such questions, drawing on two scientific traditions, positivism and phenomenology. At the onset, these traditions are considered contrasting or even oppositional. It is the role of science however, to ask direct and critical questions. This requires not only an honest investigation of contrasting scientific traditions, but also, an equally demanding investigation of one‟s own perspective. With this in mind, we may be permitted to seek the “truth” by allowing contrasting and seemingly contradictory scientific traditions to communicate with one another and form a double optic towards a holistic understanding of grief, moving beyond what either paradigm alone can accomplish. Doing so may cast additional light towards the discovery of yet unrecognized foundations for knowledge and understanding.

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Uncovering “truth” in this way may help the dedicated researcher towards unearthing hither to unknown “realities”. Positivistic and phenomenological perspectives of grief are on the onset contrasting. The one utilizes diagnosis based, symptomatic phases for understanding, far different from a pre-cultural understanding of this phenomenon of lived human experience found in the other. Despite their differences, the foci of both traditions include the human experience of grieving, as well as, finding meaning in experience. This makes it possible to view both perspectives simultaneously using a double optic. Thus, widening the lens on our understanding, we view human grief from a new perspective. This perspective requires having the courage to build bridges of understanding between long established “islands of scientific rivalry”. However, this double optic may be the means to illuminate our view, offering new perspectives towards increased meaning and a holistic understanding of human grief. A study exploring lived experiences among spouses/cohabitants of persons with bipolar affective disorder found how a cumulative process of up to 10 illness-related challenges experienced over a period of time, initiated a process of grief over loss. Individual processes of grieving led those with longest lives together with their partner through a cumulative process of dawning acceptance, reconciliation and a new hope. In this process past experiences created pre-understanding affecting current perceptions, coping, and ability to adjust to new lived experiences. As a theoretical frame of reference, gestalt therapy theory was chosen to shed light upon the empirical data of lived experience. Gestalt therapy has its origin in psychology of perception, based within a positivistic paradigm. This approach does not block the understanding of empirical data on grief seen as a lived phenomenon, utilizing a phenomenological hermeneutic method for data collection and analysis. In this study, access to both paradigms helped form new possibilities of understanding, utilizing a double optic in which seemingly contradictory paradigm are encouraged to communicate with one another. An approach of this nature may be of interest, empowering health care professionals who emphasize personalized- and holistic care for persons suffering from grief over loss. The phenomenological hermeneutic use of gestalt therapy theory as framework for discovery helped create a theoretical understanding of the empirical data. Thus, burdensome experience such as grief over loss can be seen as an inner imbalance in spouses/cohabitants as each of them struggles to find meaning in their experiences. When only part of the whole is perceived, an incomplete gestalt is formed, and the person‟s lived experience counteracts equilibrium within the organism. New insight helped

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them to find meaning in the lived experience and helped each on their journey through their own grieving process, which also includes dawning acceptance, reconciliation and new hope. In this process, previous incomplete gestalts were replaced by a new holistic understanding, strengthening their capacity towards self-support. New insights enabled each, increasing their capability to tend their own fundamental needs, organize inner and outer sensory impressions into meaningful intrapersonal and interpersonal gestalts, and meet the organism‟s need for equilibrium. Nurses and allied healthcare professionals can play an important role in the empowerment of spouses/cohabitants whose partners suffer from bipolar affective disorder. Humane empathetic care, health-promoting guidance and insight enriching dialogues were found to be important means towards encouraging them to move forward in their grieving process, beyond grief over loss, towards dawning acceptance, reconciliation and a new hope for the future. Reviewed by Professor Dagfinn Nåden, Oslo and Akershus University College.

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REFERENCES [1] [2] [3] [4]

[5]

[6]

Det Norske Bibelselskap (The Norwegian Bible Company). (1973). Bibelen (The Bible). Det Norske Bibelselskaps Forlag, Oslo. Yogi, M. M. (1967). Bhagavad Gita.International S. R. M. Publications, London. Dover Publishing Inc. (1958). The Koran: Selected Suras. The Heritage Press, New York. Cowles, K. V., & Rodgers, B. L. (1991). The Concept of Grief: A Foundation for Nursing Research and Practice. Research in Nursing & Health, 14, 119-27. Gustafsson, L-K., Wiklund-Gustin, L., & Lindström, U. Å. (2010). The meaning of reconciliation: women‟s stories about their experience of reconciliation with suffering from grief. Scandinavian Journal of Caring Sciences, 25, 525-32. Stroebe, M. S., Stroebe, W., & Hansson, R. O. (1999). Bereavement research and theory: An introduction to the Handbook. In M. S Stroebe, W. Stroebe, & R. O Hansson (Eds.), Handbook of bereavement: theory, research, and intervention (4th reprint, pp. 3-19). Cambridge University Press.

Psychology of Sadness, Nova Science Publishers, Incorporated, 2012. ProQuest Ebook Central,

Grief, Grieving and Beyond [7]

[8]

[9] [10]

[11]

[12]

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

[13] [14] [15]

[16]

[17]

[18] [19] [20]

25

Furnes, B., & Martinsen, K. (2010). Ulike perspektiver på sorg, og følger for omsorg og hjelp (Contrasting perspectives on sadness and consequence for help and caring). Michael Quarterly, 7 (2), 270-81. Tranvåg, O., & Kristoffersen K. (2008). Experience of being the spouse/cohabitant of a person with bipolar affective disorder: a cumulative process over time. Scandinavian Journal of Caring Sciences, 22 (1), 5-18. Perls, F. S. (1984). Gestaltterapiens metode (The Method of Gestalt Therapy). Munksgaard, Copenhagen. Hostrup, H. (2003). Gestaltterapi. Indføring i gestaltterapiens grundbegreper (Gestalt Therapy. Introduction to the Basic Terms of Gestalt Therapy). (3rd ed.), Hans Reitzels Forlag, Copenhagen. Baronet, A-M. (1999). Factors associated with caregiver burden in mental illness: a critical review of research literature. Clinical Psychology Review, 7, 819-41. Rose, L. E., Mallinson, R. K., & Gerson, L. D. (2006). Mastery, burden and areas of concern among family caregivers of mentally ill persons. Archives of Psychiatric Nursing, 20 (1), 41-51. Ablon, S. L., Davenport, Y. B., Gershon, E. S., & Adland, M. L. (1975). The married manic. Am J Orthopsychiatry, 45, 854–66. Mayo, J. A. (1979). Marital therapy with manic-depressive patients treated with lithium. Compr. Psychiatry, 20, 419-26. Sanders, S., Ott, C. H., Kelber, S. T., & Noonan, P. (2008). The experience of high levels of grief in caregivers of persons with Alzheimer's disease and related dementia. Death Studies, 32(6), 495523. Sandvik, O. (2003). Hva er sorg, og hvordan kan den forstås? (What is grief, and how can we understand it?). In K. E. Bugge, H. Eriksen, & O. Sandvik (Eds.), Sorg (Grief), (pp. 15-42). Fagbokforlaget, Bergen. Worden, J. W. (2009). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (4.ed). New York: Springer Publishing Company Cowles, K. V. (1985). The death of a pet: Human responses to the breaking of the bond. Marriage and Family Review, 8 (3/4), 135-48. Stephenson, J. S., & Murphy, D. (1986). Existential grief: The special case of chronic ill and disabled. Death Studies, 10, 135-45. Katz, S., & Florian, V. (1986-87). A comprehensive theoretical model of psychological reaction to loss. International Journal of Psychiatry in Medicine, 16 (4), 325-45.

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[21] Steward, T., & Shields, C. R. (1985). Grief in chronic illness: Assessment and management. Archives of Physical Medicine and Rehabilitation, 66, 447-50. [22] Lukse, M. P., & Vacc, N. A. (1999). Grief, Depression, and Coping in Women Undergoing Infertility Treatment. Obstretics & Gynecology, 93 (2), 245-51. [23] Doka, K. J. (1986). Loss upon loss: The impact of death after divorce. Death Studies, 10 (5), 441-49. [24] Kimball, S. W. (1969). The Miracle of Forgiveness. Salt Lake City, USA, Bookcraft. [25] Church, J. S. (1974). The Buffalo Creek disaster: Extent and range of emotional and/or behavioral problems. Omega, 5 (1), 61-63. [26] Kelley, M. M. (2010). Grief. Contemporary Theory and the Practice of Ministry. Fortress Press, Minneapolis. [27] Dyregrov, A., & Matthiesen S. B. (1987). Similarities and differences in mothers‟ and fathers‟ grief following the death of an infant. Scandinavian Journal of Psychology, 28, 1-15. [28] Thuen, F., & Schlytter J. E. (1996). Sudden Infant Death Syndrome: Long term reactions among mothers and fathers. Psychology, Health & Medicine, 1 (3), 259-71. [29] Walter, C. A., & McCoyd, J. L. M. (2009). Grief and Loss Across the Lifespan. A Biopsychological Perspective. Springer Publishing Company. New York. [30] Worden, J. W. (1985). Bereavement. Seminars in Oncology, 12 (4), 472-75. [31] Eisenbruch, M. (1984). Cross cultural aspects of bereavement II: Ethnic and cultural variations in the development of bereavement practices, Cultural Medicine and Psychiatry, 8 (4), 315-47. [32] Fyhr G. (2003). Hur man möter människor i sorg (How to meet grieving individuals). (2nd ed.). Bokförlaget Natur och Kultur, Stockholm. [33] Bugge, K. E. (2003). Hvordan kan vi hjelpe mennesker i sorg? (How can we help grieving individuals?). In K. E. Bugge, H. Eriksen, & O. Sandvik (Eds.), Sorg (Grief), (pp. 64-85). Fagbokforlaget, Bergen. [34] Linnéer Axelson, B. (2011). Tab. Om sorg og livsændringer. (Loss. About grieving and life changes). Hans Reizels Forlag, Copenhagen. [35] Holm, H. J., & Martinsen, E. W. (1982). Inkorporering av det tapte objekt: En spesiell type patologisk sorg (Incorporation of the lost object: A special type of patological grief). Nordic Journal of Psychiatry, 36 (5), 259 -67.

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[36] Newson, R. S., Boelen, P. A., Hek, K., Hofman, A., & Tiemeier, H. (2011). The prevalence and characteristics of complicated grief in older adults. Journal of Affective Disorders, 132, 231–38. [37] Boelen, P. A., & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: a confirmatory factor analysis study. American Journal of Psychiatry, 162 (11), 2175–7. [38] Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stressdisorder? A test of incremental validity. Journal of Abnormal Psychology, 116 (2), 342–51. [39] Dillen, L., Fontaine, J. R., & Verhofstadt-Denève L. (2009). Confirming the distinctiveness of complicated grief from depression and anxiety among adolescents. Death Studies, 33 (5), 437–61. [40] Skjervheim, H. (1976). Deltakar og Tilskodar og andre essays (Participants and Onlookers and other essays). Aschehoug, Oslo. [41] Eikeland, T. J. (1999). Evidensbasert behandling; kvalitetssikring eller instrumentalistisk mistak (Evidencebased treatment; Qualitive assurence or instrumental mistake). Tidsskrift for Norsk Psykologforening (Journal of the Norwegian Psychological Association), 36, 1036-47. [42] Delmar, C. (2006). The phenomenology of life phenomena - in a nursing context. Nursing Philosophy, 7, 235-46. [43] Furnes, B. (2008). Å skrive sorgen – bearbeidelse av sorg. Prosessorientert skriving i møte med fenomenologisk språkforståelse. En hermeneutisk fenomenologisk studie av skriving hos etterlatte (To write the sadness – working through sadness. Process orientated writing in conjunction with a phenomenological perspective. A hermeneutic phenomenological study on writing among bereaved individuals). Doctoral Thesis, Faculty of Medicine, Departement of Public Health and Primary Health Care, Section of Nursing Sciences, University of Bergen. [44] Husserl, E. (1997). Fænomenologiens ide (The idea of Phenomenology). Hans Reitzels Forlag A/S, Copenhagen. [45] Travelbee, J. (2001). Mellommenneskelige forhold i sykepleie (Interpersonal aspects of nursing). Gyldendal Norsk Forlag, Oslo. [46] Popper, K. R. (1966). The Open Society and Its Enemies. (5th ed.), Routledge & Kegan Paul, London. [47] Attig, T. (2001). Relearning the world: Making and Finding Meanings. In R. A Neimeyer (Ed.) Meaning Reconstructions & the Experience of Loss (pp. 33-54).Washington DC., American Psychological Association.

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[48] Davis, C. G. (2001). The Tormented and the Transformed: Understanding Responses to Loss and Trauma. In: R. A. Neimeyer (Ed.) Meaning Reconstructions & the Experience of Loss (pp. 13756).Washington DC., American Psychological Association. [49] Neimeyer, R. A. (2001). Meaning, Reconstruction & Loss. In: R. A. Neimeyer (Ed.) Meaning Reconstructions & the Experience of Loss (pp. 1-9).Washington DC., American Psychological Association. [50] O‟Mallon, M. (2009). Vulnerable Populations - Exploring a Family Perspective of Grief. Journal of Hospice and Palliative Nursing, 11(2), 91-8. [51] International Council of Nurses. (2006). Code of Ethics of Nurses. Available at: http://www.icn.ch/about-icn/code-of-ethics-for-nurses/ [52] Ricoeur, P. (1988). Fra tekst til handling: En antologi om hermeneutikk (From Text to Action: An Anthology on Hermeneutics). (P. Kemp, & B. Kristensson Eds.), Brutus Østlings bokforlag, Stockholm, (Symposium). [53] Ricoeur P. (2002). En hermeneutisk brobygger. Tekster av Paul Ricoeur (A Hermeneutics Bridgebuilder. Texts by Paul Ricoeur). (M. Hermansen, & J. D. Rendorff Eds.), Forlaget Klim, Århus. [54] Lindseth, A., & Norberg, A. (2004). A phenomenological hermeneutical method for researching lived experience. Scandinavian Journal of Caring Sciences, 18(2), 145–53. [55] Kvale, S. (2004). Det kvalitativeforskningsintervju (The Qualitative Research Interview). (6th print), GyldendalAkademisk, Oslo. [56] Martinsen, K. (1991). Omsorg, sykepleie og medisin. Historiskfilosofiske essays (Care, Nursing and Medicine. Historicalphilosophical Essays), (1st ed., 2nd print), Tano AS, Otta, Norway. [57] Martinsen, K. (1996). Fenomenologi og omsorg. Tre dialoger (Phenomenology and Care. Three Dialogues), Tano Aschehoug, Oslo. [58] Martinsen, K. (2005). Samtalen, skjønnet og evidensen (Dialogue, Discernment and Evidence), Akribe AS, Oslo. [59] Falk-Rafael, A. R. (2001). Empowerment as a process of evolving consciousness: a model of empowered caring. Advances in Nursing Science, 24(1), 1–16. [60] Tones, K., & Tilford, S. (1994). Health Education: Effectiveness, Efficiency and Equity, (2nd ed.), Chapman & Hall, London. [61] Beattie, A., Gott, M., Jones, L., & Sidell, M. (1993). Health and Wellbeing. Macmillan, Houndmills.

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[62] Hummelvoll, J. K. (2004). Helt – ikke stykkevis og delt. Psykiatrisk sykepleie og mental helse (Completely – not partially nor divided. Psychiatric nursing and mental health), (6th ed., 1st print). Gyldendal Forlag As, Oslo.

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Chapter 2

KING OF SORROW: PERCEPTION AND EXPERIENCE OF SADNESS IN MUSIC Tuomas Eerola and Marko Punkanen University of Jyväskylä, Finland

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ABSTRACT Negative emotional experiences such as sadness are interesting topic due to their inevitability in the daily lives of people but also for the paradoxical enjoyment related to them in the context of arts. Sadness, for instance, is in principle an aversive affective state but is nevertheless immensely enjoyed in the arts as witnessed by prevalence of the theme in literature, films, and music. Music in particular is a rich and natural source of emotions for a large number of people in everyday situations. Although the induction and recognition of emotions has received a lot of attention during the last decade, negative emotions such as sadness induced by music, has been less frequently explored. In this chapter the emotion regulation strategies of the nominally sad music are presented. Also the mood congruent biases caused by such affective state are reviewed. Sadness and negative emotions in general are also considered in a clinical context, where long-term mood changes such as depression bestows systematic negative biases to recognition of emotions in music. Case examples of the processes and biases of depressed patients‟ during music therapy treatment are given. The diagnostic implications of such results are highlighted. The potential benefits of undergoing negative emotions in a safe context (such as music therapy setting) are discussed in detail. For example, musical improvisation together with a music

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Tuomas Eerola and Marko Punkanen therapist can offer to a depressed patient a safe, creative and playful medium for expression of negative emotions and aid the patient in learning to utilize more beneficial emotion regulation strategies such as reappraisal and self-disclosure.

INTRODUCTION

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“I wonder if this grief will ever let me go I feel like I am the king of sorrow, yeah” – King of Sorrow (Sade) The purpose of this chapter is to summarize recent research on negative emotions in general as seen through the art, particularly music. In the arts, negative emotional experiences are particularly interesting, since these emotional experiences are in principle aversive states but are frequent and enjoyable themes in literature, films, and music. It seems that people in general are able to regulate and process their negative emotions such as sadness by engaging in musical listening. Music is a rich and natural source of emotions for most people, which they know how to use to influence their moods and emotions in everyday situations. During the last decade, a large number of studies have focused on the recognition and induction of emotions by music (summary in Juslin & Sloboda, 2010), yielding important insights into the typical ways music is able to affect listener emotions. However, the negative emotions such as sadness induced by music, has been less frequently explored. Sadness is known to induce both negative and positive aspects of emotions (such as melancholia, nostalgia, and longing), although the precise mechanisms of how this is achieved, is not entirely understood. Yet the positive aspects of such processes are known to be highly valuable and enjoyable for individuals. After reviewing the state of art research in music and emotion research, we highlight how nominally sad music is often used for emotion regulation purposes. One of the regulation strategies relates to comfort and solace, when people are feeling “down”, disheartened, depressed or sad and people use the appropriate music to get through the emotions (Saarikallio, 2008). In a similar vein, when people are experiencing different moods, there is a strong biases to evaluate emotions in music in a mood congruent fashion. In clinical context, the biases to emotion recognition and experiences are more extreme. We will use an example of recent depression study (Punkanen et al., 2011) to highlight the type of systematic biases the depressed patients

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have in comparison to non-depressed controls in recognition of emotions in music. These include consistent negative bias in most perceived emotions and especially with anger, which is often repressed and turned towards oneself while depressed. Such results also imply that recognition of negative emotions represented by music can be used as diagnostic aids. The chapter will discuss the potential benefits of undergoing negative emotions in a safe context (such as music therapy setting) provided by arts, particularly by music. For example musical improvisation together with music therapist can offer to a depressed patient a safe, creative and playful medium for expression of anger and sadness and thus help her gradually to learn to use more beneficial emotion regulation strategies such as reappraisal and selfdisclosure.

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MUSIC AS A SOURCE OF EMOTIONS Music is a potent inducer of emotions, feelings and moods, which encompass a broad spectrum of affects that range from joy to awe and sorrow. Music can make one to experience the many varieties of grief, as underlined in the lyrics and the music of the famous song „King of Sorrow‟ by Sade. For some reason, music is particularly adept in evoking strong experiences that involve feelings of sadness, loss, and melancholia. What is more tantalizing, such ostensibly negative emotional experiences are time and time again loved and immensely enjoyed by listeners (Garrido & Schubert, 2011). How these nominally aversive, negative emotional states are actually turned into pleasurable experiences, is a fascinating dilemma that has puzzled music scholars for decades (e.g., Levinson, 1997). Music is a rich and natural source of emotions for most people, which they know how to use to influence their moods and emotions in everyday situations (Juslin & Laukka, 2004; Juslin et al., 2011). During the last decade, a large number of studies have focused on the recognition and induction of emotions by music, yielding important insights into the typical ways music is able to affect listener emotions (reviewed in Zentner & Eerola, 2010). Some claim that music cannot evoke any true emotion at all (e.g., Kivy, 1990). However, these assertions have been counterclaimed many times with results from studies using behavioral, physiological, and neurological measures, all of which indicate that listeners respond affectively to music (e.g., Krumhansl, 1997; Mitterschiffthaler et al., 2007; Witvliet & Vrana, 2007).

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Tuomas Eerola and Marko Punkanen

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COMPONENTS AND MODELS OF EMOTIONS Emotions are often defined of comprising of subjective feeling, cognitive appraisal, physiological arousal, motor expression, and behavioral tendency. Moods are often used synonymously in the field, and despite the fact that moods are associated with lower intensity, longer time span and less specific elicitators than emotions (Frijda, 1994), moods and emotions can be considered as closely homogeneous particularly in music (see Juslin & Sloboda, 2010). Even if it is generally accepted that music does induce emotions, there are debates about the specific emotions which music actually induces. Traditionally, the utilitarian emotions – such as the fear, anger, happiness, sadness, and disgust – are usually the kind of basic emotions included in the framework. The basic emotion model posits that all emotions can be derived from a limited number of universal and innate basic emotions (Ekman, 1999). Also, the basic emotion framework builds on the assumption that an independent neural system exist for each discrete basic emotion, although there is no consistent evidence to support this theory (for a review, see Barrett & Wager, 2006). In studies investigating music and emotion, the basic emotion model has often been modified to better describe the emotions that are commonly represented by music. Dimensional models of emotion have also gained support among music and emotion researchers. The most well dimensional model, the twodimensional circumplex model (Russell, 1980), proposes that all affective states arise from two independent neurophysiological systems: one related to valence (a pleasure– displeasure continuum) and the other to arousal (activation–deactivation). In other words, all emotions can be understood as varying degrees of both valence and arousal. This model has received a great deal of attention in music and emotions research (Zentner & Eerola, 2010). Finally, it has been argued and empirically demonstrated that a few primary basic emotions seem inadequate to describe the richness of the emotional effects of music (Zentner et al., 2008). Emotions, such as transcendence and wonder, not present in either discrete and or dimensional models are often induced by music. These, sometimes called aesthetic emotions, do provide much more nuanced way describing the induced emotional experiences. Geneva Emotional Music Scale (GEMS) by Zentner and his colleagues (2008)

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constructs musical emotions belonging to nine components, which contain such distinctive and special emotional experiences such as Wonder, Transcendence, Power and Nostalgia. GEMS model also contains a distinct Sadness component, but here again a difference to utilitarian emotions is emphasized; sadness induced by music is typically characterized by the positive and cathartic aspects of the emotional experience rather than as a negative emotional state. In sum, there are no large discrepancies on how to label the sadness induced by music but whether such experiences are considered as negative or positive is question that has not been adequately resolved yet.

SADNESS IN THE FIELD OF AFFECTIVE SCIENCES

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“I'm crying everyone's tears And there inside our private war” – King of Sorrow (Sade) Despite the steep rise in music and emotion research during the last 10 years, negative emotions such as sadness, has been minimally explored. Sadness is known to induce both negative and positive aspects of emotions such as melancholia, nostalgia, and longing (Vuoskoski & Eerola, 2011), although the precise mechanisms of how this is achieved, is not entirely understood. Yet the positive aspects of the outcome of the process are known to be highly valuable and enjoyable for individuals. It has also been recently demonstrated that music-induced sadness is able to cause similar biases in memory and judgment than autobiographically induced sadness (Vuoskoski & Eerola, in press). These results, which utilized subtle indirect measures of emotions, strongly suggest that the emotional experiences set forth by music are practically indistinguishable from any actual, real-life sadness. To better understand the roles and effects of sadness in music, the functions of sadness and mechanisms for inducing sadness are first reviewed. Sadness-related emotional regulation in the context of music is considered next and finally these insights from clinical research about sadness and negative emotions and music in general is surveyed.

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SADNESS HAS AN ADAPTIVE FUNCTION AND UNIVERSAL CHARACTERISTICS

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“It's just a day that brings it all about Just another day and nothing's any good” – King of Sorrow (Sade) Sadness is an integral part of human emotional life. It is considered to be a basic emotion, and closely related yet separate of grief, which is more complex and long-lasting emotion (Bonnanno, Goorin, Coifman, 2008, p. 798). The central adaptive function of sadness is to “promote personal reflection following irrevocable loss of a person or object of importance to the self” (Lazarus, 1991). In sadness, the attention is turned inward, towards resignation and acceptance. This is designed to allow us to revise our goals and plans. Interestingly, sadness has been demonstrated to produce more detail-oriented information processing, including more accurate decision-making less reliance on stereotypes (e.g., Storbeck & Clore, 2005). There are distinct physical and physiological signatures involved in sadness such as slumped posture, diminished physical activity, loss of appetite to name a few. Also facial and auditory displays of sadness serve an important adaptive social function. Facial expression of sadness shapes the responses of others by evoking sympathy and helping responses from others (Keltner & Kring, 1998). The same goes for auditory make-up of the sadness vocalizations. In a similar fashion, music seems to emulate the vocalizations involved in sad state. For instance, most acoustic features of sad music (slow tempo, lower pitch level and pitch range, low dynamics) are similar to the characteristics expressed in sad speech (Juslin & Laukka, 2003) since both reflect the same underlying physiological markers, lowered physical activity and more precisely, reduced acetylcholine that decreases muscle reactivity (e.g., Siegal & Sapru, 2006). In this way, music recruits similar, empathy-related sadness processes and reactions, but the actual emotion induction mechanisms in music-induced sadness are undoubtedly more varied than just relying on the surface details of the acoustic signal. In music, listener may recognize musical work representing sadness due to a string of acoustic and musical cues and there is a possibility that the listener actually adopts a similar emotional state by means of emotional empathy. However, this is not a guaranteed at all, as the emotion induction is dependent on a variety of situational and individual factors. Several different mechanisms

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that contribute to emotional experiences have been put forward by Juslin and Västfjäll (2008). For music-induced sadness, when music expressing sadness (with the known cues of sadness) and listener empathically imitates this expression, this mechanism is called emotion Contagion. This important mechanism utilizes the empathic engagement of listeners. Music may also evoke a particular memory in the listener and this mechanism, called Episodic memory. It is also possible that the music has been paired with other events with emotional connotations that are linked with sadness. This mechanism is called Evaluative conditioning. There are other mechanisms for emotion induction, such as Brain stem reflex and Visual imagery, and Musical expectancy, but for sadness, contagion, memory, and evaluative conditioning probably provide the most relevant mechanisms.

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EXPERIENCE OF SADNESS IS EMBODIED, CONSOLING AND CATHARTIC “I suppose I could just walk away Will I disappoint my future if I stay It's just a day that brings it all about Just another day and nothing's any good” – King of Sorrow (Sade) When we are experiencing any emotion, there are significant physiological and endocrine changes involved. Our emotions are vitally grounded to our physical self and to our perceptual, hormonal, and motoric experiences (collectively referred to as “embodiment” (e.g., Maiese, 2011). For example, the induction of sadness, for instance, utilizes emotional empathy, which is thought to involve mirror neurons (Rizzolatti & Craighero, 2004) with direct consequences for bodily reactions such as endocrine responses. Mounting evidence from other domains suggests that physiological and endocrinal changes involved in empathy-related mechanisms lie at the core of such negative yet potentially positive emotional experiences. The functional role of neuropeptides (particularly prolactin, oxytocin and cortisol derivatives) in sadness provides an account of how the endocrine system attempts to alleviate psychic pain (Panksepp, 2008) and psychosocial stress (Heinrichs et al., 2003), and to stabilize the psychological and physiological

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processes involved in coping with personal loss (Lazarus, 1991). The hormonal changes have been at the core of much older theories of sadness, namely the idea of catharsis. Moreover, emotions are heavily intersubjective and intermodal. In other words, emotions are always framed as enactive interactions with other humans or agents. For instance, we do not casually make a list of other people facial contortions and moisture around his eyes but we rather form a direct perception another person‟s sadness in a way that “we perceive them in the movement and expression of the other‟s body” (Gallagher, 2001, p. 90). Therefore the physiological and hormonal changes involved in sadness serve the underlying machinery for the emotions and contribute to changes in attitudes and thinking but the outward signs are modulated by our capacity for social and intermodal interactions. The cathartic and consoling effects of the arts are actually derived from precisely these elements of sorrow. Music has been shown to play a central role in the self-regulation of emotions in everyday contexts. Saarikallio and Erkkilä (2007) found that mood improvement and mood control were the main goals for adolescents while using music for mood regulation purposes. They found – and later verified with larger sample (Saarikallio, 2008) – seven different regulatory strategies used by adolescents. Those were entertainment, revival, strong sensation, diversion, discharge, mental work and solace. Nominally sad music is often used for emotion regulation purposes, particularly for discharge and solace strategies. In discharge, people seek emotional disclosure by releasing sadness through suitable music. The strategy called solace represents search for feelings of being accepted when feeling sad. In some instances, the adolescent reported using music for maintaining or increasing negative mood such as sadness. The immersion in sorrow due to a personal incident (such as a death of a pet) serves the function of going through and processing the sorrow linked with the event that caused the negative emotions. This idea resembles the process of catharsis, discussed in more detail next, but the basic idea of letting one to maintain negative affect state is not considered harmful when they promote wellbeing and understanding in the long run (Larsen, 2000). Although the term catharsis, a Greek word for „purification‟, carries a association with the psychoanalytic theories from the late 20th and early 21st centuries (Freud and Breuer), the basic ideas of catharsis have been offered and detailed by Aristotle. According to his view, catharsis is act of purifying the mind by witnessing or playing out such emotions on stage (2001, p. 1458). Nowadays the definition is expressed more in terms of “discharge of affects connected to traumatic events … by bringing these events back into

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consciousness and re-experiencing them” (VandenBos, 2007, 153). There have been several treatment paradigms such as psychodrama (Kipper, 1997), primal therapy (Janov, 2007), and emotion-focused therapy (Greenberg et al., 2008) that utilize the principles of cathartic venting, but to date, the evidence about the positive results in therapy is controversial. Also the idea about rumination or venting out the negative affects as a means for getting rid of these has been shown to be problematic (Bushman, 2002). However, the studies about venting typically involve such tasks that are not common in everyday life (such as punching). Emotional disclosure – not the mere physical venting – in a variety of formats including engagement with music has been considered a positive, adaptive strategy that seeks to restructure thoughts and feelings (Salovey et al., 1999). Current ideas in trauma therapy suggest that cathartic experiences as such might be harmful for the clients without interactive regulation by the therapist. Therapist‟s role is to help to keep the client inside her window of tolerance and not get overwhelmed by strong emotions. By titrating evoked strong emotions while helping a client to complete the defensive action that typically has been disrupted by the traumatic event, therapist will help a client to integrate traumatic experiences into her autobiographical memory. (Ogden et al., 2006; van der Hart et al., 2006.) These principles have been implied into music therapy practice with depressed patients as well to help them express their emotions in safe manner. Next we will give some examples from research findings and clinical experience how music and sadness appears in clinical context.

MUSIC AND SADNESS IN CLINICAL CONTEXT “I'm crying everyone's tears I have already paid for all my future sins There's nothing anyone Can say to take this away It's just another day and nothing's any good” – King of Sorrow (Sade) When we consider sadness in clinical context we are dealing with the depression, which is a highly prevalent mood disorder affecting approximate 121 million people worldwide (WHO, 2010). Depression impairs a person‟s social skills and affects also strongly to the quality of life. It can also cause

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problems in expressing and regulating negative emotions such as anger and sadness. In severe depression the experience about life can really be like in Sade‟s song that “there‟s nothing anyone can say to take this away”. Depression affects one‟s ability to represent and regulate mood and emotion (Davidson et al., 2002), which easily lead for example to hopelessness and inability to experience pleasure (Kalia, 2005). Studies have shown that depression affects a person‟s ability to recognize facial emotions (George et al., 1998) but how does depression affects one‟s perception and preferences of musical emotions and how could music be used in treatment of depression?

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BIASED EMOTIONAL RECOGNITION IN DEPRESSION In a study by Punkanen et al., (2011) it was investigated how depression affects to the perception of emotions conveyed by music. In this study both healthy and depressed participants were presented with a set of 30 musical excerpts, representing one of five basic emotions (anger, fear, sadness, happiness and tenderness), and asked to rate each music excerpt using five Likert scales that represented the amount of each one of those same emotions perceived in the example. Main result of the study was that depressed participants showed moderate but consistent negative self-report biases both in the overall use of the scales and their particular application to certain target emotions, when compared to healthy controls. Also the severity of depression had an effect on the self-report biases. Depressed participants‟ ratings on the scales of anger and sadness across all excerpts were significantly higher than the non-depressed participants. This bias was also shown in the patterns of misinterpretation and confusion made by depressed participants between emotion scale and target emotions. For example depressed participants gave significantly higher anger ratings for sadness examples than non-depressed participants. Depressed participants also gave higher ratings of sadness for tender examples than non-depressed controls, which demonstrated how positive emotions are mistaken for negative ones when person is suffering from depression. In addition to this, depressed participants gave lower happiness and tenderness ratings for happy and tender examples. (Punkanen et al., 2011.) The study showed that depressed patients‟ perception of emotions in music differs from that of non-depressed controls. Depressed patients emotional evaluations were negatively biased and the severity of their clinical state affects the level of negative bias. That raises a possibility that this kind of

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self-report measure could work as an additional diagnostic tool for depression. It might give valuable information for clinicians about a depressed patient‟s state by using her perception of music. In another study by Punkanen et al., (2011) it was found that depression also affects person‟s preferences about music. Depressed participants gave significantly lower preference ratings than the non-depressed controls for examples for music, which were high in energetic arousal. Reason for that might be related to problems of energy management in depression (Craig, 2005). Depressed patients preference ratings also differ from non-depressed controls with anger examples. The depressed patients‟ dislike of anger examples is probably related to their general problems in dealing with anger (Riley et al., 1989).

EXPRESSION AND REGULATION OF EMOTIONS THROUGH MUSIC THERAPY

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“I wonder if this grief will ever let me go I feel like I am the king of sorrow, yeah” – King of Sorrow (Sade) If deep sadness like in depression makes us perceive and prefer musical emotions differently, it raises a question how music could be used in therapeutic way in such situations. Music therapy seems to offer a safe, creative and playful medium for to examine perception and expression of anger and sadness and thus help a person gradually to learn to use more beneficial emotion regulation strategies. In a study by Erkkilä et al., (2011) it was studied how music therapy intervention based on clinical improvisation can help to reduce symptoms of depression. Improvisation is an integrative experience where bodily, emotional and cognitive levels of experience are present at the same time. In musical improvisation the whole body is used to express intentions, emotions and thoughts. At the same time music and sounds expressed can be heard and that makes musical improvisation such a special form of self-expression. Improvisation experience often brings up important emotions, memories and images, which can be shared and processed further with the therapist. In this way the client is able to construct meanings and get insights from emerging sensations, emotions, thoughts and images.

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CASE EXAMPLE 1: SOFIA’S JOURNEY FROM REPRESSED ANGER AND HATE TO RECONCILIATION One example of the recovery process can be given from Sofia‟s music therapy. In the beginning of the therapy process Sofia‟s improvisations had very clear structure, which indicated Sofia‟s insecurity and need to control the situation. Gradually in session 8 she was able to liberate herself from the strict structure and she started to play around, trying to find new ways to express different emotions through the mallet instrument. That made her smile and she felt herself more calm than usual. Symbolism also appeared more and more in her playing. In the beginning we approached instruments with the idea to find out what kind of sounds we could create with them. Little by little she started to play about her relationships and get more in touch with her real feelings, like anger and sadness. She could express those feelings in her playing and afterwards when we listened to improvisations she could also reflect and verbalize her experience. Session twelve was a clear turning point in Sofia‟s therapy process. It was also very meaningful when evaluating the development of her symbolic process through improvisation. In the initial discussion Sofia told that she had felt very anxious during the day and tried to regulate her anxiety through different activities. She said that she really needed something new in her life. The starting point to our improvisation was to express present feelings through sounds. What followed was a 30 minute long improvisation with the mallet instrument and djembe drum. Sofia began improvisation with low notes and increased the dynamics and intensity of her playing quite soon beginning to use the whole range of mallet instruments‟ scale. I followed Sofia‟s playing and supported her strong emotional expression with my playing. What was different in the characteristics of this improvisation compared to her earlier improvisations was the great use of dissonance and chaos in her playing. There were no more strict limits or restrictions in her musical expression and for the first time she also used the djembe drum of her own will. This was a remarkable progression and change in her recovery because the drums most clearly symbolized aggression and hate, which had been forbidden and frightening emotions to her for many years. When she reflected her emotional state after the improvisation she spoke of how she felt relieved and much calmer than before improvisation. After some hesitation she also told me

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that symbolically she went through the act of suicide in that improvisation. This was clearly a symbolic and creative act to express and share something that she had held inside herself for many years. Now she was able to express her anger outwards and experience that other people can tolerate and share her emotions. After this improvisation Sofia‟s recovery process developed very fluidly. She was able to participate and enjoy activities that she used to love to do but which were impossible for her during severe depression and anxiety. Music therapy can offer a new and alternative channel for depressed patients like Sofia to express their emotions. This is very important in situations where the client has difficulties to verbally describe her inner experiences. Sometimes music can work as an opening vehicle for verbal expression. In the therapy process there are also phases when thoughts and ideas are not yet clearly formed and musical expression is the main forum for self-expression. For depressed patients music can offer a possibility to express and release their suppressed emotions, for example, anger as in Sofia‟s case. This releases energy to process things further and makes it possible to begin to learn to use more beneficial emotion regulation strategies such as reappraisal and self-disclosure in their daily lives. Depressed patients sometimes describe their musical expression experience as cathartic. This leads them to feel themselves in a new way, capable to deal with difficult emotions, which before was denied and rejected. Musical, improvisational expression, which activates the whole body and is spontaneous, leads on many occasions to corrective emotional experiences in further verbal processing. In therapy processes it is quite common that participants feel that anger is something that they are not allowed to feel and express. Expression of anger leads very easily to the feelings of guilt. In these situations symbolic distance offered in musical activity enables expression of this forbidden emotion in a safe and tolerable way. This aspect of active doing is rather unique property of music therapy and seems to be a meaningful dimension for dealing with difficult emotions like anger and deep sadness.

CASE EXAMPLE 2: SARA AND LIFTING THE VEIL OF DEPRESSION Another example can be given from Sara‟s case, which demonstrates beautifully how she was able to find a way to express her anger through musical improvisation but at the same time needed active interactive

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regulation by the therapist. Sara was a 30-year-old single woman who lived alone. She had been depressed for two years and had had several short periods in hospital during that time. She had been trained as youth worker and had worked in that area for several years. She had not been able to work since she got depressed. She felt very anxious and was not able to see any positive aspects in her life. Her social contacts were very limited and she felt lonely. In the first music therapy session she talked about her negative emotional state and feelings of sadness and hopelessness. She told that she didn‟t have skills for regulating her negative emotions and that made her tired of living and raised thoughts and wishes about death. Sara became familiar with the working method used in music therapy quite quickly and she always wanted to improvise together with the therapist. This was interpreted as her need for support and her need to use interaction for emotional regulation. In the sixth session Sara was very defensive and withdrawn. Her energy and arousal level was low. I encouraged Sara to participate in mutual improvisation. During improvisation she expressed some anger towards her father in her playing. After the improvisation she said that this was the first time that she could express something negative towards her father and she felt herself relieved. However in the next session she was very anxious and spoke about her feelings of guilt. She felt that she was not allowed to express her anger. The next improvisation was initiated from the idea to find ways of playing in a manner that feels good and safe for her. The music was very soft and harmonious and there was good interaction between her and the therapist during improvisation. When reflecting on the improvisation Sara told of how this time playing gave her feelings of security and trust. She felt very calm and relaxed in herself. In the next session she told that the feelings of calmness and relaxation lasted for the whole evening and the next day and she was very surprised and happy about that. She asked if it would be possible to get that improvisation onto a Compact Disc so that she could listen it at home when feeling herself anxious and fearful. I made the CD for her and she started to use it at home to regulate her unbearable emotions. Beforehand medication was the only way for Sara to regulate strong emotions and the CD became a new and alternative way for interactive regulation. This was the first turning point in Sara‟s therapy process and shows how depressed patients need to balance between emotional expression and emotion regulation.

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FROM DEFENSIVE STATE TO PLAYFUL STATE: SARA’S CASE Depression affects a person‟s action systems so that the defence action system dominates person‟s perception about herself and the outer world. The defence system activates when a person experiences insecurity, discomfort, or danger. For example in Sara‟s case she reported many times during the therapy process that she has great difficulty in trusting other people. She was very defensive in the beginning of the therapy but little by little she was able to let herself to enter into social engagement with the therapist. When she felt safe enough, she was able to use her action systems of exploration and play. Improvisation in music therapy offers a safe and motivating playground for exploration and play. Sounds stimulate to create more sounds and sooner or later the client is in a creative process where the defence system is deactivated and enjoyment of interactive play with the therapist takes over. Two beautiful examples of how improvisation moved the client from the defensive state to exploration and creative play can be given from Sara‟s process. In the sixteenth session Sara was very anxious about what had happened with her friend the previous night. I helped her to calm down a bit and she chose the theme for improvisation. She wanted to play what she feels right now and what she would like to do with her life. The music was soft but she played around with notes more than usual, tasting the feelings of low notes (which symbolizes her depression and other negative feelings) and high notes (which symbolizes her hope and joy). When Sara was reflecting on the improvisation after her playing she said that it expressed the possibility to stay calm with those evil and anxious emotions, which try to destroy her. She said that the improvisation symbolizes her wish to face difficult and negative emotions so that she wouldn‟t panic herself. During the whole therapy process there were lot of feelings of guilt in Sara‟s mind and she felt that other people‟s wishes had directed her choices in her life. In the nineteenth session she started to realize that she should listen to her own needs and wishes and start to live her life for herself. These thoughts activated strong feelings of sadness, which she was able to feel and stay with. She wanted to play about the idea that she is able and allowed to trust her own feelings and needs. In this improvisation she created some beautiful, harmonic melodic lines and used quite a lot of dynamic changes in her playing. Her first comment after improvisation was “oh, how beautifully I talked to myself”. She said that it has always been difficult for her to receive positive feedback from

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other people and maybe it was so because she didn‟t accept herself as she is. After this improvisation she also said that she feels beautiful and good just the way she is. The given examples demonstrates beautifully how music therapy can offer a possibility for depressed patients to learn safe and playful ways to express their suppressed emotions, like anger and sadness, through creative musical expression. Interactive emotion regulation by a music therapist will gradually help the depressed patients to learn to use more beneficial emotion regulation strategies such as reappraisal and self-disclosure. When they are able to implement these new learned strategies in their daily life, it will lead to better general functioning and quality of life like one participant described in her feedback from the therapy process.

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“I felt that I benefited a lot from my music therapy process. I learnt new ways to react and behave in different situations by understanding my own and other people‟s behaviour better. It was surprising for me that improvisation enabled me to express difficult emotions like anger. Improvisations brought up new things and ideas, which were processed further in verbal discussions with the therapist.”

CONCLUSION “The DJ's playing the same song I have so much to do I have to carry on” – King of Sorrow (Sade) Everyday uses of music is widespread and it has been quipped that Americans spend more money on music than on prescription drugs (Levitin, 2006). For this reason, increased awareness of the processes and the strategies involved in transforming one‟s negative emotions into positive ones via music engagement may have positive consequences for a variety of people coping with negative emotions. Although adolescents are probably at an age where emotion regulation strategies are constructed and perfected, the elderly probably have more significant instances for using music as medium for dealing negative emotions. As the adaptive function of sadness is to come to terms with loss, it is more likely that the elderly encounter more situations where such losses take place (losing colleagues, friends, family members) than

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younger people. In such instances, the mechanisms for inducing emotions by music are also leaning towards the personal memories of songs in particular era and situations. Also, it is not only music listening that has an influence to wellbeing but active music-making might be even more beneficial way of regulating one‟s mood. For instance, a host of studies has suggested that choir-singing provides significant social, psychological health benefits (Clift et al., 2010). These effects are assumed to occur not only due to music but the social context and the physical exercises involved in performing. Music is not unique in its ability to transform negative into positive emotional experience. All arts, particularly literature and films share this capacity for eliciting sadness and deriving strong enjoyment from it. One of the over-arching explanations is that they all provide a meta-level perspective to the emotions (Schramm & Wirth, 2010). In a meta-level appraisal, the present situation including one‟s own emotion at the particular moment is evaluated. Listeners of sad music, for example, would pose a following question to themselves: How do I feel about my own sadness that has been evoked by this particular music? Such a monitoring of one‟s own feelings facilitates the alteration of one‟s own emotional state (see Wirth & Schramm, 2007). In this way, we are able to conquer and overcome the desolate feelings of sadness and, to borrow the title from the song by Sade, become truly the “King of sorrow” in a positive sense. In music therapy context, such processes are usually portrayed in terms of safe processing of difficult emotions with the distance provided by a symbolic relations offered by music. Sometimes it takes time to feel safe enough to notice that the root of one‟s perception of the outer world exists in her own, felt experience. In these cases music offers a safe symbolic distance towards unbearable emotions. It is easier first to talk about music, like “this music is very sad” and let the music contain the emotions, which are too difficult to bear. Little by little with the help of music one may be ready to understand that “it is me who is sad too”. (e.g., AhonenEerikäinen, 2007.) It is important to make a distinction between perception and experience of sadness in music and examine how these are related to each other. In clinical context, such as in music therapy, both sides are always present. When you improvise music you also perceive it at the same time and it will affect your felt emotions. In that way the dialogue between perception and experience is naturally present. The negative bias of perception in depression will keep a

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person in a defensive state towards the outer world. But transforming the experience of sadness to expression of sadness through music will gradually change the perception as well. Therapeutic aspects of different art forms can offer a lot of possibilities to increase well-being and develop emotional skills of children and adolescents in school settings. There are already successful examples of how music, art, drama and dance movement therapy have been applied in mainstream and special schools. The results of these pioneering pilot studies encourage implementing therapeutic uses of art forms in everyday school practice. (Karkou, 2010.) Finally, as the excerpt from the song “King of Sorrow” again exemplifies, it is common to listen to favorite music repeatedly. When going through emotions dealing with sorrow and loss through music, it is typical to depend on particular favorite musical piece or track that addresses that particular state and memory in moving manner. Increased familiarity with the music usually gives the listeners stronger experiences and it is worth mentioning that music and art in general does not wear out with the use easily. However, what might be strongest asset in these situations is the prevalence of music listening in general and the delicate yet effective strategies that people intuitively utilize when dealing with the negative emotions in context of music. Music may give the words, sentiments and tangible audible content to the emotions that are otherwise difficult to summon and ultimately come to terms with. By actively doing this, the listener is engaging in a mood-repair or maintaining activities that typically lead to deeper and better processing of the emotion. Such activities need not always be originated by a negative incident since we as listeners are perfectly capable of engaging in sadness induced by music for its own sake. This is possible through our capacity for empathetic engagement, which may be one of the ways we refine, update and rehearse our complex repertoire emotions. In musically induced sadness, it is important to acknowledge not only the different mechanism that give rise to the emotion but to the fact it is embodied, it is felt in our bodies and has a strong interpersonal component. It is precisely for these reasons that sadness also has the potential for becoming consoling and cathartic emotional experience. The physiological comfort reactions involved in actual sadness help us to overcome and decrease psychic pain. The interpersonal and empathic engagement in sadness addresses the essential social and contagious aspect of sadness. Without these consoling and social aspects that may be fluently activated musical engagements, we would be locked “inside our private war, … as the King of Sorrow”.

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REFERENCES Ahonen-Eerikäinen, H. (2007). Group analytic music therapy. Gilsum NH: Barcelona Publishers. Aristotle. (2001). The basic works of Aristotle. McKeon, R. (Ed.). New York: Modern Library. Barrett, L. F., & Wager, T. (2006). The structure of emotion: Evidence from the neuroimaging of emotion. Current Directions in Psychological Science, 15, 79-85. Bonanno, G.A., Goorin, L., & Coifman, K.G. (2008). Sadness and Grief. M. Lewis, J. Haviland-Jones, & L. Feldman Barrett (Eds.), The Handbook of Emotion (3rd Edition). New York: Guilford. Bushman, B. J. (2002). Does venting anger feed or extinguish the flame? Catharsis, rumination, distraction, anger, and aggressive responding. Personality and Social Psychology Bulletin, 28(6), 724-731. Clift, S., Hancox, G., Morrison, I., Hess, B., Kreutz, G., & Stewart, D. (2010). Choral singing and psychological wellbeing: Quantitative and qualitative findings from English choirs in a cross-national survey. Journal of Applied Arts & Health, 1(1), 19-34. Craig, A. D. (2005). Forebrain emotional asymmetry: a neuroanatomical basis? Trends in Cognitive Sciences, 9(12), 566-571. Davidson, R. J., Pizzagalli, D., Nitschke, J. B., & Putnam, K. (2002). Depression: Perspectives from Affective Neuroscience. Annual Review of Psychology, 53, 545-574. Ekman, P. (1999). Basic emotions. In T. Dalgleish & M. J. Power (Eds.), Handbook of cognition and emotion (p. 301-320). New York: John Wiley. Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi, M., Vanhala, M., & Gold, C. (2011). Individual music therapy for depression: Randomized controlled trial. The British Journal of Psychiatry, 199, 132-139. Frijda, N. H. (1994). Varieties of affect: Emotions and episodes, moods, and sentiments. In Ekman, P. & Davidson, R.J. (Eds.) The nature of emotions: Fundamental questions, pp. 197-202. Gallagher, G. (2001). The Practice of Mind: Theory, Simulation or Primary Interaction? Journal of Consciousness Studies 8 (5–7), 83-108. Garrido, S., & Schubert, E. (2011). Individual differences in the enjoyment of negative emotion in music: A literature review and experiment. Music Perception, 28, 279– 296.

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George, M. S., Huggins, T., Mcdermut, W., Parekh, W., Rubinow, D., & Post, R. M. (1998). Abnormal Facial Emotion Recognition in Depression: Serial Testing in an Ultra-Rapid-Cycling Patient. Behavior Modification, 22(2), 192-204. Greenberg, L. J., Warwar, S. H., Malcolm, W. M. (2008). Differential effects of emotion-focused therapy and psychoeducation in facilitating forgiveness and letting go of emotional injuries. Journal of Counseling Psychology, 55(2), 185-196. Heinrichs, M., Baumgartner, T., Kirschbaum, C., & Ehlert, U. (2003). Social support and oxytocin interact to suppress cortisol and subjective responses to psychosocial stress. Biological Psychiatry, 54(12), 1389-1398. Janov, A. (2007). Primal Healing. Franklin Lakes, NJ: Career Press. Juslin, P. N, & Laukka, P. (2004). Expression, perception, and induction of musical emotions: A review and a questionnaire study of everyday listening. Journal of New Music Research, 33, 217-238. Juslin, P. N., & Laukka, P. (2003). Communication of emotions in vocal expression and music performance: different channels, same code? Psychological Bulletin, 129, 770-814. Juslin, P. N., & Sloboda, J. A. (2010). Handbook of music and emotion: Theory, research, applications. New York: Oxford University Press. Juslin, P. N., Liljeström, S., Laukka, P., Västfjäll, D., & Lundqvist, L.-O. (2011). Emotional reactions to music in a nationally representative sample of Swedish adults: Prevalence and causal influences. Musicae Scientiae, 15, 174-207. Kalia, M. (2005). Neurobiological basis of depression: an update. Metabolism, Clinical and Experimental, 54, 24-27. Karkou, V. (Ed.) (2010). Arts therapies in schools. Research and practice. London & Philadelphia: Jessica Kingsley Publishers. Keltner, D. & Kring, A. M. (1998). Emotion, social function, and psychopathology. Review of General Psychology, 2(3), 320-342. Kivy, P. (1990). Music Alone: Philosophical Reflections on the Purely Musical Experience. Ithaca, NY: Cornell University Press. Krumhansl, C. L. (1997). An exploratory study of musical emotions and psychophysiology. Canadian Journal of Experimental Psychology, 51, 336-352. Larsen, R. J. (2000). Toward a Science of Mood Regulation. Psychological Inquiry, 11(3), 129-141. Lazarus, R. S. (1991). Cognition and motivation in emotion. American Journal of Psychology, 46, 352-367.

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Levinson, J. (1997). Music and negative emotion. In J. Robinson (Ed.), Music and Meaning (pp. 215-241). Ithaca and London: Cornell University Press. Levitin, D. (2006). This is your brain on music. The science of an obsession. New York: Penguin. Maiese, M. (2011). Embodiment, Emotion, and Cognition. Palgrave, New York, US. Mitterschiffthaler, M. T., Fu, C. H. Y., Dalton, J. A., Andrew, C. M. & Williams, S. C. R. (2007). A functional MRI study of happy and sad affective states induced by classical music. Human Brain Mapping, 28: 1150–1162. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W. W. Norton & Company. Panksepp, J. (2008). The affective brain and core consciousness: How does Neural activity generate emotional feelings? In Lewis, M. and HavilandJones, J.M. and Barrett, L.F. (Eds.) Handbook of emotions, pp. 47-62, Guilford Press, London, UK. Punkanen, M., Eerola, T., & Erkkilä, J. (2011). Biased emotional recognition in depression: Perception of emotions in music by depressed patients. Journal of Affective Disorders, 130, 118-126. Punkanen, M., Eerola, T., & Erkkilä, J. (2011). Biased emotional preferences in depression: Decreased liking of angry and energetic music by depressed patients. Music and Medicine, 3(2), 114-120. Riley, W. T., Treiber, F. A., & Woods, M. G. (1989). Anger and Hostility in Depression. The Journal of Nervous and Mental Disease, 177(11), 668675. Rizzolatti, G. & Craighero, L. (2004). The mirror-neuron system. Annual Review of Neuroscience, 27, 169-192. Russell, J. A. (1980). A circumplex model of affect. Journal of Personality and Social Psychology, 39, 1161-1178. Saarikallio S. (2008). Music in mood regulation: Initial scale development. Musicae Scientiae, 12(2), 291–309. Saarikallio, S., & Erkkilä, J. (2007). The role of music in adolescents' mood regulation. Psychology of Music, 35(1), 88-109. Salovey, P., Bedell, B. T., Detweiler, J. B. & Mayer, J. D. (1999). Coping Intelligently: Emotional Intelligence and the Coping Process. In C. R. Snyder (Ed.) Coping: The Psychology of What Works (pp. 141-164). New York: Oxford University Press.

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Siegel, A. & Sapru, H. N. (2006). Essential neuroscience. Lippincott, Williams & Wilkins, New York, US. Storbeck, J. & Clore, G. L. (2005). With sadness comes accuracy; with happiness, false memory. Psychological Science, 16(10), 785-791. VandenBos, G. R. (2007). APA Dictionary of Psychology. Washington, DC: American Psychological Association. Van der Hart, O., Nijenhuis, E., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: Norton. Vuoskoski, J. K. & Eerola, T. (in press). Can sad music really make you sad? Indirect measures of affective states induced by music and autobiographical memories. Psychology of Aesthetics, Creativity, and the Arts. Vuoskoski, J. K., & Eerola T. (2011). Measuring music-induced emotion: A comparison of emotion models, personality biases, and intensity of experiences. Musicae Scientiae, 15(2), 159-173. WHO. (2010). Depression. Retrieved 15.2.2010, 2010, from http://www.who. int/mental_health/management/depression/definition/en/ Witvliet, C. V. O., & Vrana, S.R. (2007). Play it again Sam: Repeated exposure to emotionally evocative music polarises liking and smiling responses, and influences other affective reports, facial EMG, and heart rate. Cognition & Emotion, 21(1), 1–23. Zentner, M. R., & Eerola, T. (2010). Handbook of music and emotion. In P. N. Juslin & J. A. Sloboda (Eds.), (p. 187-221). Boston, MA: Oxford University Press. Zentner, M., Grandjean, D., & Scherer, K. R. (2008). Emotions evoked by the sound of music: Differentiation, classification, and measurement. Emotion, 8 (4), 494–521.

Lyrics Sade, 2000. „King of Sorrow‟ On album Lovers Rock, CD, New York: Epic records.

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Chapter 3

GRIEF, DEPRESSION AND PREGNANCY F. Susan Cowchock Center for Spirituality, Theology & Health, Duke University Medical Center, North Carolina, US

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ABSTRACT Depression associated with gestation is a major obstetric health problem, affecting as many as 20% of women pregnant in the past year. Depressive episodes are most prevalent in the postpartum period, with some level of suicidal ideation occurring to 9% of women. Half of women with diagnosed bipolar disorder in one series had episodes during the postpartum period. Perinatal grief is a normal response to the 15-20% of pregnancies that end in loss, and may persist until/recur in a subsequent, normal pregnancy. Pregnancy-related grief and depression are often complicated by symptoms of coexistent anxiety or posttraumatic stress. Men, too, grieve pregnancy losses, and up to 10% suffer depression in the post-natal period, but fathers' pregnancy-related sadness has not been extensively studied. Risk factors for depression in the peripartum period include past depression, a past/present eating disorder, anxiety disorders, prior perinatal loss, or a pregnancy complication. Moderating factors may include higher maternal age, religiosity and social support. Maternal salivary cortisol levels correlate with peripartum traumatic stress symptoms and depressive states, and may in the future serve as diagnostic markers and targets for treatment.

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F. Susan Cowchock Treatment of depression and grief complicated by anxiety or symptoms of post-traumatic stress in pregnancy is based on the same modalities as treatment for these diagnoses outside gestation. These include cognitive processing therapies (individual or group), psychiatric drugs, supportive counseling, or (for post traumatic stress) eye movement desensitization reprocessing. Cautions about the use of psychotropic drugs during pregnancy and lactation are reviewed here. There are only a few studies of any other therapies in pregnancy – these mainly focus on group cognitive behavioral therapy for postpartum depression.

MEASURING GRIEF AND DEPRESSION IN THE PERINATAL PERIOD

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Depression Sadness associated with pregnancy could not be documented or studied until testing instruments were developed and validated for use in the perinatal period. The routine evaluation for post-partum depression at the first post-natal period that is current North American practice, for instance, was established well after the Edinburgh Postnatal Depression Scale (EPDS) was published in 1987. [1-3] The EPDS has been used for evaluation of depression during the pre-partum period as well, but antenatal use of this scale has only recently been validated. [4;5] Other depression scales, such as the Patient Health Questionnaire, the Beck Depression Inventory, the SCID Mood module, the Hamilton Rating Scale for Depression, and the Postpartum Depression Screening Scale (PDSS) have been compared to the EPDS, and all seem to perform equally well in the pregnant or post-natal population. [5-7] The EPDS has two subscales; 3 items directed to symptoms of anxiety and 6 items directed to symptoms of depression. Hence the EPDS has also been used to screen for anxiety associated with pregnancy. [8;9] A 2005 meta-analysis of published reports on the prevalence of major and minor depression included studies reporting results using the EPDS as well as results from DSM III/IVbased structured/standardized clinical interviews. [10] Gjeringen et al have pointed to lower-than-expected rates of depression diagnosis in a postpartum study when results from a SCID (Structured Clinical Interview for Depression) interview were compared to scores based on completion of a rating scale, the PHQ-9 (Patient Health Questionaire-9).[11]

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Grief

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At about the same time (1988) that the EPDS was published, the Perinatal Grief Scale (PGS) appeared in press; first in the original 84 item version, and then in the 33 item (“short”) version that is generally used. [12;13] Other grief scales have been developed for perinatal use, for example the Perinatal Bereavement Grief Scale, but the PGS has been the most extensively used and validated.[14;15] The short version of the PGS has three subscales, based on factor analysis: Active grief, Difficulty coping, and Despair. Active Grief occurs frequently, and “was strongly” (r = 0.43) associated with gestational age at loss.[12] There was a very high correlation (0.80) between Difficulty Coping and Despair, and a lesser, but significant correlation between these subscales and Active Grief (0.70 and 0.56 respectively). For these reasons, Active Grief has been considered a “normal” response to pregnancy loss, while Difficulty Coping or Despair may suggest chronic or more pathological grief, but there really is no clinical evidence to support this concept. Practically speaking, there are close correlations between scores on scales measuring grief, depression, anxiety, and even post-traumatic stress symptoms (PTS) after pregnancy loss.[16] Seldom do these symptoms of psychological distress and pain appear in isolation in this group of women patients.

HOW OFTEN ARE CASE LEVELS OF MAJOR OR MINOR DEPRESSION ENCOUNTERED IN PREGNANCY? Depression The frequency of a diagnosis of major or minor depression from published studies are reported as the point prevalence (the percentage of the population with depression at a given point in time), the period prevalence (the percentage of the population with depression over a period of time), or the incidence (the percentage of the population with new depressive episodes that began within a given period of time). Gavin et al., using meta-analysis, estimated that as many as 18.4% of pregnant women are depressed during their pregnancy (period prevalence) and that as many as 19.2% of new mothers may have major or minor depression in the first three months after delivery. [10] Historically,

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depression has been thought to be most frequent or severe in the postpartum period, but the authors stress that all these estimates of frequency have broad 95% confidence intervals, and thus are not significantly different. Gavin et al‟s estimates seem high: The period prevalence of minor or major depressive disorder was 12.4% from 3 months of pregnancy to delivery, and 9.6% in the postpartum period, in a recent (2011) European study of 1,066 pregnant women that used the EPDS and the Structured Clinical Interview for diagnosis. [17] Le Strat et al reported a similar prevalence of 12.4% in 2011 using information from the Canadian 2001-2002 NESARC (National Epidemiological Survey on Alcohol and Related Conditions). Note that the Canadian estimate was based on “past year pregnant women”, which included the post-partum period. [18]

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History of an Affective Disorder Women with a past or current diagnosis of a major affective disorder are at higher risk, especially postpartum: Viguera et al reported that 23% of women with bipolar disorder had episodes during pregnancy and 52% had episodes in the post-partum period. [19] Among women with unipolar disorder, 4.6% had episodes during pregnancy and 30% during the postpartum period.

Male Partners Fathers, too, may have depression during a partner‟s pregnancy. In Paulson and Bazemore‟s meta-analysis of published reports, 10.4% (95% CI 8.5% - 12.7%) of men were depressed when their partner was pregnant, and the rate was higher in the 3-6 month postpartum period at 25.6% (95% CI 17.3%-36.1%). [20].

HOW OFTEN DO SYMPTOMS OF DEPRESSION OR GRIEF APPEAR AS A RESULT OF PREGNANCY LOSS? Pregnancy loss is a common event. The overall risk of miscarriage, defined as the unintended termination of pregnancy before 20 weeks gestation,

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is 10% to 15%. [21-23] Individual risks for miscarriage may be higher or lower than this estimate depending on a number of known risk factors that range from race, maternal age, obstetric history, ultrasound identification of fetal heart action, to the chromosome karyotype of prior losses. [24-26]. The terms stillbirth or fetal death are used for losses from 20 weeks to delivery or for loss of a fetus weighing more than 500g. (These definitions are not similar as gestational maturity may be more important to viability than fetal weight.) Using these cutoff levels, the general risk for late fetal death is 0.4-1.2 per 1,000 singleton pregnancies. [21;22]

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Pregnancy Loss and Depression Klier et al have thoroughly reviewed studies of depression after miscarriage with a focus on those studies with comparison cohorts.[22] These studies showed an increase in depressive symptoms among women who had miscarried. They pointed out that elevated symptom rates did not necessarily confirm diagnoses of DSM disorders. The authors suggest there is mixed evidence to support gestational age at pregnancy loss as a risk factor for depressive symptoms, although it is logical to expect greater maternal attachment to the baby as pregnancy advances.

Pregnancy Loss and Grief Grief is, of course, a normal response to loss of a potential child, but evidence suggests that there are abnormal levels of grief, as well as unusually persistent or complicated grief. Abnormally “high” levels of grief after pregnancy loss were defined as scores above the 97.5th percentile on the brief PGS and its subscales for women who had suffered perinatal loss.[15] This is a relatively high cutoff, which has not been established with other covariates such as social functioning or quality of life.

Influence of Gestational Age at Loss on Grieving Results from the original study that developed the PGS showed that gestational age at loss was the strongest predictor of women‟s scores on the Active Grief subscale, but was of less importance as a predictor on the

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Difficulty Coping and Despair subscale scores.[13] Late pregnancy loss, including termination of pregnancy for fetal anomalies, is associated not only with higher levels of grief, but also with symptoms of post traumatic stress; both after the pregnancy loss and during a subsequent pregnancy. [16;27-30] Recurrent miscarriage is also a traumatic event resulting in high levels of grief (PGS) and post traumatic stress symptoms (as measured by the Impact of Event Scale/IES).[13;31]

Do Fathers Grieve Pregnancy Loss? From the original study resulting in the PGS, data from male partners generally showed that men had less intense levels of grief symptoms after their partner‟s pregnancy loss. However, men do grieve after pregnancy loss, and a subset of men had scores higher than most women. Men also did not differ from women with respect to scores on the subscale “Despair”.[34]

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How Long Do Symptoms of Grief Persist? When depression and grief are high after loss, symptom scores are likely to remain high even at one-year follow-up. [35] Using PGS scores, Lin and Lasker showed that the expected decline in grief over time was observed in 41% of women followed for two years after pregnancy loss. The authors reported three additional primary grief patterns: These patterns were a “reversed” pattern (13%), a delayed resolution” (17%) and a “low, unchanged” grief pattern (28%). [36] No clear “normal” trend could be derived from their data. Grieving does not end with conception, or even delivery of a next normal pregnancy, although grief levels are generally reduced.[22] Pregnant women who have suffered a prior traumatic pregnancy loss frequently deal with depression, grief and anxiety, as well as post-traumatic stress symptoms during their next pregnancy. [16;32;33]

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MODULATORS AND PREDICTORS OF RISK FOR GRIEF AND DEPRESSION ASSOCIATED WITH PREGNANCY OR PREGNANCY LOSS Identification of predictors or potential modulators of grief and depression is most important to identify groups at high risk for further screening. It is, of course, also important that research designs involving between group comparisons establish equivalence of treatment groups with respect to factors other than those under investigation.

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Depression Increased maternal age has been reported in a number of studies to be protective against both depressive symptoms and grief. [13;37;38] One study of postpartum women using the EPDS and a clinical interview noted that suicidal ideation was associated with younger age and higher parity. [39] The diagnosis of a major depressive episode during pregnancy was associated with younger age, single status, and pregnancy complication in a Canadian population. [18] Viguera et al pooled information from more 2,252 pregnancies among 1,162 American women with clinically treated DSM-IV bipolar I/II disorder or recurrent major depressive disorder. They reported that factors associated with episodes in pregnancy, in descending order, were younger age at onset, previous postpartum episodes, fewer years of illness, bipolar disorder, fewer children, and not being married. [19]

Grief There is less information about predictors for grief, or PTS symptoms, after pregnancy loss. Gestational age is an important predictor in most studies. Korenromp et al studied parental coping after termination of pregnancy for a fetal anomaly.[40] Measures of parental coping included the Inventory of Complicated Grief, the Impact of Event Scale, the Symptom checklist 90 (SCL 90 for general psychiatric dysfunction), and the EPDS for depression. Significant maternal predictors of grief were age at termination, commitment to a religion, the lack of any other children, and partner support. Commitment to a religion was also a significant predictor for postpartum depression in

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fathers. In contrast, Mann et al reported that, in addition to maternal age, white race and religious attendance at least a few times a month were significantly inversely related to grief scores following pregnancy loss [37]. The influence of religion cannot be evaluated with consistency using simplistic categories like religious attendance or self-rated religiosity. We analyzed religious data collected from the original Lehigh Valley Perinatal Loss Project (used to develop the PGS) and found that religious struggle, agreement with statements classified as negative religious coping, and continued attachment to the baby were associated with more severe grief [41]. More recently we reported data from a small study of women who had traumatic pregnancy loss, i.e. a second trimester termination of pregnancy for fetal demise or fetal anomaly. In contrast to the findings in the first study, in which several statements from the Intrinsic Religiosity Scale were analyzed as an aggregate, we found no significant correlation with grief symptoms. We did find that intrinsic religiosity using the entire Hoge Scale was predictive of significantly lower levels of symptoms on the PGS subscale for Despair, but did not predict scores on the IES scale for PTS symptoms, on the DDI scale for depression, or on the GAD measuring generalized anxiety in this group of patients.[16]

THE POTENTIAL DIAGNOSTIC OR PREDICTIVE USE OF MATERNAL CORTISOL LEVELS The regulation of maternal cortisol levels during pregnancy is complicated by the influence of the feto-placental unit. The placenta produces corticotrophin releasing hormone (CRH), although one study suggested that placental CRH has little influence on baseline maternal adrenocortical function in pregnancy. [42] Although the fetal adrenal gland is enormous compared to its mother‟s, the primary steroid produced is dehydroepiandroserone sulfate (DHEAS). Most of the cortisol in the fetal circulation is produced from placental progesterone. [43] Nonetheless, maternal salivary cortisol was higher in women carrying male fetuses compared to levels in those carrying female fetuses until 30 weeks gestation, when the ratio was reported to reverse. [44] Despite this complicated relationship, maternal salivary cortisol levels do seem to reflect the well-being of the maternal-fetal unit to some extent. A study that measured the rise of salivary cortisol on awakening in gestational weeks 13-18 and 35-37 weeks in 81 women reported that newborns of mothers

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with higher cortisol levels in pregnancy had lower birth weights and were shorter at birth, even though they could not relate maternal cortisol levels to scores on stress scales. [45] In non-pregnant populations, cortisol responses to dexamethasone and to early morning rising have been used to aid in diagnosis or to monitor therapies for depression (morning cortisol levels fail to suppress in some depressed patients after low dose dexamethasone) and PTSD (where the expected 15-60 minutes post awakening morning rise may be suppressed). [46-49] Since maternal salivary cortisol levels may give information on the maternal-fetal unit, the use of these measurements in pregnancy has obvious applications. Maternal cortisol responses to stress are not uncomplicated. Obel et al reported that during early pregnancy (median 14th week gestation) women who reported stressful life events had a blunted rise in morning cortisol, and did not have higher evening cortisol levels. Women later in pregnancy (median 30th gestational week) who were also under stress, had unaffected morning levels, but significantly higher (27%) evening levels.[50] A comparable study of 25 primigravida women, less than 20 weeks pregnant, used a standardized psychiatric diagnostic interview for PTSD and PTS symptoms. The women whose symptoms met diagnostic criteria for PTSD or partial PTSD had lower peak basal salivary cortisol levels. [51] Pluess et al also measured salivary cortisol in 66 pregnant women in both early and later pregnancy. They collected data on depression, pregnancy-related anxiety, perceived stress and negative life events. Only high levels of maternal trait anxiety predicted low baseline cortisol awakening levels. There are, as yet, few studies on salivary cortisol levels in depressed pregnant women. O‟Keane et al measured blood levels of ACTH and corticotrophin releasing hormone (CRH), and salivary cortisol levels in pregnant women with and without major depression. They reported that second trimester CRH and mean salivary cortisol levels were higher in the evening in the depressed women. [52] Urizar and Munoz compared two therapy groups, cognitive behavioral stress management (CBSM) and usual care, of women at high risk for depression to a low risk group. They measured infant and maternal cortisol levels at 6 and 18 months postpartum. They reported that infants of women in the CBSM and low risk groups had significantly lower levels of cortisol than infants of high risk mothers in the usual care group at 6 months postpartum. Women in the CBSM group had lower cortisol levels than women in the usual care group at 18 months postpartum. The results suggest that maternal treatment of major depression during delivery had salutary effects on their infants after delivery.[52]

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IS “TRAUMATIC GRIEF”A BETTER DESCRIPTION OF THE DISTRESS SUFFERED BY WOMEN AFTER PREGNANCY LOSS? The pioneering work of Hughes and coworkers demonstrated that a prior stillbirth after 24 weeks gestation resulted in case-level symptoms of PTSD, as well as depression and state-anxiety in up to 20% of pregnant women. [30;32] A number of investigators have since used the Impact of Event Scale (IES) and/or clinical interviews to evaluate women who have suffered a range of losses, and even pregnancy complications for symptoms of PTS both after the event and during a subsequent pregnancy. [27;28;30;53-58]. As a result of these studies, traumatic grief is a new diagnostic term, meant to include older terms such as “Complicated Grief Disorder (CGD)” or pathologic grief. [28;29;59-66] Traumatic grief, as currently understood is a stress syndrome with components of both “separation distress” and “traumatic distress”. [65]

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MEASURING TRAUMATIC GRIEF The Inventory of Complicated Grief was developed by Prigerson et al (1995) to evaluate elders whose spouses had died for maladaptive symptoms of grief that might predict long-term functional impairment. [64] Similarly Horowitz et al (1997) evaluated bereaved subjects, ages 21-55 years, whose spouses had died 6 and 14 months earlier. They developed diagnostic criteria for CGD. They concluded that criteria for a new diagnosis of CGD would include the experience (more than a year after loss) of strong yearning for the deceased, continued feelings of aloneness and emptiness, trouble sleeping, and/or strong avoidance of reminders of the deceased. A consensus panel convened in 1999 established four preliminary criteria for “Traumatic Grief”: Criterion A specified that the symptoms occur after the death of a significant other, and include intrusive, distressing, separation distress. Criterion B included eleven marked and persistent symptoms that reflect the bereaved person‟s feeling of devastation. Criterion C specifies that the duration of symptoms must be at least two months. Criterion D requires that the disturbance causes clinically significant impairment in functioning.[62] Unfortunately, these last two diagnostic systems do not show good agreement. In a study comparing the two, using an elderly population of whom 18.9% had experienced a major bereavement, a minority of cases received positive

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diagnoses of both complicated grief disorder and traumatic grief. The prevalence rates were 4.2% using Horowitz et al criteria and only 0.9% with the consensus panel‟s criteria [60]. Loss of a wanted pregnancy, especially after the first trimester, is considered a traumatic pregnancy loss, because it may result in severe psychopathology consisting of mixed symptoms of grief, post-traumatic stress, depression, and/or anxiety. These symptoms may be present for years after the loss, and may persist, or reappear, in a subsequent normal pregnancy. [16;2729;32;37;40;53;55;67-69] Traumatic grief, as currently understood is a stress syndrome with components of both “separation distress” and “traumatic distress”. [65] We have already shown a significant correlation in a small group of women, pregnant after a traumatic loss, between responses to the statements on both the PGS and the IES reflecting symptoms of a mixture of grief and traumatic stress. [41] Table I compares statements from the PGS [12] compared to the consensus Criteria for Traumatic Grief.[65] Assignment of statements from the PGS to a particular category was somewhat arbitrary. Despite the difference in format (patient – completed statements rated by a Likert scale versus clinicianrated diagnostic criteria), there is very good agreement between PGS statements and the diagnostic criteria for traumatic grief. Differences were few: The PGS does not ask about searching for the deceased, or about difficulty acknowledging the death. (It also does not ask about the mourners‟ assumption of symptoms or behaviors of the deceased, but this would be unlikely in the case of an unborn child.) The PGS included two questions about maternal guilt, which might also be appropriate for a diagnosis of traumatic grief. The criteria for traumatic grief did not ask about depression, taking “nerve” medication, or suicide risk (as did the PGS) – but these are symptoms of depression, rather than grief. There are also two reverse-coded items on the PGS which have no correlates in diagnostic criteria (“I feel I have adjusted well to the loss”, and “It feels great to be alive.”). Based on this comparison, it seems likely that most women who score high on the PGS would meet the criteria for diagnosis of traumatic grief. In an important first step, Kersting et al studied a group of 62 women suffering a traumatic pregnancy loss between the 15th and 32nd gestational week. The authors used Horowitz‟ criteria for a complicated grief disorder. [68] Fourteen months after termination for fetal malformation, 13.7% of the women fulfilled the criteria for a complicated grief disorder, and 16.7% were additionally diagnosed as having a psychiatric disorder (affective and anxiety disorders) according to DSM-IV.

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Table 1. Comparison of statements from the Perinatal Grief Scale (PGS) and the Criteria for Traumatic Grief (TG) TG Criterion A2: Response involves 3 of these 4 symptoms experienced at least sometimes:

PGS Corresponding PGS Statements §

1. Intrusive thoughts about

2. I feel a need to talk about the baby.* AG

about the deceased

5. I get upset when I think about the baby. *AG 6. I feel physically ill when I think about the baby. ***D

2. Yearning for the deceased

3. I am grieving for the baby. *AG 4. I very much miss the baby. *AG

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3. Searching for the deceased

No corresponding statement

Criterion B: 4 of the following 8 symptoms experienced as mostly true: . Puposelessness or feelings of despair about the future.

2. Subjective sense of numbness, detachment, or absence of emotional responsiveness among friends.

10. Time passes so slowly since the baby died. *AG 7. I worry about what my future will be. ***D 5. I am frightened. *AG 2. I feel empty inside. *AG 5. I try to laugh but nothing seems funny anymore.**DC 9. I feel somewhat apart and remote even among friends.**DC

§ Statements numbered as in short PGS (12), *AG from the Active Grief subscale, **DC from the Difficulty Coping subscale, ***D from the Despair subscale

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No corresponding statement

4. Feeling that part of oneself has died. 6. The best part of me died with the baby. ***D 8. I feel worthless since he/she died. ***D 5. Shattered world view 4. I feel unprotected in a dangerous world since he/she died. ***D 9. It is safer not to love. ***D 11. Being a bereaved parent means being a second-class citizen. ***D

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7. Assumes symptoms or harmful behaviors of, or related to, deceased person 8. Excessive irritability, bitterness, or anger related to the death

No corresponding statement

1. I find it hard to get along with certain people. **DC 6. I get cross at my friends and relatives more than I should.**DC 8. I feel as though I am just existing and not really living since the baby died. **DC

§ Statements numbered as in short PGS (12), *AG from the Active Grief subscale, **DC from the Difficulty Coping subscale, ***D from the Despair subscale

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F. Susan Cowchock Table 1. (Continued)

Criterion C: Duration of the symptoms listed at least 2 months. Criterion D: The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

1. I cry when I think about him/her. *AG 2. I can‟t keep up with my usual activities. **DC

5. I have left people down since the baby died. **DC 7. Sometimes I feel like I need a professional counselor to help me get my life together again.**DC

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10. I find it difficult to make decisions since the baby died**DC. § Statements numbered as in short PGS (12), *AG from the Active Grief subscale.**DC from the Difficulty Coping subscale, ***D from the Despair subscale

The study also administered the Munich grief scale, which differs from the PGS discussed earlier, as well as the IES, but did not report any correlations between scores on these scales. What is needed is a comparison of PGS scores and clinical interviews to validate the newly developed consensus criteria for traumatic grief in an obstetric population. It is likely that complicated/traumatic grief will eventually be listed as a distinct mental disorder in DSM-V. [63] If the larger number of studies using the PGS can be used to inform our consideration of this diagnosis, we would be much closer to identifying those at risk, and choosing appropriate treatment.

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TREATMENT OF DEPRESSION IN PREGNANCY OR POSTPARTUM Treatment for depression during pregnancy is similar to treatment outside of pregnancy. It consists of group or individual interpersonal psychotherapy and/or prescription of antidepressants. Antidepressant therapy is complicated in pregnant or nursing women because of the possibility of teratogenesis or unwanted effects on the infant neurological system.

Psychotherapy

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Interpersonal psychotherapy, group or individual, has been shown to be effective treatment for depressive symptoms in both pregnant and postpartum women.[(70-74] There does not seem to be any important difference in outcome when cognitive behavioral therapy is compared to interpersonal psychotherapy for treatment of postpartum depression. [75] There also is no evidence to show that it is more effective than antidepressant therapy, and it is likely to be more expensive. [73;76]

Light Therapy Two groups have conducted trials of bright light therapy for treatment of depression during pregnancy. The first conducted a pilot study of 10 pregnant women with DSM-IV major depression randomized to receive 7000 lux active treatment or 500 lux placebo treatment. In a 10 week trial, active light produced a significant treatment effect with a treatment size similar to that in antidepressant drug trials. Treatment was associated with phase advances of the melatonin rhythm. [77] A second study treated 27 pregnant women with nonseasonal major depression disorder, who were randomly assigned to 7000 lux (active) or 70 lux (placebo) light administered at home in the morning upon awakening for 1 hour per day for 5 weeks. The response rate at week 5 using depression rating scales was 81.3% with bright light compared to 45.5 % for placebo light. Remission was attained by 68.6% versus 36.4% respectively (p