Imagined Grief/Worry/Concern Has Real Effects

There I sat one morning, crying. Nothing had happened yet. The day was still ahead of me, same as the day before. The to do list sitting on my computer. The cat snuggled up on my lap. Me trying to wake up at 5 AM. But this morning a few tears flowed even though "nothing" had happened...yet. 

While anticipatory grief refers to grieving before an event is finalized, such as getting a cancer diagnosis or other terminal illness, we can even experience bouts of grief based on what we think the answer to a test result might be. Our brains interpret what we believe as a real event. If are thinking that this might really happen, we start processing as if it already has. Much like when watching TV, your brain doesn't know it's fake or artificial.  The emotions you experience are very real.

For me that morning, it was waiting on a diagnosis for my father. I’m still waiting as I write this. No matter, the stress is real in any case. Learning to cope effectively with these kind of events is the reality of our modern age. So much of what we experience is "artificial." I'm not sure that's even the right word since we are in uncharted waters. Gone are the days when two months later a letter came in the mail that your spouse died on the battlefield. Now at every newsflash your heart quakes with worry, was that near his/her posting? Gone are the days when you went on with life, frequently thinking about your children, hoping they were doing well across the country as they started a new life for themselves. Now, we obsessively check Facebook and worry when our texts are not returned in a few minutes. We don't have to wait for news to come by pony or even postal truck, now we are connected to the entire world 24/7. 

Stressors are at an all-time high in our artificial world. It’s artificial in the sense that the event hasn’t happened yet, we are being bombarded by information that may or may not be relevant or real.  Millions of us watch a fake, make up world on fictional television. Even our social interactions on social media is partly artificial because we don’t express exactly what is going on but rather share cherry picked pictures and ideas.   

Our brains and bodies have to adapt to whole new world in this fast modern digital age. So how can we cope? How can we take back control from the flood of information that changes our perception of reality, even if reality hasn’t changed? Step back. Give yourself time away from all the banter, the electronics, the world. Spend a few minutes in a natural, real environment. Walk the dog in a park, do some gardening, bake some cookies, have tea with a neighbor, take up sewing, the list is just about endless. Do something outside in nature adds some other health benefits, but there’s a lot you can do even in your own home. Brainstorm what would be helpful for you. The only parameters, you need to enjoy it, it must be something in the moment and physical or tangible. 

What about those moments of sadness, worry, or stress when we are just thinking of what might be? Well, those emotions are real even if the event isn’t. Embrace it for a moment, then work on your thoughts. Deal with any distortions you might be having. Make sure you’re not catastrophizing, making it bigger than it is in this moment, or overgeneralizing, i.e. this one event ruins my entire life (a future event can't take away your past). More on clearer thinking here. Right now you’re worried and you have every right to feel stressed and concerned. Whether the test results are for you or for family member. Or maybe you’re at dissipating grief for some other reason in any case embrace the moment and move through it. For more on anticipatory grief check out my previous blog article here.

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

 

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. 

Bibliography:

Anticipatory Grief. (n.d.). Retrieved from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=P03043

Grief, Bereavement, and Coping With Loss. (n.d.). Retrieved from https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-hp-pdq#link/_167_toc

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.

When Crying Feels Good -- 5 Benefits To Tears

I once heard someone say crying is like a celebration of that which you've lost. That was such an amazing revelation to me. That's often exactly how I feel. Like I'm enjoying a piece of history.  Emotions are not as cut and dry as we'd like to think.  Life is fluid why should we expect our emotions to be static as if they are box in neat little packages.  Reality is our lives and our emotions are dynamic and integrated with each other.  We can be happy and cry, sad and laugh, or even bemused and angry, all at the same time.  Embracing this dichotomy is healthy.

Have you ever tried to avoid crying, holding it all back, distracting yourself to keep the tears in, only to feel an immense release once you allowed yourself the freedom to let it all out?   I know I have. In fact, I find from time to time I need a good cry. It's like a cathartic release of stress, grief, anxiety, and in that moment I actually feel good.

Did you know there are benefits to crying.  Here are five:1

• Part of healthy grieving
• Helps with emotional balance
• Restores body balance
• Improves mood
• It can dull pain

Crying is part of a healthy grieving process.  I already mentioned it's like a celebration of what you've lost.  That loss can be a person, job, dream, or even goal.  It can be part of life transitions for example your child who is now all grown up. These can be happy celebrations or real struggles. Granted we don't have to cry to grieve, each person has their own unique ways of dealing with loss, but often tears are a catharsis that is beneficial.

"'Crying activates the body in a healthy way,' says Stephen Sideroff, Ph.D., a clinical psychologist at UCLA and director of the Raoul Wallenberg Institute of Ethics. 'Letting down one's guard and one's defenses and [crying] is a very positive, healthy thing. The same thing happens when you watch a movie and it touches you and you cry... That process of opening into yourself... it's like a lock and key'... Stress 'tightens muscles and heightens tension, so when you cry you release some of that,' Sideroff says. '[Crying] activates the parasympathetic nervous system and restores the body to a state of balance.'"2

Not only can crying work with the parasympathetic nervous system, but it can also trigger endorphins like oxytocin and opioids.  These chemicals produce a reaction in the body to produce a sense of calm and ease pain.1   This ability to dull pain might explain why children or even adults cry when injured.  Here you thought it was just to get sympathy.

So, the next time you feel a dampness around your eyes, don't hold back.  It's not only ok to express yourself, but it's healthy!

Next week we'll look at gratitude and the benefits of being thankful.

Sources:

1. “9 Benefits of Crying.” Healthline, Healthline Media, www.healthline.com/health/benefits-of-crying. 

2. Govender, Serusha. “Is Crying Good for You?” WebMD, WebMD, www.webmd.com/balance/features/is-crying-good-for-you#1.