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Grief And Recovery |
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The value of life depends on the impact on others.
- Jackie Robinson
Grief
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Grief is a normal, necessary psychological process that helps a person adapt to the loss of a loved one. The survivor is depressed and often withdraws from former interests, activities and even friends. Grief is a very personal experience; even among members of a family who lose the same person, the experience of the loss will be different for each person. The closer the relationship to the deceased, the greater the loss.
For an adult, the psychological work of grief is connected with remembering and reliving the experiences shared with the person who has died. Grief is not a consciously determined task; rather, it is set motion automatically and proceeds at the rate that is bearable for the individual. Grieving is painful because, as we remember good times as well as bad, the very process of remembering requires a continuing recognition that the person we loved is no longer present.
The outward signs of grief are similar to those of depression and generally include intense mental anguish, remorse and sorrow. But these are mere words, and cannot describe the emotional pain and shock experienced by a person who mourns. He or she has lost love, goals, friendship or security, none of which are immediately replaceable.
The depth of grief is unpredictable because it depends on so many factors, including the availability of support from family, children, and friends; one's culture or religion, and the degree of preparation for the event. Although there is no universal approach to the grieving process, many people follow specified religious procedures. Each of the major religions observes a degree of ritual, quite similar in format, when dealing with death.
As health care providers we deal with these problems frequently, and try to prepare a patient's family and friends for an anticipated death. We do this by providing medical information and by holding family conferences on the patient's progress. Yet no matter how thoroughly we prepare them, families still experience shock and momentary disbelief when death occurs. In addition, questions will be asked and decisions required of them. "Will there be a postmortem"? "What funeral arrangements must be made". The doctor can be helpful at such a time, because those that were close to the patient are typically not thinking or remembering clearly. If the disease was chronic, funeral arrangements may have already been completed, or at least initiated by the family.
When the funeral is over, the family, as well as members of the medical team who have been involved with the patient, need time for their own sorrow to abate. At this time, we usually write the family a letter expressing both sympathy and hope for the future. A review of the patient's medical problem and the therapy is provided, along with pertinent autopsy information if required. These steps help to clear up any questions or misunderstandings among family members about what actually occured, especially during the final days, when their comprehension may have been clouded by concern for the patient. We have found this approach very helpful for the grieving process.
During the first few weeks, phone calls, visitors and cards of sympathy distract the attention of the grief-stricken. Often there is denial of mourning, an attempt to hold back tears and suppress grief. Crying is believed by some people to be a sign of weakness, but it is merely a means of releasing pent-up emotions.
When the attention diminishes and one is left alone with the uncertainty of the future, the feelings of fear and loneliness arise and are natural. However sometimes grief occurs simultaneously with unremitting depression, in which the survivor becomes obsessed with loss. When this happens, feelings of persistent loneliness, helplessness, guilt, shame and anger may lead to a repressed state, and professional help may be required. Grief seems to be endless and recovery may seem impossible, but grief must be allowed to run it's course.
The Duration Of Grief
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To the survivor, grief may seem endless and recovery impossible. Nevertheless, a process does begin whereby grief and recovery occur simultaneously in alternating patterns and moods. Of course, nothing is ever the quite the same again. The survivor's attitudes may be permanently altered by the long acquaintance will illness, suffering and death; quite likely he or she will emerge from the ordeal a stronger, more mature person.
The means and length of time required for recovery will vary. Those who are alone will have a more difficult time and may need additional and continuing support from clergy, social workers or the medical team to help them through their period of grief.
Slowly a new pattern of life evolves. At first the bereaved may feel guilty when experiencing brief episodes of enjoyment. To feel happiness may seem inappropriate, like being a traitor. Yet it is these interludes of enjoyment that gradually create new hope. As they accumulate, they coalesce into a new vision of the future, and the survivor becomes able to acknowledge emotionally what he or she always knew intellectually: that vitality and involvement with others will return.
Little by little, the painful memories of the departed person's suffering and illness become less poignant, and it becomes easier to relive and enjoy thoughts of earlier, happier times. From these cherished memories the bereaved may also derive courage, by identifying with the positive qualities of the person who is gone. At the same time, the survivor begins to recognize with diminishing guilt that his or her own needs continue. This is the turning point.
There is no prescribed time that elapses before a grieving person begins to mobilize his or her interests toward the present and the future. There is no line of demarcation between grief and recovery. Old memories are kept alive while new ones are being created.
Acute And Chronic Loss
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The way a person dies can affect how that person's survivors grieve. There is a major difference between grieving an acute loss (a sudden death) and grieving a chronic loss (a death that is expected).
Grief is more acute with a sudden death -- for example, an auto accident or from a an unexpected post surgical complication. An unexpected death allows no time for planning. On the other hand, when a person has a chronic illness such as cancer, kidney failure or heart disease, people know that death is coming. One is often given support from friends, family and clergy about what to expect where death is concerned.
When someone we care about is dying we often feel anticipatory grief. We may begin to fear the loss and may go through phases of depression, anger or just difficulty coping with the situation, knowing that death is near.
This is a time for compassion, where people often put their trust and faith in their belief system or religion. Visits from family, friends and the clergy to offer compassion and support during a chronic illness can prepare the family for death. The family of a patient who enters a hospice program also have time and built-in support; after death, they can get additional counseling.
There is a feeling of sorrow throughout this chronic process; on behalf of the patient who is suffering, we may often wish for mercy -- that the process would end. This sometimes leads to feelings of guilt. Accepting that the shortening of life is not fair results in anger when the impending death occurs.
There are great vicissitudes or changes during the course of illness. With a sudden, unexpected death, there is no time for preparation; suddenly, one experiences a grievous loss. The death of a loved one in war might be expected, yet people on the home front constantly pray and do many acts, often of kindness, aimed psychologically at helping prevent that death. When the dreaded telegram arrives, it is such a crushing blow and shock that totally alters the recovery process. When shootings or assaults result in a sudden death, survivors may suffer for years. Recovering from acute death is often difficult and slow.
People try to keep hope alive through the realization that life continues during the many crises one undergoes during a chronic illness -- and also preparing for the eventual death. In Planning for Your Future by Getting Your Affairs in Order we describe many ways to prepare for death; we also provide forms and sample documents; such as wills and funeral instructions. Having such documents in place can avert suffering and pain, and help family and friends honor the patient's wishes.
We also discuss ethical wills in which people transmit their thoughts either verbally or with an audio or video recording. An ethical will communicates a person's thoughts, love and philosophy to survivors, providing a chance to say goodbye and to leave a legacy of encouragement and support, as well as to give instructions on how the estate and possessions should be distributed.
Frequently we have participated in conversations where a dying person tries to alleviate feelings of guilt in his or her partner by advising the loved one to become romantically involved again if the opportunity presents itself. We believe grieving can be shortened and eased when survivors receive explicit permission to continue living, and strong advice that although memories of the deceased will always be alive, life must go on.
The ethical will is a great avenue for recording such thoughts. When curing or controlling a person's cancer is no longer possible or practical, an ethical will can provide the patient with a continuing sense of hope that although he or she will not live longer, he or she will live better. Peace of mind comes with having shared important events in our life and with knowing that we will live what remains of our life without pain or suffering.
The ethical will also allows people to acknowledge that their life has been successful: for example, having raised a family, or leaving a moral or financial inheritance that reflects their values. This often gives a sense not only of the value of life but also of continuing hope for the future -- that family and friends will continue to grow, mature and emulate the moral standards and patterns we set. This hope can comfort a dying person, strengthen his or her beliefs and faith, and provide a sense of inner peace despite the most stressful circumstances.
In ethical wills, patients often express hopes that my family will be all right when I am gone. Some hope for some extra time that has meaning; others for a peaceful death that will not traumatize their family. Those whose religious faith includes a belief in life after death hope that at some time in the future, they'll be reunited with their loved ones.
Patients have expressed such feelings as I hope I die peacefully and painlessly, and that my memory will linger and I hope that my life has had meaning that will give strength to my survivors, and that I have served others in a way that has enhanced my feelings of what I term a successful and happy life. Such expressions not only give solace, and comfort to the family but are very helpful to remember in the grieving process to come.
Those who have had angry relationships or discord within their family may try to mend their fences, so that when does occur, they will have achieved better peace of mind for themselves and their family. People who have not talked to a relative or friend for years -- angry because of an incident that occurred a long time ago -- have called or met with the other person so that they could make peace. Others have sought forgiveness for deeds they have come to regret. Reaching out in this way can be very helpful for the survivors, softening the grieving process.
Expressions of what a dying person perceives as the meaning of his or her life can also be a touchstone for survivors. Though patients may see no hope for themselves, they may hope that recalling the events that made their lives meaningful will provide for their survivors with hope for the future. Often during such a period, religion can play a role through the belief in God who has shown them a path of righteousness and a way of life. They know that when God takes them, their family will be comforted by the faith that although their body is no longer present. their spirit will continue and will be remembered.
Some have remarked that their illness has renewed religious feelings, giving them reassurance. This can improve the quality of life for whatever time remains, and can transmit strength to the survivors. The patient and the survivors have put their faith in God's hands for comfort, and know that is not up to them alone.
We have often heard people say -- after either going through a final confession or receiving the sacraments -- that they are now at peace and are no longer worried. Receiving absolution helps not only the dying but also the survivors to continue their anticipatory and subsequent grieving process. This often requires an acknowledgement that the dying no longer have control over their life or the disease, and that even though they will not attain remission, they are now ready to continue living as best they can.
Those who do not have strong religious convictions can experience similar peace by reaffirming their faith in humanity.
Intimate Conversations
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Saying goodbye may be one of the most difficult aspects of dying for both patient and loved ones.
Discussion and implementing ways to assist survivors, as described in the Legacy Project -- by signing living and ethical wills, and by trying to answer difficult questions for relatives, such as What do you think that cancer has done for you, and how has it affected your life? -- can be very supportive to those around the patient. It can also allow them to interact with one another in loving supporting ways that can be a touchstone to help in the grieving process. But there are times when such an approach will not work: the dying person may be denying reality, or may not be interested in or able to have such sensitive discussions.
This type of anticipatory grief session or conversation can cause great anxiety as well as sadness, because it accentuates the loss of life that will soon occur. It also means grieving for the time that will never be spent together and the anger at being denied this precious time. Even so, we have found that it gives great strength to the survivors. It can involve admitting some inadequacies -- for example, that one has not prepared enough to provide well for one's survivors. It can also involve expressing guilt. But an honest approach to the reality of life can be consoling, and the advice that is given can often be helpful and supportive for family and friends.
There is no right time to have such a conversation. Often, though, having it weeks or months before death occurs can help in the anticipatory grief process, as well a lay the foundation for support during the actual after-death grieving. Speaking frankly and setting future standards for one's family's expectations, as well as compassionately discussing and revealing the inadequacies of life, can be very meaningful during this difficult and serious time. Such a somber experience may help renew faith in beliefs and give a sort of breath of life, not only to the dying person (because it may relieve anxieties) but also to his or her survivors (to whom it may give future strength). This is a recognition of the frailty of life and humanity, but is also an expression of the meaning of one's spirit and philosophy.
Some people hope for a miracle, putting great effort into treatments -- whether conventional or alternative -- only to experience disappointment and depression when those treatments fail. Talking about one's concerns, one's fears and even talking about one's death can be a strengthening experience that gives people a bridge to the future.
The ability to confide one's thoughts which may not have been possible for many years, and also the ability to listen nonjudgementally, can help a dying person acknowledge and reaffirm the feelings of sadness and acceptance, reflecting the resilience of the human spirit and reducing some of the shock, pain and ongoing feelings of loss in the grieving process.
Ways to Help with Grieving
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- 1. Engage in conversations about what should happen after death. Prepare an ethical will; leave instructions for what kind of funeral you want -- for example, who should officiate and whether should be private. Such information can relieve the guilt that survivors often feel during the crisis that occurs after a loved one's death, when decisions must be made while grief clouds the mind. It can also prevent unnecessary expense, since many people do not wish to be remembered in a more elaborate way, with a special public memorial, can make this clear.
2. Use a memorial service to try to consolidate the survivor's feelings about the person who has died. This formal means of expressing feelings can initiate and accelerate grieving. Often survivors talk about their feelings and express their love at such a service, which can be a positive, reaffirming experience.
3. During the mourning period, make use of visits from family and friends. Most religions go through rituals and periods of observance that aid in the grieving process. For example, a wake -- a party to celebrate a person's life -- is a Christian custom. In Judaism during a week of intense mourning (called Shiva, seven), mirrors are covered, the immediate family sits on the floor or lower than visitors, and meals are provided by friends and family. After this week, the family gradually progresses back towards the living. The setting of the headstone, approximately 11 months later, is supposed to end the period of mourning so that life can go on.
Emotional counseling and support from clergy, family and friends is more available during the first week or two. As time goes on, friends and family return to their homes and their lives. Calls and letters come less frequently, and the grieving person is gradually left more alone to face the finality of the loss. Periodic letters and telephone calls give continued support but in reality, the grieving person has to take over, regain control of his or her destiny and resume taking care of self, family and friends. Life will go on at its own pace.
We often tell people that this is the time when they need courage and fortitude, and that in part, they could take such strength from their lost relative or friend, who exemplified strength in going through the illness. The survivors now need to emulate that person, calling on a similar strength to continue living in a way that honors the person's memory.
If grief persists without abating over 6 to 12 months, becoming the dominant force in the survivor's life, spiritual or psychological support becomes essential in order to help the bereaved return to an active productive life. There is a need for a purpose in life and for setting new goals.
Most terminally ill patients have already thought about these concerns, and the questions they are asked may come as no surprise. Giving the person the chance to express him/herself, especially in the presence of loved ones, can be a very positive aspect of the coping process.
There are clearly many things on a person's mind during life's final episode. Expressing these concerns can be a effective part of palliative care, improving the quality of the remaining time. It also provides a unique opportunity to help family members bond in a way that fosters both current and future faith and hope, enhancing their courage and giving them strength to face the future.
Love and care begin early in life, and there needs to be some level of satisfaction before death. How a person dies also makes a difference, because survivors will remember many events from the final days, hours and minutes. Compassion shown by the medical team, clergy, psychologists and social workers can reduce the chance that grieving survivors will feel angry that not everything possible was done. There are always questions along the lines of whether a person could have lived longer had the medical team only kept him or her on the respirator or the feeling this death is not fair. Feelings that my life is now ruined and now I have to fend for myself are normal and natural, but can often be lessened through appropriate guidance during the final episode in life. Attacking the psychosocial as well as the medical issues can reduce or eliminate many of the emotional crises common to grieving.
In facing your own death by taking the steps described in this article, you may help your survivors live better and lessen their grief of loss. Not everyone can provide this type of help, though. In part, our resistance to doing so may relate to Freud's suggestion that the unconscious mind does not recognize it's own death, and regards itself as immortal... It is indeed impossible to imagine our own death; and whenever we attempt to do so, we can perceive that we are, in fact, still present as spectators.
Often, even near death people act in an unknowing way. A sudden death, which denies the dying person a chance to express helplessness, abandonment or fear of death, presents a more difficult situation. The difficulty, in part relates to one's ego when the final event is taking place.
In the hospital, the approach of death is often denied until the time it occurs. Media revelations of magical cures and new treatments give false hope. Elizabeth Kubler-Ross reports that only 2 percent of dying patients reject the chance to discuss their dying, but many staff members become so emotionally upset that they cannot help in helping a dying patient share the experience with staff, family or friends. Such discussions are usually less upsetting to the dying person that to those around him or her. The fear of death can provoke withdrawal, depression or a heroic transcendence into a more giving and gracious attitude. The dying person can provide a touchstone for the survivors and future generations by reflecting on the meaning of life and by giving hope that his or her spirit and thoughts will continue.
The care of the dying provokes a pervasive fear in many people -- that they themselves will die and be extinct, helpless, abandoned, lose their self-esteem. People who wallow and struggle in their own mortality during the final episode of the dying process may be detaching themselves from reality. This is one of the normal mechanisms of escape, but such repression of death and anxieties about the future, although normal, can affect not only how the dying person copes but how the survivors cope.
This leads to what has been termed appropriate grief, where the mourning resolves around recognizing and integrating each person's feeling of live or hate for the person they are mourning. Our attitudes toward life and death play a role not only in how we live and how we die but also in how we grieve. The process of death and grieving is thus different for each person. Preparing for death through physical means (such as preparing for funerals, buying plots and deciding on code status) and through emotional means (such as making an ethical will) can alter the grieving process.
Final Thoughts
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Courage
It takes a lot of courage and compassion to stand and act with others during times of distress.
The virtue of courage in approaching reality can be an expression of our inner feelings and philosophy on how to live as well as out emotional capacity to endure difficult crises.
This can provide a springboard for thoughts and acts toward relatives and friends, as well as a chance to share strength and support with companions during times of great stress and woe.
Benevolent acts, no matter how small, such as doing kind deeds or giving friendship, compassion and support, can infuse support and hope.
The philosopher David Hume stated, "Compassion is a natural feeling which by moderating the violence of love of self in each individual, contributes to the preservation of the whole species. It is this compassion that hurries us with reflection to the relief of those who are in distress."
By giving compassion, we share our emotions and our philosophy with another, supporting the hope not only that life is worthwhile but also that it will have meaning. This process supports the desire and will to live. Like birth and marriage, death is a turning point for the dying person and for those around him or her. It is only through kindness and giving that one extends oneself.
This is well stated by Emily Dickinson in her poem
"If I Can Stop One Heart from Breaking":
If I can stop one Heart from breaking
I shall not live in vain
If I can ease one Life the Aching
Or cool one Pain
Or help one fainting Robin
Unto his Nest again
I shall not live in vain.
First appeared October 29, 2008