AnticipatoryGrief:
ThePeaUndertheMattressandtheElephantintheRoom
Presentedon11/13/2009byJenniferAllen,LMFT,ATR‐BC&authorof
BONEKNOWING:ATrueStoryofComingtoLifeintheFaceofImpendingLoss
www.jenniferallenbooks.comforresourcesandfreepodcast
DisenfranchisedGrief=griefthatissocially/culturallyunsupported(Doka2002)
Duetotypeof:relationship(ie.in‐law,samesexpartner),loss(prenatalloss,anticipatorygrief),griever(ie.child),death(ie.suicide)
*alsoHiddenGrief(Kastenbaum2004)‐Heathcareworkershidegriefduetofearedperceptionofbeingineffective&lossofobjectivity.
AnticipatoryGriefisakindofdisenfranchisedgriefthathappensinanticipationofalossandincludeslossesalongtheway.Examplesinclude:
Diagnosisofalifethreateningillness(selforlovedone),Alzheimer’s,dementia,birthdefect,goingtowar,post911,livinginwarzone,beinginagang,beingahealthcareproviderforendof–lifecare,domesticviolence,pendingdivorce,suicidallovedone,high‐riskbehavioroflovedone(drunkdriving,unsafesex).
Myths&Realities
Myth:Anticipatorygriefreplacesbereavement(afterloss)
Reality:Anticipatorygriefcanhelporientonetogriefandhowtocope,aswellasgrievemanylossesthathappenalongtheway;however,oncethepersonhasdied,therearenewlossestogrieve.
Myth:Suddenlossvs.anticipatedlossiscorrelatedwithPTSD.
Reality:Bothcanbe.AnticipatorygrieversoftenmanifestPTSDsymptomsastheyhavebeenexperiencingthe“threat”ofalovedone’sdeathforalengthoftime.
Myth:Anticipatorygriefautomaticallyhappensuponreceivingalife‐threateningdiagnosis(selforloved‐one)
Reality:Noteveryoneengagesinanticipatorygrief(ie.denial),butthosewhodousuallybeginatpointofdiagnosis.
Myth:Anticipatorygrief(andpost‐lossgrief)manifestsonlyasfeelings.
Reality:Anticipatorygrief(andpost‐lossgrief)manifestsinallareasofbeing:physical,spiritual,social,cognitive,behavioral,etc.
Paradoxicaltasks:
Grieve/HopeAllowforanticipatorygriefprocesswhileholdinghope.Redefinehopeasneeded.
Cure/HealActtowardcure(treatment)whileattending“healing”(holisticsenseofwellbeing)
Plan/WaitPrioritize/balancefutureplans(ie.advanceddirectives,vacation).Takingcareofbusinessallowspresent‐timeliving.Also,lifecontinues,despiteillness.
Suppress/ExpressDiscernwhereanticipatorygriefandconversationwillbesupported.Usethissupport.
Needhelp/GettingHelpisStressfulCounterisolation&caregiveroverwhelmwithasupportnetworkstructuredtominimizeintrusion/tracking.
Helper/HelpeeTrustthatgivingandreceivinghelpismutual.Customhelpingpreventsfrustrationofhelplessness&receivingisoftennew“edge”
Knowingahead/DenyingUseknowledgeasacatalystnottowaittolive/plan,pepperingdenialintotemperoverwhelm/freezing.
Intimacy/disconnectUnderstandrelationshipchangesasillnessprogresses(lossesadjustedto).Intimacyatgreatheightsbutalsotimesofindifference/pullingaway.
ImplicationsforTherapy:PAVES
PPsycho‐educateaboutanticipatorygrief,5stagesofgriefcanapplyinanticipatorygrief,lossesalongtheway,catch22’sandparadoxicaltasks.
A–Assessbyaskingclienthows/heexperiences(vs.feels)anticipatorygriefandlistenforcuesofintuitivevsinstrumentalstylesofgrief.Treataccordinglyandnormalize.
V–Validateclient’sexperience.Thisisimportantforanytypeofdisenfranchisedgrief.Oftenthoughts/feelingshavebeensuppressedtomaintainsociety’s“griefrules”.
E–Empathize–teachingempathyasself‐compassionvsself‐pityorself‐judgement.
S–Socialsupportvianetworkconcept&communityresources(caregivergroups,hospicecare,etc.).
Catch22’sandtasks:survivalmode
disenfranchisedgrief
• Loved‐one is diagnosed with life‐threatening illness. • Implica9ons of illness and death may include losses that trigger survival mode: financial stress due to loss of income and medical bills, loss of house, loss of co‐parent, etc
Result is a need to begin preparing for survival during and aAer the loss and end‐
of‐life plans
• A. Survival mode uses the “flight or fight” part of the brain, making it difficult to access the ( limbic) feeling part. Emo9onal processing is put on hold for lengths of 9me & hyper arousal stresses body = set up for caregiver breakdown. (Bowers 2009) • B.Pa9ent and/or others may perceive caregiver’s focus on planning premature and as a loss of hope. This percep9on may also prevent both caregiver and pa9ent from geVng needed support. (ie. hospice)
A. Intui9ve griever – stuck
B. Instrumental griever ‐ stuck • Sense of being “in limbo” not able to plan for future (due to implica9ons of giving up hope/foreshortened future) , while also having difficulty con9nuously being present (grief feelings blocked by fear of impending loss)
• Helplessness
Task: hold hope and grief simultaneously. Enlist support that understands this
(hospice/support group/therapy )
Task: priori9ze & balance future plans with present care (ac9on)
Helpingparentssupporttheirkidsthroughanticipatorygrief:
•Listen,reassureandanswerquestionshonestly(ageappropriately)•Keeproutineasmuchaspossible&discusschanges.•Invitetheirhelpwithcaringforpersonwho’ssick.•Allowchild’sleadoncontact/visitingwithpersonwhoissick.•Createasupportnetworkthatincludessupportforkids.•Encourageoutletsforsharingandexpression.•Letschool,church,coach(etc.)knowwhat’shappening.•Getsupportforyourself,soyoucanbestsupportyourkids.•Getinfo.onlocalsupportgroupsforkids(ie.ExpressGroupsforYouth,goto:www.jenniferallenbooks.com)
Bibliotherapy:Story,likeart,isasafeentryintodifficultissues.
Onceyouarefamiliarwithstory,youcanrecommendclientslistentoapplicablechaptersbetweensessionsasacatalystforworkingonsimilarissuesintheirownlives.BoneKnowingaddressesthefollowingissuesthroughstory:
•Anticipatorygrief(chapters130)•Coping(successfulandfailedeffortsthroughout)•Suicide(chapters4&8)•Substanceabuse(chapter6)•GettingHelp(chapters12&15)•Spiritualcrisis/transformation(throughout)•Miscarriage(chapter9)•Intuitionvs.reason(throughout)•Hospice(chapters14,19,20,&30)•Endoflifeissues(chapters14&17)•Dyingprocess(“Days”section)•Deathrituals(3134,36&Epilogue)
Websiteresources:www.jenniferallenbooks.com
•Freepodcastsofindividualchaptersforlistening(oncomputerordownloadtoipod)•Catalystquestionsfordiscussiongroups•Blogavailableforopenforumdiscussion•Bibliotherapybooklists(PDF)foranticipatorygrief&bereavementforadults&children•Article(PDF)onsettingupasupportnetwork•Article(PDF)onanticipatorygrief•Howtotalktochildrenaboutalovedone’sseriousillness
Wantmore?*FridayMorningExpressCEUs(4)on:AnticipatoryGrief/UsingArttoHelpKidsThroughGrief/UsingArtinTherapyspacelimitedto6.Begins1/10
Bowers,Duane(2007)Grief:Immediate,PracticalandEffectiveInterventions.CMIEducationInstitutePresentationCable,DanaG.&Martin,Terry,L.(2007)CounteringEmpatheticFailure,SupportingDisenfranchisedGrieversinDoka,KJ.(Ed.)LivingwithGrief:Before&AftertheDeath.HospiceFoundationofAmerica,Washington,D.C.Doka,K.J.(Ed.)(2007)LivingwithGrief:BeforeandAftertheDeath.HospiceFoundationofAmerica,Washington,D.C.Doka,K.J.(Ed.).(2002).DisenfranchisedGrief:Newdirections,strategiesandchallengesforpractice.Champaign,IL:ResearchPress.Kastenbaum,R.J.(2004).Death,SocietyandHumanExperience.(8thEd.)NeedhamHeights,MA:Allyn&Bacon.Rando, T.A. (1997) Living and Learning with the Reality of a Loved One’s Dying: Traumatic Stress and Cognitive Processing of Anticipatory Grief. In K.J. Doka (Ed.) Living with Grief: When Illness is Prolonged. Washington, D.C.: Hospice Foundation of America Smith,Douglas(2009)DifferentWaysofGrieving,DifferentWaysofHealing.CMIEducationInstitutePresentation
Recommended
