Complicated Grieving and Bereavement

Understanding and Treating People Experiencing Loss

Gerry R Cox, Robert A Bendiksen, Robert G Stevenson, Gerry Cox, Robert Bendiksen, Robert Stevenson, Gerry R Cox, Robert A Bendiksen, Robert G Stevenson

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780895032133
• eBook ISBN: 9781351845342
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

Losses may provide a turning point where an individual faces personal and social choices. Still, one may derive significance through the experience of loss, while another may encounter bereavement with less consequence. "Complicated Grieving and Bereavement: Understanding and Treating People Experiencing Loss" examines complicated grief in special populations, including the mentally ill, POW-MIA survivors, the differentially-abled, suicide survivors, bereaved children, those experiencing death at birth, death in schools, and palliative-care death.

SECTION 1

Theories of Complicated Grief

CHAPTER 1

Relearning the World: Always Complicated, Sometimes More Than Others

Thomas Attig

Some time ago I was called by a US television network that was preparing a segment on grief and loss for their news magazine program. The caller began by asking me to tell her my view of “the stages of grief.” I said, “I don’t believe grieving is as simple as the unfolding of a series of stages. We do not become as much alike when we grieve as that kind of thinking suggests. Nor is grieving something that happens to us; it is what we do in response. We relearn the entire world of our experience.” “Well, if it isn’t a matter of stages, what is it like then, in your view? Is it like a roller coaster?” she went on. I reiterated, “It really isn’t that simple either. It really isn’t a very simple matter at all. Relearning a world of experience just doesn’t boil down to any such thing.” She said curtly, “We’ll get back to you,” and I never heard from the network again.

They didn’t want to hear that grieving is complicated. But any who have been bereaved or who have listened carefully to the bereaved know that grieving nearly always is complicated. “Nearly” because sometimes we grieve moderately: for some who are not particularly close or whose lives are not extensively intertwined with our own. Ordinarily, grieving involves nothing less complicated than relearning the world, including our physical and social surroundings, our place in the greater scheme of things, our selves, and our relationship with the one who has died (Attig, 1996).

Here I do three things: First, I offer clarification of the meanings of “complication.” I urge the importance of distinguishing between ordinary and extraordinary complications in bereavement and grieving as a key to estimating when it is more likely that professional support services will prove useful. Second, I show how ordinary grieving as relearning the world is “always complicated” through discussion of how bereavement entails complex suffering and how grieving inevitably involves complex responses to that suffering. Third, I show how grieving is complicated “sometimes more than others” in extraordinary circumstances. In them we encounter “special challenges” that add to the mixture of those we ordinarily face in ways that adversely affect our effectiveness in responding to them. Throughout I consider what the bereaved themselves and their caregivers, including family, friends, and professionals, can do to meet the challenges of relearning the world and overcoming interference in effectively relearning.

ABOUT “COMPLICATED”

The dictionary offers several definitions of “complicated,” including “consisting of an intimate combination of parts or elements not easy to unravel or separate; involved, intricate, confused” and “complex, compound, the opposite of simple” (Oxford English Dictionary, 1971, I, 729). At most something is complicated when it is a complex mixture or combination. And, correspondingly, a complication is something added that either makes something simple complex or that further compounds already existing complexity.

Given these definitions, we need not hesitate to refer to either bereavement or grieving as complicated. None can deny that bereavement is a complex state resulting from the death of another that affects us in all dimensions of our lives at once. And none can deny that grieving is a complex process of response to our being cast into that state.

None of the dictionary definitions of “complicated” carries the connotation of “additional symptom or pathology” so frequently associated with the term in medical contexts. And it is appropriate to resist this medicalizing connotation when describing bereavement and grieving. Bereavement following the loss of a loved one is a state of deprivation that we all experience many times. It is far less physical than either a disease or a wound and far more like other non-physical deprivations, disruptions, or crises in our lives. Grieving is our normal response to deprivation and loss. In contrast to disease and pathology, effective grieving is functional and adaptive. Bereavement is unusual insofar as it takes us out of the normal patterns of our daily lives and disrupts the smooth unfolding of our life stories. And grieving is a response to the unusual challenges bereavement presents. But neither is unusual in the way that symptoms or pathologies are. There is nothing “wrong with us” when we are bereaved or when we grieve. Bereavement and grieving in themselves are not complicated in this medical sense of the term.

We should also resist the idea that complication entails anything about our need for professional services or their nature when we are bereaved and grieving. In medical contexts, complications are usually cause for alarm and typically rouse professionals to expand or intensify their efforts. The ordinary complications of bereavement and grieving entail no such things. In medical contexts, expanded and intensified professional efforts usually involve the further application of medical treatments to passive recipients, or patients. But none of the ordinary complications of bereavement or grieving are appropriately addressed through the laying on of professional services while we remain passive. Rather, we welcome professional help and benefit from it when it acknowledges that grieving is an inherently active process and when it enables and supports us as we actively respond to what has happened to us (Attig, 1991).

It is, of course, important to identify when those of us who are bereaved or grieving are at risk of unnecessary suffering and more likely to need professional services. And the concern to use limited mental health resources and target services to optimize benefit is legitimate. But referring to complicated bereavement or grieving (as if there were much of either that is not complicated) will not do the work that is required here. On one hand, it would be a mistake to conclude that we will nearly always benefit from professional services because bereavement and grieving are nearly always complicated. We are remarkably resilient and often capable of coming to terms with our suffering and relearning our ways of being and acting in the world in separation from those we love without such services. On the other hand, it also would be a mistake to conclude that we will most likely never benefit from such services because ordinarily we grieve effectively using our own resources and drawing upon the help and support of family and friends. We often meet with challenges that compromise or even block our own effectiveness in grieving, and when we do, we are very likely to benefit from professional services.

A more fruitful question to ask, then, is not whether bereavement or grieving is complicated but precisely how either sometimes becomes complicated in ways that make it more likely that we will benefit from or even need professional services. Many elements in these experiences are nearly universal (or ordinarily present), and most of us manage to contend with them reasonably well on our own most of the time. Some elements in these experiences that I call “extraordinary complications” are less universal, and they tend to give us more difficulty than we can typically come to terms with on our own. In what follows, I look first at the ordinary complications of bereavement and grieving. Then I offer a categorization of the extraordinary complications that make it more likely that we will benefit from or need professional services.

THE “HURT” OF ORDINARY BEREAVEMENT AND GRIEVING

Too often bereavement and grieving are treated as if they reduce simply to a kind of undifferentiated hurt we experience when someone close has died. As if the experience of emotional pain and anguish were itself without complexity. As if the experiences of bereavement and grieving were entirely emotional in character without equally important psychological, physical, behavioral, social, intellectual, and spiritual aspects and dimensions. And as if the only appropriate help or support for those having such experiences would be listening, comfort, and emotional support.

In focusing on the “hurt” of ordinary bereavement and grieving, I in no way intend to treat these experiences in these simplistic ways. Instead, I intend to describe and analyze the pain and anguish of bereavement and grieving to underscore the complexity of the pain and anguish we typically experience. This analysis serves as a prism through which we can see the complex psychological, physical, behavioral, social, intellectual, and spiritual aspects and dimensions of the experiences that I have described and analyzed more directly in another essay (Attig, 2000a).

Bereavement hurts. When someone we love or care about dies, we are thrust into the state of deprivation we call bereavement. A participant in a workshop years ago perhaps best captured the wrenching character of deprivation when she called bereavement “a choiceless event.” It is something that happens to us without our consent. We feel helpless and powerless, at the mercy of, and sometimes victimized by events beyond our control, such as terminal illness, suffering, accident, and death. We may also feel bitter and resentful.

Deprivation also hurts because it entails loss of something precious. We would not experience the death of another as a deprivation or as a loss were it not for our valuing, even cherishing, the living presence that has been extinguished and taken from us. We feel robbed of someone unique and irreplaceable. We experience our lives and our selves as immeasurably diminished and compromised, distant from so much that made life worth living.

When we are bereaved, we suffer a shattering loss of wholeness. The patterns of connections to things, places, other people, experiences, activities, and projects in our daily lives are in tatters. Our individual, family, and community life histories are disrupted and cannot follow the courses we expected them to follow had our loved one lived. Lines of connection to larger wholes and our sense of place in the larger scheme of things within which we find and make meaning are broken, undermined, or threatened. We feel undone, at a loss as to how to go on, anxious, insecure, unsafe, vulnerable. We may also feel abandoned or betrayed.

“Grieving” understood as the painful emotion that accompanies bereavement is itself a complex mode of hurting. We feel the pain of missing those who have died. We long to love and be with them still. The experience of separation from them permeates our experience of the world. Again and again we realize painfully that we will never see or be seen by, hear or be heard by, touch or be touched by, share daily life with, or walk the world with them. Their absence haunts us. We notice it everywhere. We still carry within us most, if not all, of the desires, motivations, dispositions, habits, expectations, and hopes that shaped and directed our lives while they were with us. We feel sharp dissonance between these things within us and the near constant and often poignant reminders that they are no longer with us. Reality again and again brings us up short. We feel profoundly sad and lonely. We feel the frustration of unfulfilled assumptions, desires, expectations. We miss the satisfactions and fulfillment that only their presence could bring.

Our very souls ache when those we love die. We experience soul pain as we feel uprooted, as if the ground has been pulled out from under us. We feel homesick for the familiar and settled life we knew with those who have died that nourished, sustained, and comforted us. We recognize, and are perhaps ashamed, that we have taken so much for granted. We feel out of place, as if we don’t belong anymore among the things, within the places, and with the fellow survivors our loved ones left behind. We are at a loss as to how to reweave familiar threads of caring about these remnants of our lives with those who have died into patterns of daily life without them. We fear that we cannot be ourselves in a world transformed by loss, that returning home and immersing ourselves in life again in familiar ways may no longer bring peace and contentment, that caring again may only lead to more pain.

We are often profoundly dispirited when our loved ones die. We experience spiritual pain as we feel hopeless, mired in sadness and anguish with no visible way out, at a loss as to how we can overcome what has happened and begin moving and striving again. We feel shaken in our faith and fear that life has been drained of its meaning, as if we have been abandoned by higher powers or cast adrift in the greater scheme of things. We feel joyless and fear that we may never again laugh or be happy. We are anxious about what is to become of us. We are daunted by the unknown and unfamiliar future before us. We fear we may be unable to revive hope and find the courage and capacities to meet the unprecedented challenges of giving new shape and direction to our lives.

We experience existential anguish. We feel anxious about our own finiteness and limitations. We feel small and insignificant. Change and impermanence make us feel helpless, powerlessness, without control. Imperfection and fallibility make us feel guilt, if it is our own, or anger, if it is another’s. Not knowing, not being able to make sense of things, makes us feel confused, disoriented, abandoned in an unsafe, insecure, chaotic, irrational, and meaningless world. Vulnerability to suffering makes us feel anxious for ourselves and others, fearful of what might happen next.

Our suffering tends to immobilize us. When we suffer, we experience our selves as powerless and helpless, as passive recipients (victims) of blows to our present life patterns, disruptions of our life stories, and separations from larger wholes. We experience our plight as beyond our control, our losses as irretrievable, our present distress and anguish as unending and unrelenting, and our future as hopeless.

Grieving as mourning, the process of coming to terms with bereavement, hurts. It is painful to face and wrestle with challenges. We carry the burdens of relearning the world that none can carry for us: Individually and together as families and communities we struggle to make ourselves whole again. We return home to and try to learn to trust and find meaning again in still viable connections with things, places, events, activities, experiences, and other people (soul work). We endeavor to revive hope as we face the unknown, reshape our daily lives, redirect our life stories, search for a deepened or new sense of our place in the greater scheme of things, and seek new accommodation with the great mysteries that pervade the human condition (spiritual work). We struggle to relearn our relationship with those who have died and make the difficult transition from loving in presence to loving in separation, embracing the legacies of those who have died in individual, family, and community life (Attig, 1996, pp. 163-192; Attig, 2000b). In these ways we work to make ourselves whole again as we endeavor to restore integrity to and find meaning in our daily lives.

As we wrestle with these life transitions, we change in all dimensions of our lives at once. Emotionally, we struggle to find new bases for security and stability. Psychologically, we seek new ground for our self-confidence, self-esteem, and self-identity. Behaviorally, we transform innumerable desires, motivations, habits, and dispositions. Physically, we struggle to meet our biological needs, including our need for closeness. Socially, we shape new patterns of interaction with others at home, at work, and in the community. Intellectually, we question and modify our understandings and interpretations of life, death, and suffering. Soulfully and spiritually, we seek a sense of belonging, a sense of order, a sense of purpose in daily life, a sense that there is reason to go on living, and firmer ground for faith and hope.

We do all of these things while we struggle with the pain of deprivation and loss. It is unrealistic to expect that even the most effective relearning of the world will eradicate the pain of missing those who have died. Nothing can substitute for their living presence. We struggle to learn to carry this residual hurt for the rest of our lives.

As we address these challenges and make these transitions, we feel the weight of hard work. We feel self-doubt about whether we are up to the challenges. We feel anxious and uncertain about what to do. We may become exhausted.

We can do much to mitigate our own hurt in bereavement and grieving. Finding meaningful ways of choosing and doing in response to what has happened to us tempers the pain of deprivation: our feelings of choicelessness, helplessness, and powerlessness. Recovering still viable connections, establishing new life patterns, and giving new direction to our life stories does much to mitigate our pain and anguish. It restores some degree of wholeness to our lives and tempers the shattering hurt of bereavement. As we find our ways back home in our life surroundings and in the experiences and activities of the daily lives we live in them, our soul pain moderates. As we rediscover and revive our capacities for hope, faith, and joy, our spiritual pain moderates.

Learning to love those who have died in separation gives them a new and welcome presence in our lives. We give their legacies places in our memories, practical lives, souls, and spirits. As we do, we realize how much of value in their lives has not been lost. This tempers the pain of missing them, making it unlike the agony of utter deprivation and more like the pain of separation when they were alive.

We can temper our existential anguish as we muster the courage to be. We can work to accept life with human, all too human, limitation. We can endeavor to make ourselves at home in the human condition, the ultimate challenge for our souls. We can rein in discontent rooted in our unwarranted expectations of something more than the human condition affords us while we sustain hope and faith. We can recognize that we are wrestling with mysteries, that is, elements in life, and forces that transcend our grasp and control. We can stop seeking solutions to make it all better. We can realize that our responses to mysteries are at best tentative, provisional, partial, and temporary accommodations. We can recognize that some level of anxiety and insecurity is inevitable. We can resolve to do the best we can, with what we have, where we are, for the moment.

We can cultivate wisdom that the great traditions offer about suffering. They see the tie of our suffering to “desire” and its potential to grip us and undermine our thriving. It is not a recommendation against all desire. It is instead a recommendation to rein in desire and clear our heads of unrealistic expectations. Such expectations take for granted what has not yet been granted and perhaps, or definitely, never will be. Such expectations pretend to know beyond the limits of our knowing. When they do, they become very controlling and demanding. They extend confidence beyond the limits of what we can reasonably anticipate. They are presumptuous.

The wisdom traditions recommend that we avoid reaching beyond the possible, aspiring to transcend the human condition while we remain in it. The wisdom traditions favor hopeful...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• SECTION 1: Theories of Complicated Grief
• SECTION 2: Children and Complicated Grief
• SECTION 3: Complicated Grief in Special Populations
• Contributors
• Index