Laurie Elise Gordon
New York, New York, United States

“To whom shall I tell this heartache?” – Old Russian song

Medicine is haunted by grief. In tense silences we may sense the specter. Grieving is a normal developmental process, but in some it gets interrupted. A grieving patient calls upon the physician’s most highly attuned empathy. Psychiatry has a rich literature on grief, but it has only recently begun to acknowledge that complex pathological grief syndromes benefit from specific treatments.

The physician-writer Anton Chekhov wrote in the nineteenth century of the pain of loss, and in his masterpiece The Seagull, of something like complicated grief. This phenomenon, only recently named by Shear et al., provides a new framework for understanding people who do not adapt to a traumatic loss.¹ Complicated bereavement, officially, is still a diagnosis requiring further research in psychiatry, despite its critical importance.

The varieties of grief syndromes are just starting to be explored. Many people experience acute traumatic loss. Accumulation of losses is also common. Physicians and caregivers can, as a result, experience post-traumatic stress. We experience losses, sometimes called bereavement overload, with little time between to heal.² Models of treatments for caregiver grief syndromes are just starting to be studied.

Freud’s groundbreaking 1917 essay “Mourning and Melancholia” is seen as establishing the bridge for psychoanalysis to study attachments through the lens of loss.³ He saw a crucial diagnostic difference. Mourning was adaptive; melancholia was pathological, potentially resulting in terminal hopelessness and suicidality, a result of the mourner’s identification with the lost person. Freud writes that melancholia occurs with “a painful and powerful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of self-regarding feelings…culminating in delusional expectation of punishment.”⁴ A complex and painful dual loss is present: the loss of the relationship and an alteration in one’s sense of self. By contrast, normal mourning is an ever-present process and the capacity to mourn is something we must all acquire.

History has lessons for us about grief, both adaptive and maladaptive. Holocaust survivors, for example, were not able to grieve until conditions improved for them; only then did terrible memories resurface.⁵ Group trauma, if not overcome, is then transmitted to the next generation. Societal mourners who have experienced large-scale tragedies, as well as perennial mourners, have long been described as variations of melancholics in the original Freudian sense.⁶ However, the complex emotional burden of longstanding unacknowledged grief was only relatively recently acknowledged diagnostically in modern psychiatry.

Shear’s work elucidates the mental models of complicated bereavement. Only two to five percent of grief becomes chronic; sudden and traumatic loss is predictive.⁷ Grief is a form of love; it therefore has the power to destabilize attachment and identity.⁸ The people we love shape our sense of self; when we lose them we may feel confused, disoriented or lost, even guilty. Attachment is also linked to agency and the desire to explore, learn and grow. Grief can inhibit these exploratory instincts by activating attachment insecurity. This is a compelling, nuanced and modern look at the psychology of grief. According to Shear, when adaptation fails, acute grief persists chronically. This grief is characterized by impairment in function, intense yearning and emotional pain, frequent preoccupying thoughts and memories, a feeling of disbelief, and difficulty imagining a meaningful future.⁹

Consensus is still lacking regarding the criteria and formal name for complicated grief. Shear explains it as a severe and prolonged form of acute grief rather than a unique entity. Suicidal ideation is common. Complicated grief treatment is a specific psychotherapy she developed that focuses on restoring function and assimilating the traumatic loss. She writes that it is important to distinguish this phenomenon from post-traumatic stress disorder and major depression where there may appear to be overlap of some symptoms.¹⁰ Determination of what constitutes prolonged grief can be culture-dependent further complicating the diagnosis.

Antecedents of the modern constructs of grief are found in many of Chekhov’s writings. In Chekhov’s 1886 story “Heartache”, the horse taxi driver, Iona Potapov, has suddenly lost his son. Despondent, he spends the evening trying to tell dismissive customers about his grief. At the end of the night, he feeds his horse, and he is able to speak, asking the horse for empathy. Heartache is short, spare, and potent, illustrating Iona’s urgency to connect and be heard. “When he is alone, he dares not think of his son. It is possible to talk about him with someone, but to think of him when one is alone, to evoke his image is unbearably painful.”¹¹ The reader is left pondering the pain of Iona’s future adaptation to his terrible loss.

Aged twenty six, Chekhov, having written “Heartache” and other stories, was already recognized for creating a new literary form, which Tolstoy described as “impressionist.”¹² Written in the present tense, “Heartache” focuses on “the most ordinary events, a few trivial details, a few words spoken, no plot, a focus on single gestures, minor features, the creation of a mood that is both precise and somehow elusive—such is Chekhov’s impressionism.”¹³ In a letter penned that same year, Chekhov, newly recognized as an author, set forth six principles that make for a good story:

1. Absence of lengthy verbiage of a political-social-economic nature; 2. Total objectivity; 3. Truthful descriptions of persons and objects; 4. Extreme brevity 5. Audacity and originality: flee the stereotype; 6. Compassion.¹⁴

Chekhov brought a new sparse and transcendent aesthetic to literature. His characters were ordinary Russian people and yet through their experiences he conveyed universality. He writes a prescription of sorts for writing as a balm, and for words as solace.

Chekhov—the so-called poet of hopelessness—turned to medicine for a period in 1889. Sad and shaken after losing his brother to tuberculosis, he undertook a journey to study Sakhalin, the penal colony in Siberia.¹⁵ He then published a comprehensive sociological text. Writing compassionately of the escapees, his words are evocative of heartache: “yearning for the home country manifests itself in incessant reminiscing, sad and touching, accompanied by lamentations and bitter tears, or else takes the form of unrealizable hopes, often staggering in their absurdity, and akin to madness, or else it is demonstrated as clearly evinced and indubitable mental disturbance.”¹⁶ This interest in prison escapees was essentially new to the world. The quality of the prose is spare, descriptive, and scientific where possible. The writings about Sakhalin are exhaustive; he documented the prisoners’ stories extensively and tried ambitiously to help them with various medical and educational endeavors. Chekhov viewed this work as a debt he owed to medicine.¹⁷

By contrast, his writing in The Seagull, later in his career in 1896, which contains one of his most famous dramatic monologues, is complex, ambiguous and exquisite. The character Nina compares herself to a seagull that is pointlessly and cruelly killed. This piece of writing shows his evolution along the spectrum of impressionism that he had begun to traverse, culminating in a carefully rendered chaotic portrait of a woman near madness. Nina has lost her lover, and her baby; her mood is akin to Freud’s melancholia. We see her internally fragmented state, her loss of sense of self yet determination to endure, to work:

…Do you remember the seagull you shot? You left it at my feet, he came to me and said, “I had an idea. A subject for a short story. A girl, like yourself, lives all her life on the shores of a lake. She loves the lake, like a seagull… But a man comes along, by chance, and, because he has nothing better to do, destroys her…

What was I talking about, before? I – Yes, about acting. I’m not like that anymore. I’m a real actress now! I act with delight, with rapture. I feel drunk when I’m onstage and think that I am wonderful. Ever since I got here, I’ve been walking around, walking around and thinking, thinking and even believing that my soul grows stronger every day. Now I see at last, Kostya, that in our kind of work, whether we’re writers or actors, the important thing is not fame, or glory, not what I used to dream about, but learning how to endure. I must bear my cross, and have faith. If I have faith, it doesn’t hurt so much, and when I think of my calling I’m not afraid of life.¹⁸

As physicians, as caregivers, as humans, we will all be expected to endure things we can barely imagine. How is it some find ways to manage destabilization from a traumatic loss, so that it does not take root and become complicated grief? The answers are largely unknown.

The way grief affects people, especially caregivers, overloaded with bereavement, is beginning to attract more attention. This includes a better understanding of the accumulation of multiple stories of loss and how we cope with them, whatever the circumstance. The search for emotional space to decompress from heartache should not have to feel eternal. Chekhov’s writing, in various genres, has its pulse on loss, both on the level of the personal and the universal. He foreshadows later, still evolving, conceptualizations of different kinds of grief. Much work remains to be done in the disentangling of the different kinds of grief we all carry. Bearing witness, as well as having a witness, is crucial in the self-protective adaptation to grief, an experience that can deeply resonate and potentially disrupt our identities and attachments.

References

1. Shear MK, Simon N, Wall M, et al. Complicated Grief and Related Bereavement Issues for DSM-5. Depress Anxiety. 2011; 28(2):103-117. doi: 10.1002/da.20780
2. Niemeyer R. Disentangling Multiple Losses. In Niemeyer R, ed. Techniques of Grief Therapy Creative Practices for Counseling the Bereaved. New York, NY: Taylor and Francis; 2016: 153-156.
3. Bergmann MS. Introduction. In: Fiorini GL, Bokanowski T, Lewcokwicz S,ed. On Freud’s “Mourning and Melancholia” 2nd ed. London, England: Karnac Books; 2009: 1-15.
4. Freud, S. (1917) Mourning and Melancholia. In: Strachey J, Freud A, Strachey A, Tyson A, trans. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On The History of the Psychoanalytic Movement, Papers on Metapsychology and Other Works. London, England: The Hogarth Press; 1957: 243-249.
5. Bergmann MS. Introduction. In: Fiorini GL, Bokanowski T, Lewcokwicz S, ed. On Freud’s “Mourning and Melancholia”. 2nd ed. London, England: Karnac Books; 2009: 1-15.
6. Bergmann MS. Introduction. In: Fiorini GL, Bokanowski T, Lewcokwicz S, ed. On Freud’s “Mourning and Melancholia” 2nd ed. London, England: Karnac Books; 2009: 1-15.
7. Shear MK. Complicated Grief. N. Engl. J. Med. 2015; 372 (2): 153-160.
8. Shear MK. Grief is a Form of Love. In Niemeyer R, ed. Techniques of Grief Therapy Creative Practices for Counseling the Bereaved. New York, NY: Taylor and Francis; 2016: 14-18.
9. Shear MK. Complicated Grief. N. Engl. J. Med. 2015; 372 (2): 153-160.
10. Shear MK. Complicated Grief. N. Engl. J. Med. 2015; 372 (2): 153-160.
11. Chekhov A. Heartache. In: Yarmolinsky A, ed. The Portable Chekhov. New York, NY: Viking Press; 1968: 118-125.
12. Pevear R. Introduction. In: Pevear R, Volokhonsky L, trans. Selected Stories of Anton Chekhov. New York, NY: Random House; 2000: VII-XXIII.
13. Pevear R. Introduction. In: Pevear R, Volokhonsky L, trans. Selected Stories of Anton Chekhov. New York, NY: Random House; 2000: VII-XXIII.
14. Pevear R. Introduction. In: Pevear R, Volokhonsky L, trans. Selected Stories of Anton Chekhov. New York, NY: Random House; 2000: VII-XXIII.
15. Rayfield D. Anton Chekhov: A Life. London, England: Harper Collins; 1997. 198-204.
16. Chekhov A. Sahkalin Island. London, England: Oneworld Classics; 2007. 297-310.
17. Pevear R. Introduction. In: Pevear R, Volokhonsky L, trans. Selected Stories of Anton Chekhov. New York, NY: Random House; 2000: VII-XXIII.
18. Chekhov A. The Seagull. In: Hingley R, trans. Five Plays: Ivanov, The Seagull, Uncle Vanya, Three Sisters, and The Cherry Orchard. Oxford, England: Oxford University Press; 2008: 65-117.