October 30, 2018

Anticipatory Grief: Experiencing Pain Before The Loss

(Taken from my Psychology of Grief research project)

Working through an impeding loss, or imminent death, gave rise to the term anticipatory grief by Lindemann in the 1950’s (Worden, 2009). Since then others have researched this topic with mixed results.  In fact, anticipatory grief is still controversial in both what it looks like and if it exists at all (Nielsen, Neergaard, Jensen, Bro, & Guldin, 2016) (“Grief, Bereavement, and Coping with Loss.” n.d.).  There are those who feel it is not possible to grieve until there is a loss (Reynolds, Botha, 2006). However since cognitive therapists believe emotions are often triggered by thoughts, how we think is ultimately our reality. In any case, there is stress associated with anticipating a death whatever the label it is given. With that preamble, the definition of anticipatory grief in this paper is: When an individual is anticipating an impeding loss, or death, and develops symptoms relating to that expected event.

Not everyone who knows someone who is going to die, will develop symptoms or go through anticipatory grief (“Grief, Bereavement, and Coping with Loss.” n.d.).  Anticipatory grief commonly affects those dealing with loved one who have terminal illnesses such as cancer and even long term illnesses such as Alzheimer's (Scott, 2009). Some believe it can also affect the person who is actually dying (Shore, Gelber, Wientzen, Koch, & Sower, n.d.). Symptoms range from physical one such as headaches, nausea, fatigue, sleep and appetite disturbances, to emotional ones like anxious, sad, helpless, disorganized, forgetful, angry or feeling discontented from others (Shore, Gelber, Wientzen, Koch, & Sower, n.d.). 

Due to the controversy surrounding anticipatory grief and the limited research on it, there are three schools of thought:
1.     It doesn’t exist, it’s a form of stress. (Nielsen, Neergaard, Jensen, Bro, & Guldin, 2016)
2.     It is pre-grieving or grieving started early (Worden, 2009)
3.     It is a separate event and has its own tasks or phases (“Grief, Bereavement, and Coping with Loss.” n.d.).
The University of Rochester (Anticipatory Grief, n.d.) lists the phases of anticipatory grief as:
1.     The person accepts that death is inevitable and there is no expectation of a cure. Feelings of sadness, anger, and depression can accompany this phase (Hogan, 2009).  This corresponds to Task 1 and starts into Task 2 of Worden’s model.
2.     Concern for the dying person.
3.     Death is “rehearsed” and preparations made.
4.     Person imagines what life will be like without the person.

While one might think knowing someone will die will enable them to process unfinished business, research shows mixed reactions.  Some grieve even harder after their loss, while others feel more closure (Worden, 2009) (Reynolds, Botha, 2006).  Variables are many, including some grow much closer to the person dying than in their previous relationship and thus the loss has an even greater impact, while others find they have dealt well with the unfinished business and are able to go through the uncomplicated grief tasks more effectively (Worden, 2009) (Reynolds, Botha, 2006).  

An additional note about complications.  Those whose loved ones have Alzheimer’s. One person shared she felt she was experiencing a new loss each time her husband forgot something else.  Unlike a terminal illness, a person with Alzheimer’s loses who they are bit by bit (Scott, 2009) (“Feeling Grief and Loss While You're a Caregiver” n.d.). 

Assessment for anticipatory grief is similar to grief in general except there is no death event that triggers it.  Instead symptoms may arise after a diagnosis or any time after.  An increase in anxiety is a common attribute of those suffering from anticipatory grief (Worden, 2009).  Questions, such as the following, can be used to assess a client (Use a scale to rate each one.) These have been modified from the grief assessment by Holly G. Prigerson, Ph.D., Paul K. Maciejewski, Ph.D.:
            Since the diagnosis of ________ how often have you felt yourself questioning the prognosis?
            Since the diagnosis how distressing has the though been you will lose _______ ?
            Has this thought been disruptive to your daily routine? How often?
In the past month, to what extent have you felt on edge, jumpy, or easily startled?
In the past month, to what extent do you feel that life will be empty or meaningless without _____?
            Do you find yourself wondering what life will be like after _______ is gone?

Answers to these questions can help provide insight as to further testing for depression and anxiety, and of course use the standard rating scales (At each session, in addition to suicide ideation exploration. These questions also help determine how the client is processing the tasks of grief, such as Task 1, do they accept this event.  As such anticipatory grief lends itself to really working on Task 1 and 2 of grief (Worden, 2009).  Some of the treatment suggestions recommended include:
·       Normalize the clients emotions. What they are feeling is common, ok, and real (Scott, 2009) (Hogan, 2009).
·       Help client find resources as needed. Hospice care, support network, etc. (Scott, 2009).
·       Teach the client to deal with the extra stress and strain. CBT, relaxation techniques, stress management, etc. (Scott, 2009).
·       Work through any depression or anxiety symptoms. (Hogan, 2009)
·       Start working through the tasks of grief (Worden, 2009)

While experts disagree on whether or not anticipatory grief exists and if it exists what it really is, individuals do experience real emotions and stress when faced with an impeding loss of a loved one.  These specific symptoms can be dealt with using various psychotherapy tools and techniques regardless of the label attached. 


Feeling Grief and Loss While You’re a Caregiver. (n.d.). Retrieved from https://www.webmd.com/palliative-care/caregiver-grief-and-bereavement#1

Hogan, Marty, L. M. (2009). Anticipatory Grief. Ashland: Sacred Vigil Press.

Nielsen, M. K., Neergaard, M. A., Jensen, A. B., Bro, F., & Guldin, M. B. (2016, March). Do we need to change our understanding of anticipatory grief in caregivers? A systematic review of caregiver studies during end-of-life caregiving and bereavement. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26796738

Reynolds, L., Botha, D. (2006), Anticipatory grief: Its nature, impact, and reasons for contradictory findings, Counselling, Psychotherapy, and Health, 2(2), 15-26, July 2006.

Scott, P. S. (2009, August 07). Anticipatory Grief: How to Cope With the “Living Death” of Alzheimer’s. Retrieved from https://www.caring.com/articles/anticipatory-grief-alzheimers

Shore, Julia Carl, FNP-BC, ACHPN, Gelber, Marianne Wientzen, GNP-BC, ACHPN, Koch, Lauren M., ANP-BC, ACHPN, Sower, Emily, ANP-C, ACHPN. (n.d.). Anticipatory Grief: An Evidence-Based Approach : Journal of Hospice & Palliative Nursing. Retrieved from https://journals.lww.com/jhpn/Abstract/2016/02000/Anticipatory_Grief__An_Evidence_Based_Approach.5.aspx

Worden, J. W. (2009). Grief counseling and grief therapy: A handbook for the mental health practitioner. Springer Publishing.

October 25, 2018

When You’re Angry At Someone Because You See It In Yourself

Monday morning I was eating some raspberry greek yoghurt and a thought cross my mind, I wonder how much lactose in it.  I am on a low FODMAP diet and lactose, a high FODMAP, is often a trigger for those with bowel issues. I find I can have quite a bit of lactose without having any symptoms but I was still curious since I LOVE facts and numbers. So, anyway, I Googled it, as I do when I’m researching, and as I was looking for a good source I came across a question, "If you are lactose intolerant can you still have a little cheese or yogurt?"

My immediate thought was why would you want to? I mean there’s so many other options out there that are far more healthy than dairy. Especially cheese, which is really hard to digest to begin with. Granted I am thinking this as I am eating yogurt, dairy, myself. It struck me, why did I have that thought?  I stopped to do a little self-reflection and I realized it was because I find myself eating foods that I would not normally choose to eat because I’m so limited. I found myself frustrated with those who choose to eat whatever they want because they enjoy it even if they could make better choices because I don’t have that luxury. 

There is a name for this in psychology, if you were in a therapy session would be called counter transference. I have to do a lot of self examination, counter transference work, in my assignments as a student, I thought it was kind of interesting.  I don't have counter transference with my role playing "clients" but I do have bias triggers, like this, people who make poor choices when they have better options available.  Which of course is a judgemental thought and not helpful.  I make poor choices when I have better options available too!!!  

Bias trigger is one of those things that we need to be self-aware of.  Others around us can trigger negative thoughts and feelings within us.  Add to that we can never be truly bias free. We’ll always have opinions and ideas, and those were shape and form or thoughts and feelings. We may even find hints of racist, sexist, or ageist thoughts and having to admit that may frighten us or make us feel guilty.  The challenge is not to make yourself the most politically correct person in the world, but rather to be aware the feelings and thoughts you have so that you can address those in your own mind. If we pretend they don’t exist we will never deal with them.  We have to admit our failings and faults, even embrace them and accept them.  The paradox, once we accept we are human and fail, we then can make real change.  

Sometimes just accepting it, changes it. For example: If I am deceiving myself or blind to a fault, and then I recognize and admit I am blind, just admitting it dissolves it and I see more clearly who I really am.  That doesn't work for all issues, but recognizing it then accepting it are the first two steps. Then you can work to adapt to it or crush it.  In my case, with the yoghurt and the forum participant who wanted to know if they could have a little dairy, I started to ask myself what is it like for this person?  They are a real human being with struggles, frustrations, cares, worries, and loss in their own life.  How is it that I assume they have it easier and they should just choose better.  Soon as I said "should" I remembered the 10 cognitive distortions (untruths we tell ourselves).  If you'd like to learn more about telling yourself the truth click here.  

PS: You are always welcome to chat with me. I offer a free 15 minute consultation. 

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Angela Poch, certified life coach, certified level 1 TEAM* practitioner, and certified nutritional counsellor. 

*TEAM-CBT, developed by Dr David Burns, is an evidenced-based approach to psychotherapy with Cognitive Behavioral Therapy (CBT) at its core, recognizing the connection between thoughts and emotions, and behaviour, but inclusive of various techniques across many approaches. TEAM is an acronym: Testing, Empathy, Acceptance (paradoxical Agenda setting) and Methods. 

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