From the Blog

By: Jessica Novello, MS, RN, CDP

We typically associate grief with death (bereavement) and mourning (the tasks of processing our grief). The passing of a loved one and participating in final rituals is one notable grief experience. However, there are types of grief that deal with less recognized losses. When we learn to identify these other, possibly overlooked, grief situations, we can address the loss and move forward. Unrecognized grief has negative consequences to the physical, emotional and spiritual self. This month the blog we will look at less known, but very valid grief situations, review possible grief complications, and discuss steps that you can take if you or someone you love is struggling with loss and grief.

Grief is loss.

This loss includes a change of our physical selves, normalcy, or routine and safety/comfort.  Grief can accompany any situations of change including, but not limited to:

• Divorce
• The move of a close friend or neighbor
• A change of home or location
• A career ending or changing substantially
• Financial loss or change in financial stability
• An unrealized goal
• A health change, such as a new or worsening chronic health condition
• Youth/Aging
• An identity (wife, mother, caregiver)
• Reducing or giving up driving

At the end of grief, there is acceptance even if the pain of loss remains. The process is unique to each person, but should move toward acceptance with the ability to function on a daily basis. However, some grief becomes complicated as we may get stuck in other different steps of the grief process or ignore grief long-term. See the work of Elizabeth Kubler-Ross (1969) which identifies five stages including: denial, anger, bargaining/regret, and depression (all progressing toward the final stage- acceptance). Her five-stage model is still used today, but not everyone goes through all steps and the steps are not always linear.

Grief moves on your own timeline.

Anticipatory grief happens prior to the loss (i.e. grieving the loss of function to an illness even when the loved one is still alive) and may produce a prolonged grief or can help to prepare for future losses and bring quicker closure to grief. Abbreviated grief is moving though the steps quickly while delayed grief may look like “shock” right after the event and the grieving process may happen weeks or months later- the grief must eventually be processed so as to not become dysfunctional grief. We may grieve as a group in collective grief and examples include war or the death of a public figure. Secondary grief is when you lose a person or role (just for example) and you grieve for the related losses- income, relationship, stability, identity, confidence. The secondary losses come in their own time and are normal but must be acknowledged and grieved.

Any of these timelines or situations are normal. Your emotions will conflict (i.e., you miss your family home, but feel liberation over reduced chores and yardwork). You may need to acknowledge situations of loss while finding a “silver lining” or what may be gained. Your grief may feel small some days or may surprise you unexpectedly like a large wave the next. It may linger, but the burden feels “lighter” as time goes on.

Grievers must take care of themselves physically as the your immune system may lower and the nervous system may overact with physical symptoms like headaches and upset stomach. One may feel confused, have a hard time concentrating, and need extra help to focus and get back into your normal or a “new normal” routine. Grief is a gradual process lasting 6 months to two years. The loss stays with you long-term becoming part of your life story but you can live and function with little encumbrance.

There are some warning signs that grief may be turning complicated. About 10% of grievers fall into a complicated grief situation. Complicated grief is considered outside of the variable, but generally considered normal process of grieving. Warning signs include:

• Extended time frame (more than a year or not progressing to acceptance although it can be normal to have a “bad day” occasionally)
• Unable to function in daily routines (i.e. can’t get out of bed, not eating normally, not able to focus on work)
• Extreme or continued emotional, behavioral, or physical distress
• Not able to talk about it or ignores the situation or reminders (stuck in denial)
• Feeling numb, down, depressed, and not feeling joy in situations where it was felt prior, not able to think of or plan for the future- these may be signs of depression or suicidality and need to be addressed urgently.
• Using alcohol or drugs to numb the pain- this may be signs of a developing substance abuse disorder and needs to be addressed urgently. 

Types of complicated grief or high-risk situations for complicated grief include: Absent Grief where you are stuck in denial and don’t process your grief (some people grieve delayed, privately or quickly- those folks don’t fall into this category). Ambiguous Loss (lack of closure)- this happens with long term chronic illnesses (i.e. Alzheimer’s Disease) or incarceration which produce a loss that is not complete. The person may still be present, but not reachable- physically or emotionally. Disenfranchised Grief is grief not recognized by society or social groups (i.e. the loss of a same sex partner or pet, loss from a drug over dose etc.)- this can force people who need to grieve to feel like they are not worthy to do so and they can never process their feelings in a healthy and supported way.

Traumatic Grief is when loss happens surrounding a trauma (often something unexpected) like a natural disaster or accident- this griever must also process the situational trauma so that the effects of one or both don’t produce long term damage. Chronic or prolonged grief causes extreme distress that happens for a long time period and there is not incremental progress toward acceptance or improved daily function. Distorted or Exaggerated Grief is an atypical response- extreme, intense, or odd-in nature, often anger, nightmares, or self-destructive behaviors are displayed.  Psychiatric disorders may emerge in exaggerated grief. Cumulative Grief is marked by suffering multiple losses simultaneously or close together- sometimes called “grief overload” as you may be in separate stages of one or more losses at the same time. This creates a high-risk situation for complicated grief and can occur frequently in older adults. Masked Grief may be displayed as physical symptoms or the development of maladaptive behaviors.

What helps grief? It’s a long list since there is not a “right” option and many strategies used together may help. You may have to try and not benefit from one or more options before you find the right strategy or combination for you.

• Being a “gentle judge” of yourself and others that may be grieving
• Self-care and finding moments of peace or joy (which only you can define- i.e. sitting in nature)
• Goal setting and taking things one step at a time (even if goals are new or different)
• Making a daily schedule and trying to stick to it- adjust if it is not working.
• Social support/support groups (especially useful for chronic conditions and situations like divorce; consider: Griefshare.org)
• Increasing rest or exercise (depending on your physical and emotional preferences and needs)
• Proper sleep- length and quality
• Eat healthfully- not too little or too much (emotional eating)- changes in eating that do not correct themselves over time or become extreme could signal depression or an eating disorder.
• Stay mentally engaged- with workbooks, games, or special memory care programs (especially if you are faced with a cognitive condition)
• Rediscovering or finding a hobby- arts, nature, reading, yoga, journaling, etc.
• Finding an advocate- counselor, case manager, etc.
• Stress management- breathing, massage, pain control, etc.
• Watching alcohol and caffeine intake (may exacerbate your symptoms and disrupt sleep)
• Talk about your feelings- with a friend, family, or therapist
• Volunteer (it is mutually beneficial- i.e. petting dogs or knitting hats for babies)
• Leaning into or discovering faith/spirituality and similar (pastoral counseling services)
• A helpful book (recommendations from Lakelyn Eichenberger, PhD) such as: •
  • Loving Someone Who Has Dementia by Pauline Boss
  • The Heart of Grief by Thomas Attig
  • The Other Side of Sadness by George Bonanno
  • Option B by Sheryl Sandberg and Adam Grant

When grief is complicated you may want or need to seek more intensive professional help such as:

• Cognitive behavioral therapy (counseling- inpatient or outpatient settings)
• Support groups/Group therapy host by a professional
• Treatment for anxiety, depression, or substance abuse- don’t wait to talk to your doctor or therapist if you have concerns, SAMHSA offers a 24/7 helpline 1-800-662-HELP (4357)
• Medication can be effective in treating complicated grief side effects (like anxiety or depression)

More information on grief types and grief-work can be found here:

• https://my.clevelandclinic.org/health/diseases/24787-grief
• https://www.helpguide.org/articles/grief/coping-with-grief-and-loss.htm
• https://www.verywellhealth.com/grief-and-mourning-process-1132545