Psychiatry 70(2) Summer 2007 154 Grief and Mourning in Schizophrenia Daniela Wittmann and Matcheri Keshavan Depression and suicidality after first episode of psychosis are well-documented responses in patients with schizophrenia (Addington, Williams, Young, & Addington, 2004). The understanding of depression and suicidality has been increasingly refined through careful study. Researchers have identified a number of factors that may cause depression such as insight into the illness, feelings of loss and inferiority about the illness as a damaging life event, hopelessness about having a viable future with the illness and mourning for losses engendered by the illness. The authors argue that grief and mourning are not just an occasional reaction to the diagnosis of schizophrenia, but are a necessary part of coming to terms with having the illness. They offer three case examples, each of which illuminates a distinct way in which psychosis and mourning may be related—psychosis as a loss of former identity, psychosis as offering meaning and transformation, and psychosis as a way of coping with the inability to mourn. In their view, recovery depends on mourning illness-related losses, developing personal meaning for the illness, and moving forward with "usable insight" and new identity (Lewis, 2004) that reflects a new understanding of one's strengths and limitations with the illness. DEPRESSION AND SUICIDALITY IN SCHIZOPHRENIA Depression and suicidality are well-documented responses in patients with schizophrenia (Addington, Williams, Young, & Addington, 2004). Following a psychotic episode, patients are considered at risk for both and are carefully followed by their treatment providers. While depression was initially viewed as a component of the psychotic state, the understanding of depression and suicidality has been increasingly refined through careful study. The research on suicidality in schizophrenia has demonstrated that only a small percentage of patients kill themselves in response to command hallucinations (Grunebaum et al., 2001; Harkavy-Friedman et al., 1999; Heila et al., 1997; Power, 2004) and that depression that follows a psychotic episode may be related to other factors. Kimhy and colleagues suggests that the first few weeks after hospitalization, patients are at risk because of stresses such as uncertainty about future hospitalization, employment concerns, loneliness and relationship problems (Kimhy, Harkavy-Friedman, & Nelson, 2004). Insight and a coping style that tend towards integration of the illness rather than sealing over and disregarding it are critical to adjustment to illness (Tait, Birchwood, & Daniela Wittmann, LMS W, is Assistant Professor at Wayne State University Department of Psychiatry and Behavioral Neurosciences.Mafc/ien Keshavan, MD, is Professor at Wayne State University Department of Psychiatry and Behavioral Neurosciences. Special thanks to Rocco Marciano, MSEd, for providing clinical material for this paper. The work of the authors was supported by the Michigan Department of Community Health and the Joseph F. Young, Sr., Psychiatric Research and Training Program. Address correspondence to Daniela Wittmann at University Psychiatric Center, 2751 E. Jefferson, Detroit, MI 48207; E-mail dwittman@med.wayne.edu. Wittmann and Keshavan Trower, 2004). They are also associated with a greater likelihood of depression, suggesting that patients are driven to unhappiness, perhaps despair, by recognizing the effect that the illness will have on their lives (McGlashan, 1987). When the depression does not lead to suicide, it may lead to social withdrawal and disengagement from services (Tait, Birchwood, & Trower, 2003). Of significance may be a little explored finding by Kim and colleagues who studied factors that contribute to the suicidal behavior in patients with schizophrenia. Their major finding was that the hopelessness was by far the greatest contributor to suicidality, with substance abuse, insight into illness, and higher cognitive function following suit. In analyzing their data on 333 patients, they also found, interestingly, that while patients with high scores on lifetime suicidality had insight into their illness of schizophrenia, they did not have insight into being depressed (Kim, Jayathilake, & Meltzer, 2003) THE EXPERIENCE OE LOSS IN SCHIZOPHRENIA As the field of study moved from a description of symptoms and cognitive styles to investigations of patients' internal experiences, the meaning of depression emerged as an important factor. Building on earlier work by Mayer-Gross (1920) and McGlashan & Carpenter (1976), Birchwood and his collaborators were able to develop the concept of "post psychosis depression" in which an episode of psychosis is responded to as a "life event" rather than simply experienced as an illness (Birchwood et al., 2005). Patients in Birchwood's study were acutely aware of the losses experienced as a result of their illness. More specifically, they saw themselves as having been rendered socially inferior by the illness. These patients were not necessarily more insightful than those who did not develop post psychotic depression. They were, however, likely to be more pessimistic than those who did not develop it. This finding corroborates Kim and colleagues' notion that hopelessness 155 is the key factor that predicts whether a person with schizophrenia will be at risk for suicide. In her extensive and comprehensive review of the literature on depression and suicide in schizophrenia, Lewis (2004) speaks to the fact that some schizophrenic patients must mourn losses engendered by the illness. She coins the phrase "usable insight," insight based on an accurate perception of what has been lost which then determines how one might go on into the future with a realistic appraisal of one's situation; according to her, patients have to accept what was lost (job, education, social relationships). They must also give up their psychotic symptoms which may have been a way of coping during the illness (Lewis, 2004). The experience of the symptoms and diagnosis of a chronic mental illness is a serious crisis. Any chronic illness brings with it limitations and losses, but schizophrenia is potentially more damaging because it affects the psyche itself. Positive symptoms bring about the loss of usual cognitive functioning and a capacity to orient oneself to both external and internal reality. Negative symptoms influence one's capacity to remain affectively and energetically engaged with the social and occupational world. When such altered capacity to perceive and engage is experienced as a result of war, torture, or abuse, we call it trauma. In schizophrenia, the loss of functioning is a traumatic loss. McGorry and colleagues, who interviewed 36 patients (who had experienced acute psychosis in the past 2-3 years) after discharge from hospital, found that at 4 months, 46% had symptoms of post-traumatic stress disorder. At 11 months post discharge, 36% could still be classified to be suffering from post-traumatic stress disorder according to DSM-III criteria (McGorry et al., 1991). Morrison Frame, and Larkin (2003), in their review and analysis of research on the relationship between trauma and psychosis, conclude that "since the findings of high rates of post-traumatic stress disorder in response to psychosis have been replicated in many studies with differing methodologies, it is reasonable to conclude that some people do develop 156 Grief and Mourning in Schizophrenia post-traumatic stress disorder as a response hallucinations and delusions was found when to psychotic experiences" (Morrison et al., a person who had been abused as a child was 2003). re-traumatized as an adult. They suggest, simWe may think of the loss of cognitive ilarly to the above authors, that in some cases, and emotional functioning in schizophrenia psychosis may be a way of integrating trauma. as the primary loss brought ahout hy the ill- If psychosis is a method of coping with trauma ness. The losses of independent functioning, or a defense against loss, it must be given up so such as educational, vocational and social that ordinary grief and mourning can competencies, and loss of place in a social mi- proceed. lieu can be described as secondary losses. With The issue of psychosis as a defense both primary and secondary losses can come against loss touches on a debate about the the loss of faith in self, others, and in a viable cause of the development of schizophrenia future. Birchwood's description of a sense of since it was first described by Kraepelin and inferiority or loss of self-esteem is relevant Bleuler (Bleuler, 1911; Kraepelin, 1913). Curhere. rent views are based in research and present a When Lewis speaks of the need to give rich picture that spans the gamut of non-bioup the symptoms of psychosis, she is speaking logical to biological causes of schizophrenia. to yet another loss. For some people, the de- Read and colleagues, in their review of the hisvelopment of psychosis may be an uncon- tory of schizophrenia in a scientific and scious method, a strategy, with which to face sociopolitical context, question the methodolunbearable loss. In their book The Cognitive ogy in genetic and biological research and Psychotherapy of Schizophrenia, Kingdon point to the influence of social engineering and Turkington propose trauma as one of the that affected the theory and treatment of peofour predispositions that can lead to psychosis ple with severe mental illness in the early (Kingdon & Turkington, 2005). Morrison twentieth century. They suggest that these and colleagues (2003) go so far as to suggest flawed approaches are still present in the that post-traumatic stress disorder and psy- bio-psycho-social model of schizophrenia. chosis may lie on a spectrum of responses to They propose that societal as well as familial trauma. Allen, and Console (1997) in their dysfunction, abuse, and trauma may be by far study of 266 women who were hospitalized the most important precursors of a psychotic for a number of conditions related to trauma, disorder (Read et al., 2004). The influence of found a relationship between dissociation and the environment is also examined by other aupsychosis. While cautioning against thors. Spauwen and colleagues studied 2524 misdiagnosing psychotic decompensation in adolescents between ages 14 and 24 through traumatized individuals as a primary psy- self-reports of trauma and psychosis pronechotic disorder, they hypothesized that indi- ness. They found that approximately 42 viduals who use dissociation as a way of cop- months later, a larger proportion of adolesing are sufficiently out of touch with internal cents who were severely traumatized and were and external reality to be susceptible to psy- prone towards psychosis (had schizotypal feachosis (Allen et al., 1997). Read, Mosher, and tures) were more likely to develop psychotic Bentall (2004) reviewed studies that exam- symptoms (Spauwen et al., 2006). Cannon ined the relationship between childhood and Clarke reviewed the hterature that looked trauma, loss and stress, and psychosis (Read at the perinatal environment, developmental et al., 2004). In most of the studies, they found issues, and genetic and societal influences. a strong relationship between early physical They concluded that these issues have to be and sexual abuse and hallucinations and delu- taken into account when defining vulnerabilsions, while no relationship or a weak rela- ity for schizophrenia and that early interventionship was found between trauma and nega- tion aimed at prevention is indicated (Cannon tive symptoms and thought disorder. A yet & Clarke, 2005). The precise interplay of the stronger relationship between trauma and pathways to psychosis is far from being fully Wittmann and Keshavan understood. It is necessary to consider biological, psychological, social, and cultural factors in order to do full justice to understanding schizophrenia and psychosis. This paper can only touch on these issues, but appreciation of all aspects of this complex disorder underlies our thinking about loss, grief, and mourning in schizophrenia. In the following discussion, the authors will propose that developing the capacity to grieve and mourn losses related to the illness is not just a by-product of the adjustment to the illness for some patients; it is a necessary process aimed at psychological integration of the illness for all patients diagnosed with schizophrenia. It is a process that is complex and can take many forms. GRIEF AND MOURNING IN SCHIZOPHRENIA Grief is a necessary response to loss and is defined as "the process of experiencing the psychological, behavioral, social and physical reactions to the perception of loss" (Rando, 1993, p. 24). Mourning is "the cultural or public display of grief through one's behaviors." To paraphrase, it is a conscious and unconscious process which serves to untie attachment to the past, to adapt to the loss and develop a new identity without what is lost (Rando, 1994, p. 23). There is a need for the person experiencing the loss to suspend defensive responses long enough to experience the powerlessness that comes from not being able to restore the past. After an episode of psychosis, a person needs to find meaning for what happened so as to integrate it into a sense of self that has been irrevocably changed. Larsen, in his paper on the meaning in first episode psychosis, uses an anthropological prism through which to describe this process (Larsen, 2004). According to him, people who experience psychosis use "a cultural repertoire," at least initially, to label what has happened to them. They may shift between various explanatory models sequentially or in a complementary fashion, such as the medical model, the stress-vulnera- 157 bility model, the stigma model, or the spiritual model, to make the experience of psychosis meaningful and acceptable. He suggests that while using already existing models, persons with psychosis take an active role in constructing the integration of their experience. He borrows the term "bricolage" (used by anthropologist Levi-Straus in his book The Savage Mind which deals with societal development) as a term that best describes the accrual of ever-developing explanations for reworking a new identity. Bricolage, which means a "do-it-yourself" job in French (Collins Gem, 2000) is described by Levi-Straus as an "attribute of human creativity in life and a proof of individual analytic and theory- generating capabilities (Levi-Straus, 1966, p. 462). This approach assumes an agency on the part of the person with psychosis and echoes descriptions offered by people who have described this experience from within. As Patricia Deegan, Program Director of the Northeast Independent Living Program and a person in recovery from schizophrenia, suggests: "We are fully human subjects who can act and in acting, change our situation" (Deegan, 1997). In the grief and mourning literature, a sense of agency is similarly assumed. In his generally accepted theory, Worden, in his study of children's grief, proposes four tasks rather than stages of grief and mourning to accentuate the dynamic nature of the mourner's work (Worden, 1996). The tasks are: 1) To accept the reality of the loss, 2) to experience the pain or emotional aspects of the loss, 3) to adjust to an environment in which the deceased is missing, and 4) to relocate the dead person within one's life and find ways to memorialize the person. Although the person recovering from psychosis is not grieving the loss of another person, he/she is grieving the loss of the person he/she used to be and in that sense must complete these tasks in order to cope with the loss of the past self and achieve a new identity. It must be noted that a person with a chronic illness may experience temporary re-«mergence of intense grief and mourning at significant milestones or anniversaries and that such "short upsurges of grief" (STUGs) 158 Grief and Mourning in Schizophrenia can be expected (Rando, 1993, p.64). Johnson and Rosenblatt describe this as "maturationai grief" in order to distinguish it from complicated mourning (Johnson & Rosenblatt, 1981). COMPLICATED MOURNING IN SCHIZOPHRENIA "Comphcated mourning means that, given the amount of time since the [loss], there is some compromise, distortion or failure of.. . processes of mourning" (Rando, 1993, p. 149). Complicated mourning can develop in individuals newly diagnosed with severe mental illness who have insight into their illness, but have been unable to cope with the losses and changed identity inherent in the acquisition of the illness. It becomes chronic, and Bowlby describes this as a state in which "the individual becomes and remains sadly disorganized" (Bowlby, p.lO9, in Rando, 1993). There is an extensive literature on complicated mourning, but complicated mourning in schizophrenia is an uncharted sea that beckons exploration. First, we must distinguish between complicated mourning and depression since it is depression that is typically described as a reaction to psychosis. Efforts have been made to elucidate the distinction. Horowitz and colleagues developed criteria for complicated grief disorder which relate primarily to the loss of a person, but could be adapted to the experience of complicated grief due to losses engendered by psychosis (Horowitz et al., 1997). Ogrodniczuk and colleagues, in a study of bereaved individuals, were able to isolate three dimensions of complicated grief: 1) grief (intrusive thoughts, feelings about the lost person, searching for the lost person), 2) grief experience (persistent emotional distress related to death/loss, propensity to ruminate about the lost person, painful feelings associated with the death), and 3) grief avoidance (active avoidance of thoughts and feelings associated with the lost person) (Ogrodniczuk et al., 2003). Coming to terms with psychotic illness involves many of the above-mentioned experiences: intrusive thoughts, search for past identity, persistent emotional distress related to the way the illness affected the person's life, possible avoidance of any thoughts or feelings about it, or using psychosis as a defense against loss. It would not be a stretch to consider examining and adapting Ogrodniczuk's concepts to an emotional response to the experience of psychosis. CASE STUDIES We herein describe three patients, each of whom illustrates the key issues pertaining to the relationship between mourning and psychosis. All patients have verbally consented to parts of their story being incorporated in this manuscript. We have avoided providing, and modified where necessary, any aspects of their history that might identify them. 1. Grief and Mourning of a Former Self Latoya is a 26-year-old African American woman who was a third-year college student at the time of her first episode of psychosis. Social withdrawal and increasingly poor hygiene as well as increasing paranoia for nearly 4 years led her family to seek psychiatric care for Latoya. Latoya believed that there was a family secret and that her parents were planning to kill her. She was finally hospitalized after she physically attacked her father. Latoya cooperated with medical treatment (Olanzapine, later Aripiprazol and finally Risperidone Consta), but was reluctant to engage in psychotherapy: "I didn't trust my doctor and my therapist." Her attendance in groups was also half hearted. She participated, but with little enthusiasm. By her own admission, she was having difficulty accepting that she had a mental illness. Although she tried to return to academic and work projects, Latoya was not successful initially because her field is fairly rare. She was not interested in other activities. Her motivation flagged. Her activities centered on 159 Wittmann and Keshavan her home where she lived with her parents. She was not socially involved. After a year of enrolment in a treatment program, Latoya was asked to participate in a research study that involved the description of losses engendered by the experience of psychosis. Latoya was eager to speak about what had happened to her and how she felt about it. Latoya was aware that she had experienced a number of losses. She named "time, school, job, friends, apartment" as the concrete things that she no longer had in her life. But the loss that meant the most to her was the loss of confidence, the loss of personal identity: "I am more nervous and shy now, I didn't used to be like that." Latoya said that she had experienced fears that her parents would have to take care of her for the rest of her life and that she had felt depressed to see that everything that she wanted to do in her life had to take a back seat to her illness. When asked, Latoya was able identify periods of depression since diagnosis. She was relieved to hear that some of those feelings might be grief and that grief is a normal part of adjustment to a chronic illness. She thought that she had not grieved her losses. She had not cried and she had not felt angry. Instead, she said, "I overthink". She was curious about grief and had many questions about the process and when and how she might see some changes in herself. During the following six months, Latoya continued to work with her therapist on recovery. She gradually came to accept that she had a mental illness which she had to manage while she tried to return to building a life for herself. She has steadily increased her activities, but has done so in a carefully calibrated manner. She has moved into the social arena very slowly, too. She is aware that her friends have moved on in their lives at a faster pace. Her social experiment now involves co-workers. Friendly banter is comfortable for her now, but she is not ready for more. While her parents support her and she appreciates it, she does not confide. Her therapist appears to be a valuable sounding board, but Latoya remains reserved. She can share humor and discuss concerns, but not vulnerable feelings. This may be due to pre-illness personality development or to a wish not to be overwhelmed with unbearable feelings. As she is no longer denying her illness and is moving forward, this seems to be a reasonable pace for Latoya. Analysis. Latoya's reaction is an example of Birchwood's post-psychosis depression. Psychosis was a life event which altered her irretrievably. She has identified her losses and her feehngs about them and she has used individual psychotherapy and the research project to attempt to integrate them. Early on, she was able to name several secondary losses and fearfulness about the future. As is typical in grief, she ruminated about how she got ill, what happened to her and how she could get her life back. The slow and deliberate rate at which she is now recovering may in part reflect a desire not to jeopardize her progress. In order to reconstruct her life more fully, she may need to allow herself to feel the feelings of grief and come to terms with her new identity more deeply as a woman with a serious mental illness. Then she can build the future with greater confidence, and pursue goals that are relevant and attainable. 2. Transformation of Identity through Psychosis Jeffrey is a 28-year-old Caucasian single man. He was 23 at the time of his first episode of psychosis. According to him, he had suffered mild depression and lack of focus for many years, but his condition escalated over several months into an acute episode of psychosis, depression, and suicidality. He describes himself as having lost a sense of meaning and purpose in life and could not find his place in the world which he saw as competitive, individualistic, materialistic, and violent. He was hospitalized for several weeks. Jeffrey describes his symptoms during his hospitahzation as "hallucinations, paranoid delusions and illusions, being catatonic and obsessed with trivial aspects of my physical features." He thought he had gone to hell because he had caused world destruction. When family mem- 160 Grief and Mourning in Schizophrenia bers called or visited, he was rendered mute by ing for the well-being and blessings of others, the disbelief that they had survived. When his praying that I might improve as a person in sister caringly tried to suggest that he might be kindness, love, unselfishness and generosity." going through a formative experience and He used his experience with depression as a could see this as a blessing, he saw this as being lesson that negative thoughts, words, and feelmocked by God through her. ings were not worthwhile, but promoted the Initially, Jeffrey saw himself as not ill at very experiences they were supposed to help all, but as receiving messages from God with. As a result of having mental illness, through the Internet and the walls of the hos- Jeffrey found himself feeling "a much stronger pital, telling him that he was being punished. sense of empathy and compassion... for those He felt responsible for his own misdeeds and who are experiencing pain and suffering . . . for the suffering of others. His discussions and a desire to alleviate it." Having been ill with his psychiatrist who gently challenged his taught Jeffrey that he and others were vulnerthinking led to his recognition that he was ex- able and interdependent which gave him a periencing hallucinations and delusions that sense of community with fellow human bewere related to a biological illness, but that the ings. At the same time, unlike before, he felt a content of his delusions and hallucinations clear sense of responsibility for himself as a bemight be an avenue to a deeper understanding ing "created in the image and hkeness of God" of his own spiritual beliefs. In a sense, he could with "the gift of free will." Jeffrey felt that he use the insight into his nature brought about had found the "best known psychological by the psychosis to pursue his search for remedy for worry, stress and anxiety," in meaning as he was recovering from the illness. entrusting himself to God and Jesus's Jeffrey was not resistant to this thinking. Hav- teachings. ing had caring and supportive family relationToday, he may superficially look the ships predisposed him to an ability to develop same. But inside, Jeffrey is transformed. With a solid therapeutic alliance with his doctor. He clear insight into the illness and without denyreasoned that through psychosis, God had ing the need for treatment, he has developed a given him a sense of direction to be helpful to new meaning for his experience. As he deothers and to be good. scribed it, "the true miracle isn't that our own After hospitalization, with unwavering or others' suffering, physical or psychological, family support, Jeffrey resumed his work and has been completely eliminated, but rather academic life, and gradually increased his so- that we change (with God's help) the real root cial activities. He experienced the usual anxi- of the suffering and pain: how we view it, how ety about re-entry—was he different or the we respond to it. It can become . . . the 'myssame, how would he be accepted? He was wel- tery' and 'challenge' of suffering rather than comed positively, and this boosted his merely the 'problem' of suffering. We can self-confidence. Following up on a come to realize that it has been a 'blessing in long-standing interest, he turned to reading disguise.'" Jeffrey looks on his experience spiritual literature, to prayer, and to music in with psychosis as an opportunity to find his order to ease his residual anxiety and appre- spirituality, his true nature, his compassion hension about the future. In these activities, he for others, and an inner peace: he sees himself found solace. He was treated initially with as having benefited from it in the long run. Risperidone which was eventually phased It appears to have been so for Jeffrey. out. He is maintained on a small dose of According to him, he was mildly depressed Fluoxetine. and unfocused prior to his psychosis. Now, he Jeffrey wrote a paper about his experi- sees himself as able to think as more posience of psychosis and its outcome. He de- tively, more compassionate about others' sufscribed his prayer life as having changed from fering, more able to accept help, and as able to one of "requesting, pleading or bargaining for assume personal responsibility for himself. He favors or personal satisfaction to one of pray- is in graduate school, working, and active in Wittmann and Keshavan the community as a volunteer. He was able to care for his dying father and has come to terms with his death without exacerbation of symptoms. Analysis. Jeffrey appears to have engaged with his illness by seeking a spiritual answer to his suffering. As Larsen (2004) indicates, people struck with psychosis search for an explanatory model which would enable them to integrate the illness into their identity. Jeffrey's recovery appears to have been very quick and rather successful. It appears that the major loss he experienced was the frightening intrusion of the psychosis with its attendant distortion of cognitive and emotional functioning. However, the loss of functioning was quickly reversed by medication and psychosocial treatment. He was able to read and think. He began to practice his own version of cognitive therapy—engaging in positive thinking with which to face life experience. Recovery from psychosis gave him an opportunity to seek long-desired spiritual guidance. In the Judeo-Christian tradition, suffering is often seen as a test of faith. In the Eastern traditions, worldly suffering is a lesson in compassion and selflessness. Jeffrey adopted the teachings of both traditions and actively transformed the meaning of his illness from loss into a gift. In that sense, he is not grieving. He is transcending the illness experience and incorporating it into his identity as God's plan to make him a better person. 3. Psychosis as a Defense against Loss Brent is a 29 year old single white man. He is college educated and until 2 years ago worked as an administrator in a technical field. He came to the outpatient treatment program after 6 years of uncertain diagnosis and unsuccessful treatment with mood stabilizers and antipsychotic agents. Brent had suffered from paranoid delusions, mood swings and overpowering ideas of reference which led to obsessive/compulsive activity. He had also made 2 major suicide attempts as a result of feeling utterly worthless. Immediately prior to 161 her arrival in the program, he was placed on Aripiprazol. He gained crystal clear insight and wished to engage in treatment that would lead to his recovery. His primary motive was the care of his young daughter whose custody he wished to retain and whose well being he had guarded surprisingly well even while quite psychotic. Brent had returned to his city of origin in order to be cared for and supported by his mother while he was recovering from his illness. His father who had a volatile temper had died during his adolescence and his mother, a woman who appeared to have a severe personality disorder was remarried. It became immediately obvious that the relationship with his mother had been very disturbed since childhood, including ongoing criticism, demeaning attitude and sexual abuse. At the time of admission. Brent's mother was allegedly denying his illness, refused to become educated about it and maintained a highly controlling and critical stance with him. When Brent asserted himself in the slightest manner, his mother severed contact. She also controlled all of Brent's relationships with the extended family. Brent internalized some of the criticisms, particularly vis-a-vis his weight and overly high expectations about achievement. When the Brent was ill, he was highly dependent on his mother, not trusting his own judgment in anything. Within 3 months of clear insight. Brent began to use more independent judgment in all areas of his life. This included his relationship with his mother and incurred his mother's wrath and criticism. Eventually, Brent decided that maintaining a relationship with his mother would be too destructive to himself and his daughter. He decreased contact which led to his mother abandoning contact altogether. Brent became tearful and depressed in response to these events. He felt alone and frightened, uncertain of his ability to go on. He recalled the many years of psychotic functioning which robbed him of his career and his confidence to support himself and his daughter. He became unreasonably fearful of his ex-wife's power to control time with their 162 child (he had full custody), felt much self-doubt in general and began obsessing about his weight. He was sleeping excessively, had difficulty getting out of bed and only tended to his daughter's needs. He became frightened of his depression and began losing hope. When his therapist interpreted his reactions as grief, described the typical symptoms and suggested that the Brent's feelings v^^ere normal and justified, Brent appeared greatly relieved. Since he tended to absorb rather than repel hostility and then internalized it as self-criticism, the therapist encouraged him to nurture his feelings of anger and outrage at his mother's behavior and named for him the fact that he had experienced the loss of nurturing by a parent a long time ago. The permission to experience anger led to some guilt, but mostly empowered Brent to feel some entitlement to his own feelings and point of view. His emotional reaction suddenly had a purpose instead of signifying that he was getting ill again. He experienced much sadness about having missed many formative years due to his illness per se and due to the way in which the illness made him dependent on his mother who had been controlling and destructive. He began to look at himself with more compassion and began to attach to his therapist as the source of his reality testing which he knew was impaired within himself. With this new reliance came also significant transference, the content of which was projected self-criticism, dependency and sexual attraction to the therapist. Since Brent understood the transference relationship (from previous treatment), he was able to work with transference interpretations by the therapist. As Brent gained increasing sense of himself as separate from his mother, he began to think hopefully about his future. He applied and was accepted to a graduate program. He was taking a risk not only academically, but also emotionally because the program was structured in such a way as to be stressful during time limited periods. As his anticipatory anxiety grew, he was asked to review his past behavior when he coped with work-related stress by stopping his medica- Grief and Mourning in Schizophrenia tion and relying on delusions of grandeur and self-referential interpretations of the environment rather than on working through his feelings. He acknowledged the temptation and re-committed himself to taking his medication as prescribed and to coping with the challenges of school with the help of his ordinary, non-psychotic personality. He exercised regularly, ate more simply and considered giving up smoking and caffeine. Self-regulation and self-care were in fact the condition under which his therapist agreed to support his plan to attend school. He used this success to continue his griefwork - as a testimony to the fact that he had value even when disowned by his mother. He would say vengefuUy: "I want my mother to see me when I graduate without her assistance!". He would feel guilty about this feeling, but was easily reassured when told that his feelings were just feelings and did not hurt anyone. Two months after his acceptance to graduate school. Brent's hairstylist who was also his mother's hair stylist cut his hair so short so as to make it impossible for Brent to make his hair stylish. For Brent, who was continuing to struggle with his weight, his thick and fashionably styled auburn hair was a narcissistic refuge from his more typical self-loathing. He interpreted his ugly haircut as an attack by his mother by proxy and had difficulty dislodging this belief. Given this latest blow, he was unable to cope by using his own defenses and psychotherapeutic interventions. He became increasingly depressed and immobilized. He was placed on an antidepressant (Sertraline) which gradually returned him to his ability to function and continue his griefwork. At the time of writing, he was reviewing his dating history and the chances he missed for good relationships because he was ill, had no self-esteem and could not use good judgment in choosing his partners. Brent continues to move forward in his life. He is engaged to a woman who has been a long term family friend and who provides an alternative and positive primary relationship. He is working through anxiety about his academic work and can navigate through his program successfully. He has advocated on be- 163 Wittmann and Keshavan half of his daughter and has been able to secure a private parochial school scholarship for her. He continues to attend all aspects of the outpatient program in order to maintain its therapeutic effects and he is openly facing challenges in his environment and within himself. The loss of his mother is a recurrent theme in his work. He is aware that he is 'rising from the ashes' and that he has significant strengths and talents. He is also aware that he has vulnerabilities that are related both to his illness and to his traumatic upbringing. He has, at times, recognized that when stressed, he is tempted to return to his delusional and grandiose symptoms as a way to provide himself with energy and relief from the responsibility he feels as a normally thinking and feeling adult. He is seeing that paradoxically, giving up his symptoms is also a loss: he is giving up magicai thinking. It is his ability to use his own personality, values, and his ordinary emotional responses in the face of existential loneliness that makes him be the autonomous, integrated adult that inspires his self-respect. Analysis, li we look at Brent in the context of the vulnerability-stress model, the history of mental disorder in his parents and the early abuse by his mother may have predisposed him towards a psychiatric illness. As mentioned above, there is a body of research which gives evidence to the possibility that early abuse, particularly sexual abuse may lead to psychosis (Read, et al. 1997, Read et al., 2004, Ross et al., 1994). The stress of adolescence and young adulthood may have pushed Brent further towards psychosis. In the early phases of his adult life, psychosis was a way to have energy and push through challenges and difficult feelings. With insight, this patient struggles with the years lost by unsuccessful search for effective treatment and dependence on a destructive mother. He is painfully aware that having the illness postponed his achievement of adult maturity and he can ruefully admit that at this point, it is also a loss to give up the wish to use symptoms as a misguided strategy towards mastery. The core of this case is the patient's capacity to identify and work through the many losses which may have led to his illness and complicated his development. Having given up psychosis as a method of deahng with them, he is using more mature defenses to cope. He is continually constructing new meanings and goals for himself based on his history, hmitations due to the illness and incomplete personality development, and newly acquired capacities. Like a bricoleur, he is working with what he has, forging a non-traditional path for himself with elan and creativity. As he struggles to reach each new level of functioning, he faces painful memories and limitations with grief and mourning (maturational grief). DISCUSSION We know that regardless of how much or little insight they have, patients with schizophrenia are quite able to recognize that their lives have changed as a result of the illness. Insight and style of coping are not static and evolve over time. We can observe clinically that those patients who can grieve and mourn their illness with some success are able to move forward in their lives more successfully. The work of grief and mourning has a purpose and purposeful activity is hopeful and affirming. Our clinical examples demonstrate that grief and mourning in schizophrenia can take a variety of forms. We present three: 1. some patients mourn the illness as an event that interrupted and 'stole' the lives they had envisioned for themselves (Latoya); 2. others, in the process of mourning the intrusion of the illness into their lives search for meaning and may ultimately find the experience transformational and positive (Jeffrey); 3. for others still, the illness itself has been a way of coping with losses - as they move to mourn those losses without the help of psychosis, they also mourn the loss of those symptoms that had served them as a defense against loss (Brent). Much research is necessary before anything definitive can be said about the role of complicated mourning in psychosis. We are 164 Grief and Mourning in Schizophrenia hearing from some of our patients that they are distressed by the way in which psychosis changed their lives. Others are stoic, seemingly unreflective and opaque in their emotional response. To complicate the picture, we are also trying to understand how neurocognitive changes in schizophrenia affect insight and the capacity to experience emotions. Barch, in her review of research on the relationship between cognition, motivation, and emotion in schizophrenia, suggests that cognitive deficits, particularly impaired working memory, may make it difficult for patients with schizophrenia to retain the image of the goal for which to remain motivated (Barch, 2005). She also proposes that a disturbance in the dopamine system evidenced by patients with schizophrenia may be implicated in anhedonia and thus interfere with motivation. Motivation to cope with loss and to move into the future is an important aspect of mourning. Kapur, in attempting to link biological changes in the brain to positive symptoms in schizophrenia, identifies the dysfunction in the dopamine system as a factor that may influence patients' focus on inappropriate stimuli, thus creating unusual, aberrant salience in thinking (Kapur, 2003). This, too, is a potential interference with the patient's abil- ity to appraise and experience loss, grief, and mourning. In advancing these theories, the authors call for more research that would help link the capacity for emotional and cognitive functioning with cortical changes in schizophrenia. As clinicians, we do a good job in many areas: we search for and provide correct medication, teach social skills, and offer psycho-education; we help our patients establish links back into the community and expect that they will build satisfying lives in spite of the illness. 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