Tips for Physicians Coping with the Holidays

The Holidays in 2001
In the aftermath of the September 11 tragedy, we are a country and a world forever changed. Life is very different in the wake of this event. For many the initial intense feelings of fear of further attacks and vulnerability to terrorism have somewhat abated in the subsequent months. However, fears were raised again by recent reports of anthrax-tainted letters, calls for increased national security and asking the public to be alert for potential terrorist acts occurring over the holiday season. As we approach the holidays many wonder "What kind of impact will this tragedy have on the 2001 holiday season?" How to observe the holidays in this year of major life change is a matter of personal preference and individual coping styles.

The terrorist attacks have left people realistically concerned about air travel security and afraid to travel by planes. Some are reluctant to use other modes of transportation, therefore many may be spending the holidays apart from their loved ones. We are also now a nation at war. For the first time in a long time those in the armed services are overseas supporting Operation Enduring Freedom during the holidays. Military families not only will be separated from their loved ones but they will also be dealing with the uncertainty that having someone in the armed services during war-time brings.  In addition, many have been impacted by the slowing economy, the rising unemployment, their diminishing stock portfolios and the multitude of layoffs, making the 2001 holidays one of financial hardship. Those isolated or estranged from friends and family can find this a season that intensifies the loneliness. Understandably, the 2001 holiday season will be very different; it is a season filled with uncertainty in a year full of change.

For those who lost family, friends or colleagues from the September 11 incident or those who have lost someone this year, facing the first holiday without that loved one can be very painful. Those not directly affected by the tragedy e.g. losing a loved one, may have been indirectly affected. They are dealing with different losses since September 11, the loss of innocence, loss of life-style, loss of safety and security. Many are still trying to deal with heightened fears, persisting anxiety and increased vulnerability. They are searching to make some sense or find meaning in these previously unimaginable acts of terror that have changed our once safe and predictable world. A few weeks after the tragedy speaker and author Marianne Williamson shared some of her thoughts on the how the events have changed people and the nation.

There are some improvements in our national character that have come about because of this tragedy. We're a softer people, we're a more deeply sober people. I think we realize now our  vulnerabilities in a way that make us appreciate the fragility of life, that make us kinder to each other. We're hugging our kids a little more tightly we're thinking about our relationship to other nations.  I think that when you suffer, you're more sensitive to the suffering of others.
It is important to realize that people are coping with the events of September 11 in many different way. Some may want to talk and tell their story to whomever will listen. Others may want to keep the intense feelings and emotions to themselves. Still others have turned to creative ways of expressing their grief, fundraising, or advocacy as their means of coping. Different responses to change and different ways of coping with grief are normal. Just as people are using various coping methods to deal with this tragedy, they will also decide to observe the holidays in different ways. The diverse ways of dealing with the holidays can be seen as different ways of coping with the loss.

Special Considerations for Victims and Survivors of Tragedy
For victims and survivors of tragedy holidays, anniversaries and other special occasions are often painful reminders of times past. These days can be filled with heartache and anguish. Sights, scents and sounds can trigger intense emotion of loss and the feelings of grief can be just as painful as when they were first encountered, almost like experiencing the loss anew.  Memories of holiday's past can surface often without warning upon hearing a special song, smelling a holiday scent, discovering a treasured ornament or garment, or attending traditional holiday services. Adding to the grief is the portrayal in advertising or shows of the "perfect" family celebrating the "perfect" holiday; this media barrage can be agonizing for those whose families have been disrupted by tragedy.  Holidays are a time when survivors of tragedy are understandably blue.

In light of all of the changes and disruptions and the questions about safety, this year some victims and survivors may choose not to celebrate the holidays as a sign of respect. Others will want to continue with their plans for the season viewing this as a time to connect with friends and family and celebrate the lives of those lost as a way of remembering. It is important to remember that people often cope with loss very differently even those experiencing the same loss. They should be allow their diverse coping styles. Victims and survivors should decide what feels right to them, what will work for them, and then let friends and family know.

Basic Information on Coping with the Blues
Table 1 lists some of the simple, common sense steps that can be followed to help in coping with the holiday blues.
 
 

Basics of Coping with the Blues 
  • Maintain a normal routine, or as close as possible. Try and continue with normal activities. 
  • Be sure to get enough sleep or at least rest if sleeping is difficult. 
  • Regular exercise, even walking, helps relieve stress and tension and improve moods. 
  • Maintain a balanced diet. Watch out for the temptation to eat high calorie "junk" and comfort foods. 
  • Alcohol should be used in moderation, not to mask the pain. Alcohol can also contribute to feeling depressed.
  • Take it one hour at a time, one day at a time. 
  • Do those activities, or be with the people that comfort, sustain, nourish and recharge you. 
  • Remember other times in the past when you have experienced loss and the strategies used to survive the loss.
  • Table 1

    Coping Suggestions for Victims and Survivors of Tragedy
    One helpful insight for victims and survivors of tragedy is understanding that although a person cannot control the loss, he/she can control his/her response to the loss and ultimately choosing how he/she will cope. In the words of John Homer Miller:

                   Circumstances and situations do color life.
                   But you have been given the mind to choose what the color shall be.
     
    Other helpful thoughts and insights about the grief process for those surviving tragedy include:
    · People respond to tragedy in different ways.  Each person's experience of the loss, like each grief experience, will be unique.
    · Everyone has their own way of coping. Recognize the differences in coping styles and allow people to have their own way of expressing grief, unless the methods become self-destructive (See the "When to Be Concerned" section for warning signs). It may be helpful to explain to family and friends how you are choosing to cope.
    · Be aware that it can be difficult for spouses and families experiencing the same loss to understand how different grief responses can occur. Respect the differences.
    · Allow yourself to feel and express sadness, anger or loneliness. The holidays do not eliminate the reasons for feeling these emotions.
    · For most people it is important to find a balance between honoring past traditions associated with the lost loved one and developing new ones. Some traditions may be too painful to continue. You can begin new traditions in memory of the loved one lost as solution to deciding whether to celebrate past traditions. Alternatively you can start brand new holiday traditions to reflect the change or the passage of time.
    · It is important to carefully consider any changes in traditions and make conscious decisions about how to handle them. If appropriate make it a family decision. Explain the changes to other family members and friends.
    · Plan a remembrance or find a special way of honoring the loved one lost:

    · Share favorite stories or memories about the person who has died.
    · Serve that person's favorite food or holiday dish.
    · Offer a toast, or say a prayer at the start of a family meal.
    · Hang a special ornament.
    · Listen to their favorite music.
    · Light a candle.
    · Hang a stocking for the loved one. Let people include notes of remembrance.
    · Look at photos or videos from past holidays.
    · Plant a tree.
    · Establish a scholarship.
    · Dedicate a bench or plaque.
    · Adopt a needy family or donate to a homeless or animal shelter for the holidays.
    · Donate the money that would have been spent on a gift to their favorite cause.
    · Publish an ad in the local paper.
    · Write letters or a journal to the loved one to express your feelings.
    · Explore other ways of "Creatively Expressing Grief" (See the reference for this article at the end)
    · Find a new way of celebrating-observe the holidays in a new place.
    · Volunteer. Helping others can be very healing. There are many worthy organizations some that benefit the September 11th victims, some that benefit other causes, that could use the time or the money.
    · Take time to care for yourself, to be alone with your thoughts, in remembrance or in prayer.
    · Many find solace in their religious beliefs and/or spiritual connections. Talk with clergy, spiritual counselors. Attend a service.
    · Try to stay in the present and look to the future rather than dwelling on the past.
    · Reflect on what is significant to you and still positive about life.
    · Remember the Basics (See the previous section)

    While it is normal for the holidays and other special occasions to intensify feelings of sadness and loneliness, healthcare providers need to be aware that we are entering the time period following the tragic life-altering event when the diagnosis of depression or Post Traumatic Stress Disorder can now be made. Consequently, we should watch our patients for persisting or maladaptive grief responses to the tragedy. The next section includes information on concerning symptoms.

    When to Be Concerned
    The Holiday Blues tend to be short-lived lasting a few days to a few weeks around the holiday season. The emotions-sadness, loneliness, depression, anxiety-usually subside after the holidays once a daily routine is resumed. However, if the symptoms of hopelessness and depression last for more than two weeks, persist past the holidays, or intensify during the season, a simple case of the blues may really be a case of clinical depression. Concerning symptoms include:

    · Persistent sad, anxious, or empty mood
    · Sleeping too much or too little, middle-of-the night or early morning waking
    · Reduced appetite and weight loss or increased appetite and weight gain
    · Loss of interest or pleasure in activities, including sex
    · Irritability or restlessness
    · Difficulty thinking, concentrating, remembering or making decisions
    · Fatigue or loss of energy
    · Thoughts of death or suicide
    · Feeling inappropriate guilt, hopelessness or worthlessness
    A person experiencing the blues consistently over several weeks should seek professional help from physicians, mental healthcare providers, clergy, crisis lines, support groups, or mental health centers. Talking with a professional or taking a mental health screening test can help assess whether it's the blues or depression. Those with suicidal thoughts or ideation need to seek immediate care with their physician, crisis line or the nearest hospital emergency department.

    Final Thoughts on September 11th and the 2001 Holidays
    No other recent event, except the surprise attack on Pearl Harbor has numbed, shocked, horrified, angered, enraged, and unified most of a nation, as have the events of September 11th. This incident will leave an lasting imprint on our personal and national psyche. Images of terror and inspiring stories of courage have been indelibly etched into our memories. This tragedy will reshape how we think about ourselves, our community, our country and our world. To paraphrase Stephen Levine, in order to heal from this grief we are being forced to a depth of our emotions that is usually below the threshold of our awareness. Many are  using the event to reassess and reevaluate priorities and goals. They are seeing this period as one of self reflection, a time to count blessings, to be with and appreciate loved ones, to be kinder to each other, to reach out to those in need, and to honor the strength of the human spirit in the face of adversity. This tragedy has taught all of us that life is very short and very precious.

    These events have sensitized people around the world by witnessing a common loss and made it possible for them to relate by experiencing a common grief response. We can be hopeful that after living through these events people may now be more aware of the suffering of others and no longer turn their backs on those who are grieving. This tragedy has helped to inform and educate both the public and professionals about loss, what is considered to be a "normal" grief response, and what is an "abnormal" response that requires further help. People now understand more about loss and the grief response and may be able to better cope with future losses. Ultimately this education helps in "normalizing" the grief response and enhances the recovering and healing processes.

    December 7, 2001 was the 60th anniversary of the attack on Pearl Harbor; it occurred nearly 3 months from the date of the September 11th terrorist attack. This anniversary helped remind us of our history-the strength and courage combined with the resiliency to survive, that our country has demonstrated in the face of past adversity. History reminds us also that despite national tragedies-life continues. Part of living is observing the holiday season.

    The holiday season in a world forever changed will also be changed. There is a concern that celebrating and being joyful in a time of mourning is disrespectful to the loved one lost. Some may find this season to be extremely painful. For those facing the first holidays without cherished loved ones we hope they can in time honor those lost by remembering them with joy and happiness, not sorrow and tears. Others may view celebrating as a tribute to the lives of those lost, a way of restoring hope and optimism. How best to observe this holiday season is a decision that needs to be determined by each person individually. Each person needs to consider how he or she wants to balance between the past memories of those who have died and are no longer with us, and the present memories of those who are still alive and need to keep living. Perhaps most of all in this year of tragedy and season of change, we need to remember sentiments from the season, that the holidays are a time for "Joy to the World" and "Peace on Earth, Good Will towards Men."

    Blessings of Peace and Joy to You and Yours this Holiday Season.
     

    Online Articles for More Information:

    Specific information on Coping with this Holiday Season
    National Mental Health Association
    Coping During This Holiday Season 2001. Available at: http://www.nmha.org/reassurance/holiday.cfm
    Holiday Depression & Stress. 1998. Available at:  http://www.nmha.org/infoctr/factsheets/103.cfm
    National Organization for Victim Assistance
    Spender S. Surviving the Holidays after September 11, 2001: Ten Thoughts on Coping. October 27, 2001. Available at: http://www.try-nova.org/holidaycoping_september11.html

    General information on Holiday Blues
    Center for Disease Control
    Preventing the Holiday Blues. Last Updated October 31, 2001. Available at:  http://www.cdc.gov/safeusa/blues.htm
    MentalHealth.org
    Highlights Holiday Blues. December 2000. Available at: http://www.mentalhealth.org/highlights/December2000/holidayblues/
    Journey of Hearts
    Dyer KA. The Holidays 2001: Coping in the Year of Change & Uncertainty. December 7, 2001. Available at: http://www.kirstimd.com/blues_01.htm
    Dyer KA. Thoughts on the 2001 Holiday Season: A Time of Change December 7, 2001. Available at: http://www.kirstimd.com/bless_01.htm
    Dyer KA. Creatively Expressing Grief. December 6, 2001. Available at: http://www.kirstimd.com/create_grief.htm
    Dyer KA. Basics about the Holiday Blues. December 9, 1998.  Available at: http://www.kirstimd.com/blues1.htm
    Dyer KA. More Suggestions for Dealing with the Holiday Blues. December 13, 1998. Available at:
    http://www.kirstimd.com/blues.htm
    American Association for Geriatric Psychiatry
    Holiday Blues or Depression. Available at: http://www.aagpgpa.org/p_c/blues.asp Good Assessment for Depression.
    American Institute of Preventive Medicine
    Powell DR. Defeat the Holiday Blues. American Institute of Preventive Medicine. February 1999. Available at: http://cbshealthwatch.medscape.com/cx/viewarticle/150090

    The Quote from Marianne Williamson  is from the "What Really Matters Now?" show that aired on Oprah, September 26, 2001. The URL is found at: http://www.oprah.com/tows/pastshows/tows_past_20010926_e.jhtml

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